Part II

Chapter 8

            Shawna and I spent almost an entire weekend together, which was unusual. We played golf Friday after work. I’d been trying to teach her proper pitching technique for some time. On Friday, a nice day, she was swinging the wedge like a pendulum and hitting some nice shots. Later we would have three drinks each at Park Place before ordering food. Shawna could have big appetites. Drinks, food, sex, clothes. Sometimes she just wanted more and I was all for it.

            After dinner we walked to her condo. Both of us were asleep within 15 minutes. I brushed my teeth. She brushed her teeth and took off makeup. We were both exhausted. In the morning we woke up and I served her coffee in bed. We kissed and joked and drank our coffee. It was a nice time. Shawna has a busty body, strong thighs, thick calves. It was a good body, different from Leanne’s. We made love in the bedroom, the curtains pulled to keep out the morning sunlight.

            Shawna wore a long string of pearls. They got caught, gently, on one nipple and then the other as she changed positions. The pearls bounced just a little, and her breasts bounced just a little. It was pleasing to look at, and I assume she wore the pearls for me but maybe it enhanced the experience for her as well. A man never knows.

            We napped, and later she began to tell me about her finances, which were worrying her. She was free with her credit card, although I always paid my share when I was with her. I always paid more than my fair share to tell the truth. She owed for her student loans, the condo, her car and outstanding credit card debt. A person with a six-figure income should be able to pay off the monthly balances of a credit card. “Don’t you have enough clothes for now?” is what I was thinking, but I didn’t say it. I just let her vent. I agreed with her she wasn’t managing her money well, but maybe I could help in some way. I was thinking about it, but the truth is I wasn’t going to do it. It would only cause a fight. I recommended a financial planner, but she never called him.

            We had breakfast. I helped her in the kitchen, then we took a nap, both of us exhausted from the work week. She complained about her life. She worked all the time and when she did get some time off, she slept her life away. I knew what she meant, but for me, you take a job in medicine you know they’re going to ride you like a horse, weekends, holidays, and of course a regular workload during the week.

            At one point, Shawna talked about her old boyfriend, the tall neurologist. “Everyone knows neurologists are the smartest doctors in medicine,” she said.

            She liked him. He was funny, she said. But he was inconsiderate. He claimed to be absent minded, but she felt he was inconsiderate. I had seen him one time, but didn’t know him. Just that he was tall, East Indian, handsome enough.

            I wondered what Shawna would say about me. I was selfish and did what I wanted. I tried to be fun, but a man never really knows how he’s doing. Please don’t give me a self-help book for Christmas.

            The Colorado and Manitou Springs Mountain Hospice was started in 1984 by two large, well-intentioned women. The Gold-Dust Twins, some people called them for their matching blonde hair. I met them one time. Some women can be the most marvelous caregivers. Being a caregiver is a gift, you know, a terrible gift.

            The women heard there was a better way for people to die. There was this thing in England called hospice. In the 1970s, people were dying miserable deaths, both at home and in the hospital. Doctors would do things like not allow patients to take more than a certain dose of pain medication every four hours.

            For example, let’s say a man is dying of lung cancer. Forty percent of our patients in the year of 2000 had lung cancer. You give him 10 milligrams of morphine. It works for a little bit, but at the end of two hours he’s asking for more. Now, I’ll tell you what that means. He’s not in good pain control. And yet, the family would be instructed not to give the patient more morphine until the four hours were up. A doctor wouldn’t do that now. One of the Gold-Dust Twins had a husband with cancer.

            Even in the hospital, where everything is controlled, I heard stories about terrible cancer deaths in the 1970s. Let me tell you, a small percentage of people suffer miserable deaths yet today, so it’s not like morphine can solve all problems.

            Shortly after the Colorado Springs hospice was started, a nurse took over as director of the non-profit organization and the two founders left. The nurse was dynamic and professional, just what was needed. Her name was Betty Floral.

            Betty Floral and her small band of nurses began experimenting with hospice care in the late 1980s. I know some of the nurses from those days, and I can tell you they were mostly providing hugs and morphine suppositories. They had a 40-milligram morphine suppository, and people who were having a hard time swallowing could take it. But I think they gave it to any patient who had pain. The big dose worked. The support was appreciated. They added chaplains, social workers and counselors to the team.

            Funny things happened. One cancer patient got better, for some reason, and took herself off hospice. She considered herself addicted to morphine and went to drug treatment. Was the cancer diagnosis a mistake? I never understood the story, so don’t ask me to explain.

People were constipated and some of the nurses fumbled through bowel care. They found all kinds of things could go wrong at the end of life – itching, nausea, rashes, constipation, inability to urinate, swelling of the feet, inability to take food.

            The medical director, a doctor, helped them work through the problems, but there were always issues to resolve. Since they were doing a good thing, these early hospice nurses, a lot of people helped. Pharmacists would offer the nurses suggestions. People held fundraisers. A bank officer modernized accounting and the payroll system. A young billing clerk began working with Betty Floral just as Medicare started paying for hospice.

            In 1986, Medicare accredited our hospice. We were the first in the state of Colorado. Medicare began paying a daily fee for the care of patients and the Colorado Springs hospice found stability. The economics of it are simple. A few days in an ICU can pay for weeks of hospice care.

            Things changed in the 1990s. The funds were there but how did one deal with diabetes, dementia psychosis, tremors, seizures, blood clots and blood thinners, patients going off dialysis, bed sores. New medications came along. Ulm Specht the pharmacist came along in those days. He helped the nurses begin to take patients off some medications. If the blood pressure was OK, we’d take someone off part or all of his or her blood pressure medication. The nurses had to do a lot of monitoring, of course. We took people off diabetes medications, cholesterol medications, blood thinners.

            An easy example of this medication reduction is a type II diabetic taking metformin. Who cares if his blood sugar is controlled (within reason), he is going to die, so he might as well enjoy some dessert for a change. Not managing one’s blood sugar is dangerous for young people; it decreases blood circulation. In the short term, it’s not a problem for a hospice patient just like bacon and eggs are not a problem for a heart patient.

            Interestingly, many people fought these changes. It was a form of denial. They were going to die, even admitted it, but didn’t want to make any changes in their lives just in case.

Sometimes when they’d find out they didn’t need a particular medication, they’d be grateful. Some of them. When I was there, we regularly reduced the med list by three or four medications from a list of 10 medications. It could be argued the entire United States society is overmedicated.

            Shawna worried about the toll hospice would take on me. The patients were sick and would all die. Families were sad. Medical textbooks don’t address end-of-life care, so with some patients it was a mystery as to what was going on. But also, doctors and pharmacists helped us. Many families, but not all, accepted there are not answers to all questions. And, the nurses learned. I’ve been told a dozens times someone’s bowels were obstructed by cancer tumors, but we were still able to regulate BMs. Bowel movements.

            I’ve also adopted an attitude about the work. It is not my fault these people are sick. Sometimes hospice can help. Do your best but don’t take it personally because there is too much work to do. This is not radical. All medical people must detach. Maybe people in all professions. It’s healthy.

            There is a little tension in my life that is my fault. I wonder if Leanne will show up at my house some day while I’m showing it to Shawna. I wonder if I’ll be at a restaurant with Leanne when Shawna walks in with friends. For some reason, I can’t help but fill all down time. I’m working and contributing to my retirement plan. In my spare time, I work on the house, trying to keep up my blue-collar credentials. I put in the floor joists and have finished framing the walls. I like walking on a solid floor and imagining how the house will look when the walls have been covered with sheetrock and a roof added. I run with Leanne and I hit golf balls at the range with Shawna. I go on a few dates.

            Because I need my small 1993 Toyota Tacoma pickup to haul construction supplies, I decided to buy a used Toyota Camry. I suspect I spend $10,000 a year on transportation. The seat is comfortable, the stereo sounds nice, the sun roof is nice, and I control the climate. I see why some people never want to get out of their cars. They can avoid real work and human contact. The Camry has a smooth, quiet ride.

            In my opinion, real life is outside the car and it’s a pedestrian-unfriendly world. The walk lights are too fast for old people, snow plows push the snow onto the sidewalk during the winter, some neighborhoods don’t have sidewalks, people wait on buses while diesel engines spew fumes, oil tankers pollute beaches.

            It’s class warfare. The rich are isolated, comfortable while the poor are broken down on the side of the road trying to change a tire in the rain. Cars represent the opposite of a democratic society.

            Someday, though, I will have money and no car. I will sit at my desk and look at my investments. I will go to the grocery store on a bicycle, with a basket, for just one item. Because I live in Hawaii, I won’t own a coat. People will ask to stay with me and I’ll say, “Come ahead, but you’ll have to catch a cab from the airport. I don’t have a car.”

            Some people say kill your television, but I disagree. I say, kill your car. Kill your car and all the problems in your life will go away.

Chapter 9

            I was on my way out the door of Leanne’s apartment. I had a full day scheduled. “I’m going to interview for a job with the police department today,” Leanne said. She had been working at Rocky’s, applying for jobs, going to interviews. She saw a recruiting poster and put in an application with the police department.

            I didn’t know how to feel about this. She knew this intuitively and had waited to tell me. Wasn’t it dangerous to be a police officer? “I didn’t know,” I said. “Well, good luck then.”

            “Thank you,” she said. I headed out the door. I was finding the used Camry to be good, economical transportation and comfortable as well.

            “A police officer?” I thought. “Well, we need good police officers.” I knew we would talk about it. There was a reason she hadn’t mentioned it until the last minute. Hospice work filled the rest of my day, but Leanne was in the back of my mind.

            I worked with the actress Carley Desiree on one of my first “hard” cases. The patient’s name was Ruth Derby and she was 62. She was a gardener, a good tennis player and a mother. Unfortunately, she was a smoker and when I met her I was told she had a tumor, an aggressive cancer, in her right lung the size of a tennis ball.

            I remember the first time I met her. I liked her husband right away. They lived in a nice, little home, but later I learned the husband had socked away millions. His wife was attractive, even athletic looking at 62. She looked at me, new to hospice and new to nursing, and said, “What do you think you can do for me?”

            “I’ll keep you comfortable, I hope,” I said.

              Great,” she said, sarcastically. She took Percocet by the handful, hurt all the time, and was constipated and nauseated. The doctor had been unable to help her much, so the idea a nurse would have something to offer seemed unlikely.

            We tried MS Contin, which is time-release morphine. You take a little pill and it comes unraveled in your stomach over 12 hours. Thus, a person takes two pills a day, say one at 8 a.m. and one at 8 p.m. Simple. If 15 milligrams twice a day doesn’t work, you go up to 30 milligrams twice a day. If that doesn’t work, go up to 60 milligrams twice a day.

            At 60 milligrams twice a day, Ruth Derby had better pain control, but still complained of pain. The daughters began showing up. First there was the one who had married rich on the East Coast. She was pretty but aloof.

            Then, the airline executive from Seattle arrived. She was smart and good looking.

            And then, one day, there is a beautiful woman sitting on the couch. So beautiful it took my breath away. Before I can be introduced, I realize it’s Carley Desiree. I’ll tell you, I was in love like nobody’s business. But, I’m a professional. This was proving to be a hard case and I was starting to dig in my heels. I was determined to see progress on this case. Carley went back to California, but I would see her again.

            Even at 120 milligrams of time-release morphine twice a day, the patient was rating her pain at 6 to 7 on a 1-10 scale. A student nurse visited the home with me. She was young. She had not yet learned to assert herself. The patient rated her pain a 7. In the car, I turned pale, white. I broke out in a sweat. The student nurse asked me, “Are you OK?” I told her I was frustrated.

            The doctor had ordered a 1 milligram dose of lorazepam for the patient at the hour of sleep, but it didn’t help her sleep. The patient had nausea and tried Compazine, Zofran, and then a corticosteroid but still had nausea. Only the constipation problem had been solved to her satisfaction. The daughter who was the airline executive, Linda, took time off work to stay with her parents. Carley also moved into the house.

            One day, after no success at pain management, the doctor sent her to the hospital for “pain control.” This was her primary care physician, who did not consult our medical director. The Colorado Springs hospice was picking up the hospital bill at $900 a day, our executive director reminded me. It was a budget buster. I felt like a failure. It seemed the basics I’d learned about pain control didn’t work.

            The patient came home with a PICC line, a peripherally inserted central catheter. A line went in the antecubital space of her arm and into her subclavicular vein. It infused morphine at 40 milligrams an hour, a huge dose. The other nurses at the office said, well, how could I have known her pain was going to be so stubborn. They wouldn’t have known either, they said. Still, the fact I hadn’t seen this coming bothered me. My inexperience was showing.

            We had had other patients on CADD infusion pumps, so this wasn’t a new thing. I sat up at night and reread Dr. Michael Levy’s treatise on pain control. I read about lung cancer. Still, there had to be a book somewhere on end-of-life care that would give me all the answers, but I didn’t know what it was.

            One night, Ruth took two 1 milligram Ativan tablets and slept. I found out her husband was cooking deer sausage in the mornings at a second, sportsman kitchen they had, and I asked him to stop temporarily. The nausea stopped. The strong smell of the meat was causing her nausea.

            Ruth Derby never had high praise for me. She didn’t like a thing about being sick. She said she didn’t have pain but the pain medication didn’t make her feel well, which is what she thought would happen. What she wanted was a pill that would make her feel like her old, energetic self. She said I was tenacious and she respected that, but that was all the credit I would receive. She hated being tied to the CADD infusion pump by a tube in her arm.

            I learned, though. Because of the reputation of morphine, many patients feel the pain medication should make them feel happy when with severe pain, it mostly works to deaden the pain, not make one feel well. Certainly not energetic.

            I had long talks with Linda about the airline industry. She had worked her way up from an office job by earning a college degree and doing well at every job the airline threw at her. She told me how pilots are scheduled, that they earn $300,000 a year due to a strong union. Being in that home was like getting a business lesson every day. I liked her.

            Ruth’s husband liked to hunt and he had been everywhere. He liked Alaska best of all. Better than Africa, Asia or South America. I liked to hear about other people’s travels.

            I was most enamored of Carley Desiree, however. She had smoked a cigar with Lee Iacocca. She played a part opposite Arnold Schwarzenegger. She did a favor for Danny DiVito once. She danced at a party with Harrison Ford.

            Carley admitted she had the most success in commercials. She was in a Sears advertisement, and she made quite a lot of money in an early Coors commercial. If you saw her, you would recognize her from the Coors spot.

            She had a lead part in a movie called “Honolulu Surf Company.” She was a detective playing opposite former football star Russ Fellowes. Carley’s father loaned me a videotape of the movie. Turns out it was not in wide circulation. I thought it wasn’t terrible. Certainly Carley Desiree had camera presence.

            I was getting to know the family quite well. The last month was difficult and touching all at the same time. Linda and Carley took good care of their mother. The other daughter was less involved in the family life, being on the East Coast and being Ruth Derby’s first daughter by another marriage, but there was no tension between them. Ruth’s husband obviously loved his wife.

            The patient began spending more time in bed. I was occasionally increasing the patient’s pain medication, under the supervision of our medical director. Every nurse at the office asked about the case, but none would get involved. They were afraid of the case. It was going badly and everyone knew it. No one wanted to jump in and help the new nurse.

            Ruth started taking 3 milligrams of Ativan at night, then 4 milligrams, then 5 milligrams. She became bedridden, barely responding to people. Then she took Ativan every eight hours, every six, and finally every four hours. I kept our medical director informed. Dr. Wohlfahrt just shrugged when I told him how much Ativan the patient was taking.

            One weekend, when I was on-call, I stopped by the house. I sat at the kitchen table in the early morning and did some paperwork while we waited for a cassette of medication to be delivered for the CADD infusion pump. Linda, who is beautiful with black hair, sat at the table with me reading the newspaper. Then Carley came out. Her blonde hair looked kind of wild, but even with unkempt hair she was still more beautiful that 99 percent of all the women in the world. I was charting from my notes; I’d been busy and was trying to catch up on my work.

            I could feel eyes on me and looked up. Linda and Carley laughed. Carley, always the boldest of the two, said, “Sorry. Neither of us has been with a man for a while.” I smiled but that’s a line best left alone. Nothing you can say after that will enhance your position.

            For the rest of my life, I will be a huge Carley Desiree fan. Maybe she’s just a “B” actress, but I think she’s the best.

            It was a funny day, that Saturday. It turns out the family was about to run out of Ativan. Just what an on-call nurse needs on a Saturday. I called the doctor’s office, and got the on-call doctor. His name, and this is no joke, is William Heck. I told the doctor the patient was taking five 1 milligram Ativan tablets every four hours.

            Dr. Heck, because it was hospice, said he would give us enough pills for the weekend. Then he said, “You are doing something wrong.”

            “I know,” I said. It was almost funny, but in truth I felt shamed, lectured by this doctor. I wanted to ask him to come in and show me the right way to do it. I want to learn.

            When a woman is 62 and athletic, her body does not want to give up. In the end, I could palpate a tumor in the chest wall of Ruth Derby as big as a volleyball. She was given Ativan rectally as she could no longer swallow. We had the morphine infusion at 90 milligrams an hour and her rate of breathing was 24 respirations a minute. Trust me, there aren’t any textbooks that tell you how to deal with this.

            I was at the home, and we were moving Ruth up in bed. Linda and Carley bumped into each other. Linda started to give Carley a lesson on how to use a drawsheet, while Carley broke out in tears. Linda looked at me. “I’m practical, she’s emotional,” she said, pointing first to herself and then at Carley. “The story of our lives.” They both smiled, and I was melting I was so in love with these two.

            “Thanks for letting me in on the family secrets,” I said.

            Ruth Derby died that night. Linda and Carley had kept her clean, brushed her teeth, change her position in bed every two hours, had given the Ativan on a regular schedule. Someone was always with Ruth Derby.

            They thanked me for all the time I spent there. Everyone at the hospice knew I didn’t mind being in a house with Carley the actress and Linda the beautiful business executive. The truth is, I was greatly relieved to be done.

            I got no satisfaction from the case. I was missing something. People can tell you you did your best, but it’s not enough. It’s a poor analogy, but it’s like when they interview an athlete who plays his heart out but the team loses. He isn’t happy. He wanted to win.

            I wanted a good outcome. Later, other nurses had cases like this. They are rare but they certainly happen. It was interesting to me the nurses would not admit some random case was impossibly hard. I knew it because they talked to the medical director day after day and ended the conversations with, “Nothing has worked.” The patient would die and the nurses would say, “They were peaceful right at the end.” But this was bunk, and I knew it. The nurses always felt a failure when the patient was not comfortable.

Chapter 10

            There is no accounting for how the hospice gods will treat you. I had several cases that went pretty well. I had a patient with constipation. I set up a schedule with senna and we didn’t have any more problems.

            I had a man with prostate cancer, which had spread to the bone. Vicodin weren’t working. I put him on MS Contin 15 milligrams twice a day and a 200 milligram ibuprofen tablet twice a day. He was completely free of pain. “This is great,” he said. I worked with him about three weeks, then he slipped into a coma and died. Easy.

            One side note. I had to place a Foley catheter when he slipped into a coma as the wife was having a hard time with bed care. The catheter would mean he wouldn’t soil the bed with urine. He was not a big man, but his penis was enormous. I couldn’t help myself. I laughed.

            Later his wife said, with a smile, “I really loved that man.”

            We had an old man in a run-down house. The paid caregiver was a fiery redhead who was determined to keep the old guy alive. It was another case of “We’ll defeat those hospice people.”

            One of the weekend on-call nurses. Tabitha Crist, recommended against an antibiotic when he got pneumonia. The on-call nurse was probably right in this case, but “Big Red” raised hell. She refused to let the on-call nurse come over again, ever. Big Red turned out to be right, the patient got the antibiotic and lived another two weeks. It was the second case of pneumonia that did him in.

            In the meantime, I got our best volunteer assigned to the case, an old guy with a charming manner. We won the patient over to our side, and Big Red to boot. I don’t know what it is about paid caregivers in the home. “They’re either very good, or they’re mollusks,” Tabitha said. That was one of her sayings. “You know, a big, dumb, slow animal?” Actually a mollusk is an invertebrate.

            The easy trend couldn’t last. I got Jim Cousy, 80 years old with bladder cancer. His grandson lived in the house, but I couldn’t see that he was helping out much. When Mrs. Cousy said she could use some help, the social worker Mattie Green gave her a list of telephone numbers for home health agencies.

            Excuse me, social workers of the world, but I began to see this as quite funny. Someone would be overwhelmed with grief, and want some help finding a funeral home, and Mattie Green would give them a list of telephone numbers. Someone would need help choosing a nursing home, and Mattie Green would give them a list of telephone numbers.

            Mattie Green, a good-looking, well-dressed older woman, had that drawn-in face common to cigarette smokers. One of the nurses commented that if Mattie Green were her patient, she would advise her to eat more fruit and have more sex. Myself, I tried not to think of fellow employees as sexual beings.

            I try to be the opposite of Mattie Green, and someday this may cause me trouble. If a person says they need a nursing home, I will say, “I can’t recommend any one particular nursing home, but the West Valley Nursing Home is just down the street and we’ve worked with them before.” People take the hint.

            Once, I got a new patient, and I could tell immediately he was a short-timer. I got pain medications in the home that day. The caregiver, his daughter, was young, very pretty, and her father was dying a premature death from pancreatic cancer. He was divorced from her mother, and the ex-wife was not taking him back. Certainly not now.

            Two days after he’d been admitted, I got a call from the young woman. Please, she said, come help. The man was bedridden, entering into the dying process. He was going fast, which is common with pancreatic cancer. The caregiver’s boyfriend Cory was there. I laughed because he was just like I would picture a “Cory,” young and handsome as a model.

            Cory was a good guy, but he was out of his element. The young woman had a million questions. What if he asks for food? What if he has pain and the morphine drops don’t work? What if he asks for my mother? How do I select a funeral home? What if a tornado blows the back porch off? I’m joking about this last one.

            I helped her. I told her how to give the medications. I gave them some diapers. I told her how to clean his mouth and change his position. We spent a lot of time together. Then, she left the room, and the patient turned colors, from pale white to bright jaundice yellow. He was more neon than I have ever seen. He glowed radioactive. Then he died and returned to pale white. It all happened within 30 seconds.

            Jaundice is caused by an accumulation of bilirubin, a reddish pigment that is a product of heme (an iron-containing nonprotein portion of the hemoglobin molecule) metabolism. All nurses have seen it. I just didn’t know he was going to glow yellow like a Christmas light.

            I sat down with the woman, and Cory, and told them some pros and cons about local funeral homes. They picked one. I waited with them for the funeral home to arrive. I called the medical examiner, which is the county sheriff’s office. They do not investigate hospice deaths because they aren’t suspicious. A doctor always signs the death certificate. We destroyed meds and I took the supplies that had not been opened. I spent six hours with them that day. Now, it was possible someone would look at my time card and chide me for spending six hours on one visit.

            But the Colorado and Manitou Springs Mountain Hospice was a unique place to work. Sometimes the nurses gossiped, and the staff made catty remarks if, for example, I caused an unnecessary expense like the pain clinic for Ruth Derby. But when I did something for the hospice, even if it took hours, I always got paid without complaint. I never took advantage of them, but also it was unusual for a nurse to sit around all day with a very young caregiver and explain to her all the things she would have to do before and after her father died.

            I continued going to the home of Jim Cousy and felt I was missing something. He was a little confused, but pleasant. He liked to talk. I would say, “Do you have pain?”

            He said, “Sometimes, just a sharp pain right here.” He would point to his penis. He had some mild pain pills, but never took them.

            “He doesn’t need them,” said his wife, Ella. “It’s not that bad.”

            The conversation didn’t make me think I was getting correct information. I kept visiting. Sometimes a nurse makes some visits and doesn’t learn much, then one day the patient or the caregiver will provide all kinds of useful information and the nurse will feel he or she could handle it.

            I visited twice a week, and I thought maybe Ella was starting to warm to me a little. She talked about her early years in rural Colorado. The family had struggled to make ends meet. They kept chickens, sometimes selling the eggs, sometimes butchering a chicken for dinner. Jim got a job with the railroad and this pulled them out of poverty. Now they own a little house and have grandchildren.

            They watched Colorado Springs and Denver grow into large, sophisticated cities. The world passed them by. All the people Ella knew were old. Her son stopped by, but he was a Christian and kept trying to save Jim, who didn’t want to be saved.

            I talked to the nurses in the office, but they said if Jim Cousy didn’t have any pain, don’t worry about it. When the time comes, address it. Still, I wondered what I was missing. What was this sharp pain he would feel occasionally in his penis?

            One fine spring day, I went to the office at 8:30 and began calling to set up home visits. It’s not unusual to do five or six visits a day. I called the Cousy home. It was Thursday. “Jim hasn’t peed for 24 hours,” Ella said. There wasn’t any small talk. No hello. No excuse for not calling earlier. Just, “Jim hasn’t peed for 24 hours.”

            I often thought the name of the hospice ought to be the Colorado and Manitou Springs Mobile Hospice. Like a M.A.S.H. unit, we were mobile. It took 45 minutes to drive from our office to the Cousy’s little house on the edge of town

            I said I’d be right there and left immediately. I’d set up three other appointments, but I’d just have to be late. I knew what to do. Put in a 16 French foley catheter. This is a tube that goes in the penis, up the urethra and is held in place in the bladder with a little balloon. Give him a couple of Tylenol 3s and check on him later in the day.

            When I arrived at 9:15 a.m., the grandson, a man in his 20s, was leaving the house with his fishing pole. His friend had just pulled up in front.

            “Going fishing,” he said, hurrying past me. He couldn’t get out of there fast enough.

            I went to the patient’s room and he was sweating, had a high temperature, and his heart rate was up. He was groaning. They should’ve called hours ago. I told Ella what I was going to do. “OK,” she said, but she was unimpressed by the fact I had a plan.

            I told the patient what I was going to do. I washed my hands, began to open the sterile kits, pulled out the catheter and tested the balloon. Then I cleaned the meatus, the opening of the penis, put lubricant on the catheter and began to thread it in. This is a simple procedure. Any nurse can do it.

            But the catheter bumped something a little ways in. I had the patient cough, but the catheter was a no go. I pulled the catheter out, put on more lubricant, and threaded it back in. I went slow, but I had a forceful grip on his penis. I hit something. I gently pushed. I pushed hard. It wasn’t going through. Some primitive instinct told me I was in trouble and I began to sweat out of every pore in my body. I was so alert I could’ve wrestled a bear.

            I went to my car and got a smaller catheter, a 12 French. I washed my hands. I opened the sterile packet. I put on the sterile gloves. I lubricated the catheter. I went slow, but forceful. Damn it, this thing wasn’t going in either. I had the patient cough as I tried to advance the catheter; sometimes this works. I gave the patient two Tylenol 3s. This hardly passes for legitimate pain medication, but you use what you have.

            When I first started at the Colorado Springs hospice, the charge nurse was Roberta Edwards. She was nice, but not helpful. I told her what was going on and she said something like, “Oh, my.” She didn’t offer to have any one else see my patients. She didn’t have an idea of what to do next.

            Ella Cousy watched as I picked up the papers and wrappings surrounding the bed. Medical packaging creates a lot of waste. I picked up the telephone and called the patient’s doctor. I told him what was going on. He told me a story about when he was in medical school and had a hard time with a catheterization. He got a pediatric catheter, a thin tube, the size of a pencil lead, and it worked. “This will work, I promise,” the doctor said. He also OK’d some 10 milligram morphine suppositories.

            I called our pharmacy and they said they could get the pediatric catheter for me, plus fill the morphine order. I told Ella Cousy what was going on. The pharmacy was across town, and I headed out. I was glad for the break, a chance to think, and also I had another plan.

            I returned in an hour and 30 minutes. I tried the pediatric catheter. It didn’t work. No way was this tiny, thin tube going in. At this point, I had visualized the anatomy. I guessed it was either an enlarged prostate or a tumor blocking the way. I had forcefully pushed through some narrow passageways, past some enlarged prostates, in the past. I suspect this was a tumor. That is what he meant when he said he had a pain “down there.”

            I also thought of something else. The poisons were building up inside Jim Cousy. He would die of uremic poisoning if I didn’t get a catheter in. I tried to think of the basics of how this would work. The potassium builds up in the blood, the heart starts racing, the patient dies of a heart attack. That might be it. It occurred to me how terrible it must feel not to be able to pee.

            I told Ella I was going to give the patient a morphine suppository, then call the doctor. She said she didn’t want me to kill her husband with morphine.

            I thought I’d built up some trust by visiting week after week, talking to her about their life story, by offering the services of the Colorado Springs hospice. “It’s only 10 milligrams,” I said. It won’t kill him. He’s in obvious distress.

            “No,” she said.

            I told her I needed to talk to the doctor. I explained to her what I thought was occurring. I showed her the pediatric catheter, how thin it was, yet it was not going in. I called the doctor. I told him I had done what he told me. He agreed with me a tumor must be blocking the passageway, although what difference did it make. He said he was going to call the urologist and would call me back.

            I called my boss, Roberta Edwards. I told her there was a chance the doctor might send Jim Cousy to the hospital to place a suprapubic catheter. This is a catheter placed surgically. The surgeon makes a hole through the skin – below the abdomen and above the bladder – and places a catheter.

            “You’d better find out who is going to pay for that,” Roberta said. “I’m not sure we’ll pay for that.” I hung up, waiting for the doctor’s call. It occurred to me if the patient was to go to surgery, we would have to pay for transportation. I went to my car and got my file – papers in a file folder. It had the name of an ambulance transportation company we have a contract with.

            The last thing I was worried about was asking the doctor or the family who was going to pay for the surgery. I have tried unsuccessfully for three-quarters of a working day to put in a catheter. I have three patients I have yet to call and tell them I won’t be visiting. I can’t get Ella to let me give the patient a morphine suppository. Billing is someone else’s problem.

            Is Roberta doing anything to help? No, she’s sitting in the office, near the candy dish and a telephone, wondering who is going to pay for this surgery and saying, “Oh, my.”

            I went in and looked at the patient. He has a high temperature. His heart is racing, 120 beats a minute. In the last half hour, he has taken on fluid in his lungs. I explain all this and ask Ella if I can give a 10-milligram suppository. She said she does not want to kill him with “that dope.”

            I plead with her. “Look at him,” I said. “He’s in obvious pain. Morphine’s not dope, it’s medicine, if the patient is dying and in pain.”

            “No.” She has the look of a tough Midwestern farm woman. There are no frills around her or the house. She’s not sophisticated, but surely she can see her husband’s in pain. I wonder if she’s mad at me.

            The doctor called back. I answered Ella’s phone like I owned the place. The urologist said to let him die. He has advanced cancer, it’s everywhere. Even if they can keep him from dying of uremic poisoning the cancer will get him some other way, and soon. The doctor tells me to be as generous with the morphine suppositories as I need. He will write an order covering me. I thank him for his help.

            I gave Ella Cousy the news, and all it does is put me on the side of a non-caring, large, bureaucratic medical complex. “I would take any amount of time I could get with him,” Ella said. “Why wouldn’t they let me make the decision as to whether I want him here another few days or weeks?”

            Of course, the answer is money. It would cost thousands for a trip to the surgeon, the cost of the surgery, the salaries of the many people involved. I didn’t say anything about the cost to insert a suprapubic catheter.

            I told her I would get the doctor on the phone for her, but she shook her head. I begged her to let me give the morphine suppository. At least one. It was 4 in the afternoon and I hadn’t eaten and I was tired. I sat down on the couch. “I’m not leaving until you let me medicate him for pain.,” I said. I couldn’t remember ever giving a family member an ultimatum.

            By now I have gained some experience as a hospice nurse. There was a certain sound in the lungs, a wetness to the rales. It told me the patient would die, hours to days, but for sure he would die.

            I sat on the couch. “The doctor told me to keep him comfortable.”

            “Fine,” she said. “The answer is still no.” She sat down on the chair across from me. We sat in silence for a few minutes. We could hear him breathing. The fluid in his lungs was worse. I stated my case again, 10 milligrams of morphine is not a lot. He’s dying of cancer. She is steadfast.

            It was suddenly very quiet in the room. She walked in the bedroom, then came back and said, “He’s gone.”

            I went in, checked the apical pulse, the carotid pulse, looked at his pupils. Jim Cousy was dead.

            I destroyed the suppositories. I called the medical examiner and the funeral home. I called the office to tell Roberta Edwards. I called the three families of the patients I was supposed to have visited. I grabbed my nursing bag and headed for the door. “Take care. I’m sorry,” I said.

            The grandson was getting out of a car; he had a fishing rod with him. He is a good-looking young man. He does not want to work on his father’s construction crew. Ella told me about it. Likely he was skipping out of work on this day.

            “How’s it going?” he said.

            “Not good,” I said.

            “We didn’t catch any fish,” he said. He was like a bookend to my day.

             “Kiss off,” I said, but only to myself.

Chapter 11

            Leanne had a new gun for her job on the police force. It was a Glock 9 millimeter. The Colorado Springs police force used to use .44-calber Glocks, the larger size for its stopping power. But Leanne said now, with women on the force, the 9 mm was better suited; women could load the magazine, and it was easier to shoot as it had less kick.

            “OK,” I said. That’s what I say when I don’t know how to respond to something. I didn’t know if it was a good thing or not police were using a smaller load in their guns.

            She was opening packages with dark blue shirts and pants, a belt with a holster, flashlight and collapsible baton. There was a badge in there somewhere, and durable-looking black boots.

            “It works out. You’re a nurse with a career. Now I’m a policeman with a career. Nurses and policemen are a good match,” she said.

            “I’ll start with patrol, but I have a college degree so I could advance to detective. Maybe investigate murders,” she said. “You know, I’ve had abnormal psychology.”

            I nodded. I was thinking big deal. I thought of being in abnormal psychology class. It’s required for nursing. There had been a number of good-looking women in the class, and the instructor listed all these nice guys who turned out to be serial killers. I thought it was creepy, abnormal psychology. Plus, a guy could never expect to get a date in an abnormal psychology class.

            Leanne then opened a box. “Look at this,” she said excitedly.

            There was a shield with a window in front. And a helmet with a face guard. “This will protect you from rocks and bottles when you’re called out during a riot,” I said. She shrugged her shoulders.

            “Wow. I get my own bullet-proof vest,” she said. “It’s heavy.”

            I nodded, noting that it was.

            She looked at me. “I know you’re not enthusiastic about this, but I’m going to try it. I think I might actually be good at it.”

            “The fact is, it surprises me I don’t like the idea. I like policemen and I believe in a law-and-order society. I have the feeling you will make a good cop. I care for you. I kind of don’t like the idea of people fighting and you’ll have to break it up. Or you could get shot. That’s all. It’s such a serious thing.”

            “A high percentage of policemen are divorced,” Leanne said.

            I held her. I felt the moment called for it. “It’s a tough job. I told you my concerns, but I support you.”

            She kissed me. “Thanks,” she said.

            My life, meanwhile, was an unfolding drama with the only themes being death and sadness, and a car. Yet, the job wasn’t sad. It could be, but mostly people shared their stories. Most people, once they get used to you, like to share the things they like, or tell the funny or dramatic stories of their lives.

            The Loud family was presently keeping me entertained. I called them the Louds because both husband and wife were hard of hearing. One had to talk in a loud voice to be understood by them. It was odd about the hearing loss, too, because in old age they had begun to look alike. He was tall, thin and gray, and so was she.

            He had colon cancer. The first day I visited, he asked if I was a Christian. Yes, I said.

            Mr. Hillier was 6-foot tall, and loved golf and Jesus. He was loose-limbed and I have the feeling that at one time he could really smack a golf ball.

            Hospice care is for comfort, and people who want emergency medicine should not accept our services. We ask people to call a hospice nurse, not 911 and the ambulance, when they have trouble. We drive in cars without sirens.

            We can do many things – for example we would send someone to the hospital with a broken arm – but we don’t do dramatic things to keep people alive. Mrs. Hillier said she certainly wouldn’t call an ambulance. They did that once and it almost ended up costing them $500. Then, for some reason, she left the room. It may have made her mad thinking about it.

            “I’ve always liked sex,” Mr. Hillier confided to me.

            “OK,” I said, not sure where this was going.

            “We had to call the ambulance because I took yohimbe. Do you know what that is?”

            I said no.

            He said it is to supposed to help with sexual potency. I later learned it can also cause a drop in blood pressure. This is what happened to Mr. Hillier. He took the yohimbe herb and passed out. His wife called 911, but he was OK, just passed out because of low blood pressure. Since the doctor wasn’t the one who called 911, the insurance company wouldn’t pay for the ambulance. Later, the doctor convinced the insurance company to pay, but the threat of losing $500 out of their fixed-income lives had scared Mrs. Hillier.

            Mr. Hillier began telling me about his sex life. His wife liked sex, too, he said. She wouldn’t do the oral stuff, but everything else was OK. I was getting a little too much information, but I wasn’t sure how to put a stop to the conversation.

            “There is no sex in heaven,” Mr. Hillier said finally.

            “Why do you think that is?” I said.

            “It would be too complicated.”

            We talked about other things. Mr. Hillier said he had been a good Christian, and was not afraid of dying, but it also appeared to me he was a little in denial. He finally owned up to some constipation and weight loss. I could fix the constipation.

            I was getting ready to leave, and Mr. Hillier walked me out onto the front porch. We were alone again. It was obvious he felt comfortable talking to me. I think he also knew he had revealed a lot on a first visit.

            “Tell me,” he said, “do you like sex?”

            “Sure,” I said.

            “Are you married?”

            I said no.

            “Well, good god, man, it’s time to get busy,” he said.

            I’m not proud of the fact I have had relations with women outside the sanctity of marriage. I would like to have a strong belief system and live by it. It is a curse to be sarcastic and question the value of every institution on the planet – from the police bureau to hospitals and organized religion.

            Yet, I had to laugh. A tall athlete, with a flat stomach and nice breasts, had sweated over me for half an hour the previous night and then I had drifted off into the most satisfied sleep. And this man asked if I liked sex.

Chapter 12

            I liked Mr. Hillier, and I think he has known the best and the worst of life. The Hilliers have two children. The oldest, Bob, is an executive at an airplane manufacturing company with a loving wife who watches out for Bob’s parents. The second son, Pete, is not unlike his father, tall and skinny and frankly, not educated. He owns his own landscaping business and his wife, Gracie, a nurse’s aid, is quite overweight.

            I learned a lesson with the Hilliers. All family members must be kept abreast of what is going on. When we had pain-control problems, I talked to the patient and his wife, then the doctor, and then to Bob’s wife. We started him on a low dose of an opiate pain medication, along with laxatives, and he did OK for a few days.

            Then, one Monday morning, I got a call from Mrs. Hillier saying her husband rated his pain 10 on a 1-10 scale. I said I would visit.

            Pete’s wife, Gracie, the daughter-in-law and nurse’s aid, had taken Mr. Hillier off the pain medication Sunday night because he was too sleepy. Now, she was not around when he talked about the pain, or when we set up the plan with the pain medications and the laxatives.

            “I’ve seen too many people stopped going when the doctors put ’em on pain medication,” Gracie told Mrs. Hillier.

            This is when we had the first family conference. The Hilliers, the sons Bob and Pete and their wives, and Bob’s daughter and son and Pete’s two sons all attended. And every one of them talked loud, which was shocking and hilarious to me. When Bob’s daughter spoke in the same loud voice Bob had been using, I had to suppress the urge to laugh. Then Bob talked again in that same loud voice, and then his wife. I mean, if most people talk at volume 3, they were talking at a 7. It was amazing. There was the loudest talking in that family living room I’d ever heard. “It’s the Loud family.” The Simpson’s TV show never had anything on so funny.

            I learned my lesson, though. Now, even though it takes a little more time, I try to talk to all family members instead of just the patient and maybe the main family member. I don’t always have the time to do this, but it’s funny, sometimes just a few telephone calls to answer questions saves you so much work. And saves the patient some discomfort.

            “When we had to increase Mr. Hillier’s pain medications, he was sad. He asked if he was developing a tolerance to the medication. He didn’t like the idea of being addicted. I said, unfortunately, when we increase someone’s pain medication it’s usually because the cancer is worse, not because they are developing a tolerance.

            Cancer grows exponentially (2,4,8,16), not sequentially (1,2,3,4), so when it takes off, the symptoms can be extreme.

            “You know, I’ve been praying to be cured,” he told me. He was a religious man, and I think he felt a little betrayed. All the work he’d done for the Lord, all the evangelical outreach, and now his prayers weren’t being heard.

            “If Jesus answered the prayers of all the people who wanted to be healed from illness, the world would be full of people,” I said. “Maybe Jesus has something better in mind and your prayer is not being answered in exactly the concrete terms you’re looking for.”

            Mr. Hillier smiled at me. “It’s not the dying that bothers me,” he said. “It’s the getting from here to there.”

            I nodded. It’s a sentiment I’ve heard expressed a thousand times

            Mr. Hillier ended up in a nursing home. His wife couldn’t take care of him at home once he lost the ability to walk and Gracie said she was not up to the challenge of helping her. At the nursing home, the staff asked for a family conference and the social worker set it up. The entire family was there, including the grandchildren. I know Mattie Green and the staff were shocked to hear everyone talking so loudly.

            I sat back and watched the show. The family talked derisively about the nursing home staff for some time. I was pretty sure Gracie was behind it. It turned out, after some complaining, the issue that was bothering the family most was that the patient was sleeping more and more.

            The patient took this question, and everyone listened. He said he couldn’t cut back on the pain medication, and he was too weak to ever walk again. He appreciated everyone’s support but he knew he was going to die. The family was sad and the snipping about the nursing home staff stopped.

            Mr. Hillier died three days later. His wife, sons and grandchildren visited every day. He disliked being in a nursing home, but he was comfortable and had help going to the bathroom. Knowing how rough death can be, I considered it a good outcome.

            I think the family thought of hospice as a necessary evil. The patient got weak and painful. The whole thing was distasteful and obscene.

            The funeral was as enjoyable as my conversations with Mr. Hillier. It was held in a big church and the fundamentalist pastor did not hesitate to try and save people. Mr. Hillier would have liked it. At one point, everyone told stories about Mr. Hillier. He had worked at a golf course for years, as a groundskeeper with golf privileges, before having children forced him to get a better paying job at a lumber mill. He handed out church brochures as tips in restaurants, which caused everyone in the congregation to have a good laugh. This secret seemed to be well known to everyone but me.

            He was a man I thought about sometimes. I liked to think of him as a young man on nice days out on a golf course, hitting a few nice shots and thinking he was close to making it on the pro tour. A nice dream. He told me he had sex until late in life, so I guess he got his share.