Tuesday, September 30, 2014

Supporting Mom through the Night of her Death had Similarities to Assisting Mothers in Labor

My little Mom died this morning at 5:58 a.m. The night reminded me of my years of attending women in labor. Intense and personal, I think her death "went" as well as it could have gone.

Mom and Dad - married for 50 years.
He died over 20 years ago.

My mother was nearly 97 - healthy up until April when she had two falls resulting in three fractures, and the need for a change in care from Assisted Living to an Adult Family Home. She was hospitalized a couple of months ago with a urinary tract infection - which highlighted the degree of her declining kidney function. (She was admitted with an eGFR of only 11, improving to the high 20's by the time of her discharge - and after considerable rehydration.) We all knew that Mom couldn't sustain this degree of hydration. She hated being in the hospital, pulling out her IV and begging to know, "Why are these women trying to hurt me?"

My sister and I decided to involve the Palliative Care/Hospice Team. They'd provide the care that could be provided in the Adult Family Home, with the intention of delivering comfort - not cure.

Mom holding me in 1951, with sister Bonnie looking
"delighted" about my very existence!


Mom was treated as an outpaient for another UTI. Then, about 10 days ago, she began to show more confusion - and an ominous loose cough. This was pneumonia. Strong antibiotics, adjusted for her decreased renal capacity, didn't work.

The cough grew more tenacious, and Mom grew weaker. She pushed away the oxygen that was offered, and pursed her lips together when food and fluids were attempted.

On Sunday morning, my mother told me I looked pretty (something she wouldn't typically say). She had sweet visits with my sister, her granddaughter Michelle and great grandson Mason - and, of course, with my son Tim.

Great Grandma Florence gets a visit
from Mason
But early Monday morning, Mom had no more words for me - just a sad straight-ahead gaze. Her focus was locked on the work of breathing.

I moved through my clinic day, seeing patients and checking in with my sister by phone. I arrived at the Adult Family Home at 8 p.m. Mom looked more "serious" than she had that morning: still no eye contact. Everything she had was invested in breathing. I settled in for the night - just as I often did when I was delivering babies.

I delivered hundreds and hundreds of babies over a period of 18 years - and I had been an OB nurse before that. There are observtions I made in those days that seemed to fit last night's process. For example,
  • Birth has its own timetable; there are visual, verbal, and kinetic clues you learn that go beyond knowing the degree of cervical dilation.
  • There is a single-mindedness you see in a laboring woman; there is little attention directed externally.
  • Birth has a rhythm, a pace of its own; except when intentionally stopped, labor pushes ahead.
  • Labor and delivery can be approached by helpers with love and kindness, but it can also be a time of supreme vulnerability.
Last night, I could see and feel the clues; my Mom was in a different type of labor. Her body changed as the process chugged relentlessly on. Her skin became more transparent. There was no external focus. The sounds of her labored breathing reminded me that there was no turning back. We were on the timetable of dying now.

I remember one woman in labor who stood up and announced at five centimeters, "I'm going home, right now. I don't want to do this anymore."

But just as in that situation, turning back wasn't an option. The only way out of this was through it.

The small doses of morphine deposited under Mom's tongue helped settle her breathing. Stroking her fine hair seemed to help, too.

Then I sang some songs: "On Christmas Morn" written by my friend Bob Bost, and "The Moon Keeps Me" (Through the Night)" written by my friend Rebecca Cohen. Finally, an old hymn I remembered from my childhood church choir:

"High o'er the lonely hill, black turns to gray.
Birdsong the valley fills, mist folds away.
Gray wakes to green again.
Beauty is seen again.
Gold and serene again, dawneth the day." (or something like that)

Another half dose of the blessed morphine, and Mom's face relaxed into calm - maybe even a tiny smile. Her breathing shifted again - now soft; not the exhausting, pulling breaths that had forced her tiny upper body into spasmodic contortions.

And then, at 5:58 a.m., it was quiet in the home.

She was beautiful; she was strong. She had gotten through her labor, to some other side. I think we made good choices in advocacy and love.

Take care,
Linda Gromko, MD

Friday, September 19, 2014

Fargo Trip Brings Important Information: Fatal Vascular Access Hemorrhages

I was invited to speak at the 13th Annual Sanford Kidney Services Nephrology, Dialysis & Transplant Symposium September 17. My topic - one of my favorites - was "What My Husband's Kidney Failure Taught Me About My Own Profession."

But I also had a chance to listen to several speakers before returning to Seattle. One was Lynda Ball, MSN, RN, CNN - who spoke about the alarming topic of "Fatal Vascular Access Hemorrhage." Can you imagine?


Here are some important take-home points from Lynda's talk:
  • Fatal vascular access hemorrhage accounts for 0.4 to 1.6 percent of all ESRD patient deaths annually (230 episodes annually in US)
  • 75% had access complications within 6 months (meaning there were some warning clues)!
  • The majority of these events occur away from a dialysis facility, e.g. SNF, home, jail.
Lynda stressed the importance of evaluating the patient for access complications such as stenosis, ulceration, infection, and non-fatal hemorrage. She reminded us that it's important to ask the patient, "Have you had any bleeding at your access site since your last dialysis?"

Aneurysms in a fistula can occur from repeated punctures in the same location. The skin can become shiny and smooth, but it is also stretched. The patient is likely to request a puncture at this site because it hurts less - but the skin can become thinned, and can rupture like an inflated balloon!

Any skin breakdown, ulceration, infection, or prolonged scabbing at the puncture site should prompt further evaluation.

Emergency measures in the case of spontaneous access hemorrhage include:
  • Direct pressure
  • Elevation about heart level
  • Calling 911.
Good to know.

When I speak in various locations, I'm impressed with the hard work and sincerity of the people who work in the area of dialysis: people who are clearly trying to make things better for people traveling this tough road of CKD.

Take care,
Linda Gromko MD
PS - Please take a moment to look at my medical practice's updated website: www.QueenAnneMedicalAssociates.com.