The New Normal

The process of dying, I have come to realize, is a procession of "new normals"; much like aging, but at an accelerated pace. It's frightening to look back at what my aunt could do three months ago and where she is now: bedbound and unconscious. It happens in stages.

- She went from needing assistance to walk, to a walker, to a wheelchair.

- When she first came to stay she was able to go upstairs and to shower by herself. First she lost the ability to climb stairs. We cleaned out a room used as an office on the ground floor and she moved in there. Hospice provided an aide to help her shower; that came next. 

- The bathroom. One morning she was standing brushing her teeth, turned around, lost her balance and fell (I was standing nearby and was able to catch her; no harm was done). After that I insisted that she have an escort to the bathroom. Then she needed full support. One morning as I was holding her she could not take one more step. After that it was the bedside commode. 

- Being able to stand. For a long time she insisted on eating breakfast in the kitchen and going to her chair in the living room, but in the past two weeks she has been restricted to her room. Using diapers was the last taboo; she required three people to get her out of bed and on/off the commode and to dress/undress her as she could not support herself.

- for the past week she has been minimally responsive, gradually becoming unconscious. The medications (morphine, lorazepam) have helped a lot. She fought their use for a while, as she had been a very successful member of a twelve step program for decades; but we kept explaining patiently that there was no reason for her not to use the medications. The pain finally convinced her to agree to their use.

Now we wait. I believe she has only hours left. Helping someone to die at home is incredibly difficult but also rewarding (especially given that, had she been placed in a facility, she would have had no visitors or independence; I think she would have died much sooner). 

I'm too tired to say anything else right now.

Labels: Cancer, Family

 Roses

My aunt loves roses and grew them in her backyard in the desert. (There are heat resistant roses available; a neighbor of hers once insisted on growing English roses, spent a fair amount of money on them and then watched them die in the heat and relentless sun.) Her friends who have come to visit have cut and brought the blooms with them. The living room smells of roses. 

Yesterday she developed chest pain, likely due to the tumor infiltrating into her chest wall. She is now on regular doses of morphine and benzodiazepine (for the anxiety and agitation). Hospice is coming daily. She is taking liquids by mouth but very little food. 

We vacillate between long hours of nothing as she sleeps punctuated by a concerted effort to get her to the toilet, calm her, change her clothing. I pass the downtime by cleaning the kitchen and clicking from Facebook, to Twitter, to email. The house is hushed. It is a waiting game now. 

I hope her passing is peaceful. 

Labels: Cancer, Family, Medicine

 The Dying Patient

They don't tell you what it's like to be with someone who's dying. As in, being there all the time, day in and day out. Sometimes I wonder if even the hospice doctors and staff know. It isn't that they are not kind. But the nurse, who currently is coming twice per week, checks vitals and asks about bowel movements - "Do you have any questions?" and then she is out the door within 15 minutes. I do not say this to criticize, as I have done my share of such visits. But after a while it is hard to know what to do or say, how to pass the time when not focused on such minutia. 

My aunt is suffering. Not to say that she is in pain, but she is a very social person and has always been someone who likes to stay active and do things. At holiday dinners, rather than sitting around with a cup of coffee she was always the one cleaning the kitchen or getting the meat off the turkey carcass. Now she is too weak to walk and too confused to focus. She cannot get much enjoyment from reading; cannot remember which of her friends has called her from hour to hour. Her sole consolation is conversation and I am not the best source of that. I have tried to think of entertaining topics but have long since run dry. My father is too demented to talk to her and my mother is too hard of hearing; plus my aunt has suffered vocal cord paralysis due to the tumor and can barely make herself heard.

Two days ago she told me she wanted to pursue assisted suicide (I think the preferred term is "assisted euthanasia" these days). Her first discussion with the hospice doctor is scheduled for tomorrow. I don't see how she could not qualify, I just don't know whether she will be able to last the next two-plus weeks until all the criteria are met. We should perhaps have discussed this sooner, and I feel badly about that now. I told her that once again she was a groundbreaker, as she has been so often in her life. 

She was raised in a small Southern town and went on to teach as a career - not much else was open to women in those days. Her first marriage, the product of elopement, failed shortly after she moved to Alaska (her husband was transferred there). She went on to marry again, and eventually left her second husband for a female partner. That relationship lasted 25 years. She successfully fought cancer once and then developed lung cancer more than ten years later. She has traveled, volunteered, has made many friends and excelled at entertaining them. 

Religion is not a consolation for her, she puts her trust in friends and enjoying life. She has outlived her prognosis by nearly three weeks, but I don't know how much longer this is going to go on. All I can do is to be here, and it is humbling. 

Labels: Family, Medicine, Random Thoughts

Therapy Session

Back I am at the blog, in search of counseling. Did I mention that this blog serves as my makeshift therapist? I visualize it as female, of no particular appearance, leaning forward, professionally caring but geared to forcing the truth out of me. 

Then we sit and look at whatever this truth is. 

Well, (I brace myself,) the past month has been a little tough. It's indisputable that my father's dementia is getting worse. His sister called last week to speak with him and then asked to talk to me; she wanted to know how he's doing. He can't really carry on a conversation any more, though he is always glad to hear from her. I think he had another stroke about a month ago; he has to be coaxed to eat, and often falls asleep during breakfast or dinner. He can't tell us when he has to go to the bathroom any more and is often incontinent without being aware of it. In addition to that my aunt, the one with metastatic lung cancer - remember? She's on hospice now - is becoming weaker and weaker. She is eating less and her weight loss is accelerating. A few weeks ago I made the decision to move in with them, and I've been staying there more or less full time. 

This means I won't be seeing patients for now. Not that I was seeing many, just one four hour shift per week, but it was something. It made me feel like a doctor again and not just an overloaded daughter, gave me a chance to dust off my skills rather than letting them atrophy. Even virtual visits are not an option, as it has become impossible to spend four uninterrupted hours online due to the needs of my parents and aunt.

My aunt is my main responsibility right now. She is becoming increasingly confused as well as having major memory loss (probably due to the chemo and radiation). She isn't able to keep herself occupied with much - she does read but I don't know how much of the book she retains day to day. In an effort to give her variety, I tried to show her how to use my Kindle but she simply could not fathom it, even after I set up a book for her with a large font. She could not remember how to tap it to turn the pages. Physically, she is wheelchair bound and requires oxygen at all times. Even taking her to the bathroom has become a significant journey.

Her friends have been very supportive and have made the drive from the Palm Springs area many times in the past two months to visit. Two came yesterday and two more are coming today; yesterday, two men (partners) and today two women (also partners). The women have a lovely long-haired dachshund that loves my aunt, and my aunt loves her right back. I will miss seeing her today as I had to go into town for an orthodontist's appointment (my treatments are over and I am graduating to a retainer, hooray!)

My aunt has outlived her prognosis, I think due to force of will alone. Major props to her for this. Taking care of her has taught me a lot, as I have never seen major illness from the family point of view before - only as a physician. Eventually I will go back to work part time, and I hope I will take what I have learned with me.  

I don't know whether all of this commentary adds up to anything or not. At least it is a relief to put it down.

Labels: Family, Random Thoughts, The Doctor's Life

 Daytime Television

Spending more time with my parents as I have done recently, I have become familiar with the drone of television in the background. It haunts me on an almost daily basis, to the point that it has become "white noise." I have the weekday schedule of my father's favorite channel nearly memorized: Perry Mason, then Matlock, then In the Heat of the Night, then The Waltons... you get the idea. The afternoon is a parade of Westerns, one after the other: Bonanza, Gunsmoke, The Rifleman. 

In a desperate grab to maintain my sanity I have started deconstructing these shows - at least, some of them. "Perry Mason" is still the king as far as I'm concerned. Yes, the general plot is the same episode after episode, but it has a great noir feel and the cast is just excellent. I can't get enough of Hamilton Burger and Paul Drake, not to mention Della Street - the perfect secretary and co-sleuth. But "Matlock"... ugh. The show was Andy Griffith's late-in-life meal ticket, and I can empathize with that, but it just isn't that good; from the Eighties hairstyles and power suits to the awful overacting, it is nothing short of cringeworthy.

"In the Heat of the Night" was a favorite of mine back when I was a medical resident. Set in a small Southern town, the show featured location shooting which added lots of atmosphere and overall did a good job portraying the daily life of law enforcement. Plus, Carroll O'Connor anchored the whole production as the police chief struggling with the effects of racism on the town and trying to shake his personal racist past. Sadly, on re-viewing the show it is marred by overacting among the weekly characters/suspects and more bad Southern accents than you could shake a stick at. 

"The Waltons" was a favorite of mine back in elementary school and junior high. A low-key drama, it showcased the trials and tribulations of a rural family growing up during the Depression and WWII. It was narrated at the beginning and end of each episode by the oldest son, the first in his family to go to college and who would go on to become a writer; it gave the show a retrospective and nostalgic feeling, sort of the "I remember the time Mama had to go off to the tuberculosis sanitarium" sort of thing. (Yes, that was an actual plot.) It's a comforting sort of show, but after a while it just became tiresome plus the child actors started aging out of the cast after a few years. Sometimes I like to imagine it's set in a postapocalyptic future, where Walton's Mountain is salted with booby traps and the family is living on squirrels and coffee... but it's hard to see that there would be much difference.

On to the Westerns. Not much to say here, they're all alike really. I have realized over time that Westerns are just soap operas with the addition of gunfire. "Bonanza" seems to have more variety than the others, but it all comes down to Hoss being clueless, Little Joe getting framed for murder or Adam lecturing the townsfolk about the importance of being more openminded. "Big Valley" has it all over Bonanza as far as I'm concerned. 

And then there's Adam-12. This was a Jack Webb production, similar to "Dragnet" in that it was a salute to police and their service to the public. The difference here was that the cast was younger and better looking, two earnest whiter-than-white guys in a patrol car driving around Los Angeles all day dealing with all sorts of stuff during their shift. The show is so dated that trying to imagine the patrolmen thrust into the reality of present day Los Angeles is impossible; the poor guys would get cut down by gunfire five minutes into their shift.

After "Adam-12" it's time for the evening news, returning to the 21st century once again. Not much to be said here, except that when compared to today's news these dated old shows are much more tempting. 

Labels: Pop Culture

Update

Not much new to report here. I have signed up to work in the clinic on Saturdays in March (after talking about it for more than a decade, The Firm has finally opened on Saturdays - another instance of the pandemic changing work patterns). My aunt clinically is about the same, but I don't know how long that is going to last - so I did not want to commit to more than one day per week.

It's been stressful having her here, even though I know it's the right thing for her (and she knows it too). I know she feels isolated and depressed, though at least she is not in a nursing home but with her family. It is just too difficult to talk to my parents for any length of time, given my father's dementia and my mother's severe hearing loss. My aunt and my parents spend their days at opposite ends of the house. I have not been able to come up with a solution, as my parents claim a large part of my time and to be quite frank about it I do need some time to myself if I am not to implode. She has had many visitors, cards and letters and I think that is helpful but it doesn't make up for the fact that she is facing the end of her life. My aunt has asked for a television to be installed in the living room, where she sits; so we are going to be doing that next week. She loves to watch the news, so maybe this will make her feel better. 

My study review materials for the Medical Boards have arrived, so that is something else I need to start working on. I have to recertify every ten years to keep my Internal Medicine certification. It's a couple of years early, but I would like to get it over with and this seems as good a time as any. Formerly the test was given twice a year, but (again due to the pandemic) it has been cut back to once. This will be the last time I have to take the test - but then again I promised myself eight years ago that I would not be doing this again, so there you are. 

I had my colonoscopy done, but unfortunately I have to do it again! I followed instructions exactly but apparently the prep was not sufficient. That mixture you have to drink is the absolute worst. The archaic term for it was "saline laxative" and it works by pulling additional fluid into the intestine. This rinses everything out, so to speak. It contains magnesium, potassium, citrate and other lovely things. You also have to drink a lot of water with it so as not to induce dehydration. 

Lately I have been pondering what to do when I am free to travel again. I would love to go back to Australia, to see the Netherlands and Scotland; but first of all I think I would like to travel Route 66. I'd bring along my camera and seek out some of the old buildings and locations to photograph. The route was decommissioned in 1985, with the completion of the Interstate Highway System, but has refused to die. It has a stature in American lore that I don't think will ever be replaced, partly due to the song, of course, but it is even mentioned in works like "Fear and Loathing in Las Vegas" and, of course, "The Grapes of Wrath."  A sadder bit of travel history associated with it: "The Green Book," a travel manual specifically for Black motorists, listing places that were safe - and unsafe - for them to stay. There were plenty of  "sundown towns" along the route where African Americans were not allowed after dark.

And now I have to figure out my schedule for the week. More later. 

Labels: Medicine, Random Thoughts, Travel

 Ash Wednesday 

I started Lent this year with a more introspective mindset than usual, what with my aunt on hospice and my elderly parents being themselves. (Deaf, stubborn, won't wear their hearing aids, a little confused.)  On Wednesday I had to go into the city in the hope of getting my first COVID vaccine at the hospital - most of my co-workers have completed it already but I was delayed due to contracting COVID in early January, though I feel fine now. 

It was indeed a fine and appropriate Ash Wednesday. The humbling process started early, as my staff ID was rejected when I tried to pull into the hospital parking lot (I had not been there in months, so it had been deactivated). The ID problem duly fixed, I wandered into the building and found the walk-in line for the vaccination. I was issued a ticket and a sticker marked 2/17 (for that day's batch of vaccine), answered questions regarding symptoms (none, thank you) and while in line passed a table stacked with envelopes of ashes for application. I helped myself to one, curious to see how the do-it-yourself penance kit would work. Stood in line for a while and eventually made it to the front, handed in my ticket and sat down with a friendly nurse to answer more questions and read through the information provided (we are using the Pfizer vaccine). The injection was painless; I sat and read my Kindle for the required 15 minute observation period and then left. My next injection is in three weeks and I have an appointment. It's a relief to finally get this done. 

Later that day at home I sat in my room and opened the envelope. It contained a cotton swab with a dab of ashes on it and a slip of paper with a two-sentence reading. I focused on "Dust you are, and to dust you shall return" - thinking of my aunt - and applied the ashes. 

Hopefully this year I will be more focused on Lent than I have been the last few years. As for Easter... we don't know whether my aunt will still be with us then or not. The good news is that the outreach of love and support from her friends has been nothing short of uplifting; come what may, I know I will hold these memories on Easter Sunday.

Labels: Holidays, Medicine, The Doctor's Life

 Caboose Potato Soup

One of my parents' caregivers recently bought us what looked like a job lot of zucchini, as it was on sale cheap. I happen to like oven-roasted zucchini, but my parents and aunt find it somewhat less appealing. So it was off to the Internet, the world's biggest cookbook, for soup recipes. 

I am not a fan of sliced zucchini cooked in vegetable soup; it gets really limp and unappetizing. I gave this some thought, inspired by memories of a trip to Ireland I took with my aunt a few years ago. The hotels there which cater to tour groups do the usual choice-of-three-entrees dinner menu, and the first course was always soup. Described as "vegetable soup," it was not the tomato- or broth-based type you might visualize. Rather it was a pale green puree, a cream-type soup, certainly with potatoes as a main ingredient. It was always tasty.

So I found this recipe and made it, of course with a few alterations: no garlic as my aunt hates it, vegetable broth instead of chicken because that was what we had in the house. For herbs I used the thyme and a small amount of Italian blend seasoning. I did throw in some half and half at the end. It was very well received, and I will be making it again soon. You do cook the zucchini and potatoes until very soft, then puree it which solves the consistency issues you get with long-cooked sliced zucchini. 

My father tasted it and said "My father called this caboose potato soup." Oh, really? I asked for more information and he gave me some family history I had not heard before: his grandfather was a railroad man, working the Pittsburgh-to-Chicago run. In those days of the early 20th century the crew member assigned to the caboose was the designated cook. The meal was almost always a stew or soup, due to limited kitchen facilities on board plus irregular eating hours - this could be kept hot and the crew could help themselves. Potatoes were plentiful and cheap, and make a fine soup base. So this is really more of a soup concept than an actual recipe:

Saute some onions, add broth or water plus a cooked green vegetable (peas, green beans, celery, even lettuce could work here), add the sliced potatoes and simmer; then puree when everything is soft. Add some cream or cheese if you like.  It's difficult to screw this up and it is always good. As a bonus, it freezes well. 

Labels: Ingestion

"What's For Dinner?"

As the chief cook and bottle washer for my parents and aunt I am constantly trying to figure out what to cook for dinner that they might like. I have limitations placed on me: my aunt can't tolerate garlic, my father hates vegetables, no one likes spicy food. I've been doing this for about a week and am perilously close to running out of options. Trying to feed people nourishing food on a nightly basis is not the easiest thing to do.

Dinner last night was a success: everyone loved it. Also it was easy in that most of the preparation was done the night before.  It was roast chicken, but the ingredients and technique were specific: Mimi's Sticky Chicken. Check out the recipe. I can recommend it highly. I applied the spice rub the night before, leaving out the garlic powder and cayenne in deference to people's tastes, and chucked it in the oven the following afternoon. The chicken roasts at 250 degrees for five hours. Yes, that is correct - though I confess that I got nervous and turned it up to 275 for the final hour. It was moist, tender and delicious. 

If you search for "sticky chicken" you will find several quite different recipes, so I appended a link above. We will definitely be making this again. I served it with sauteed spinach, which my father didn't eat; but then, you can't have everything.

Labels: Ingestion

Labels: Family, Pop Culture

 Recent Developments 

I'm trying to blog more. Partly because of the new crackdowns and censorship on social media platforms (namely, F and T), and partly because so much has been happening here, most of it not good. 

I left full-time work a year ago and have not regretted it one bit, though I have been continuing to see patients part time. One main reason I left was my parents' and aunt's ill health. My mother in particular has been in a slow decline for months. Just before Christmas, their caregivers were diagnosed with COVID and my parents tested positive the day after Christmas; I tested positive one week later. Fortunately none of us had to be hospitalized. My father had basically no symptoms, I had the equivalent of a bad cold; my mother had a heavy cough and bronchitis but no fever. All the caregivers were out sick and it was a very rough two weeks, but things are much better now. 

Unfortunately my aunt has metastatic cancer and without giving details, she is not doing well. I will be staying with her to provide support as she tries to make a decision about stopping treatment. Ironically, my COVID infection could not have been better timed; I'm bulletproof now, at least for the next few months, and am no longer infectious. I tested positive 17 days ago.

The inauguration is tomorrow, I have no plans to watch. I am honestly disappointed with the results of the election. I don't see things going well, what with immigrants on the march from Central America and the president-elect's plan to shut down the Keystone XL pipeline (what the hell is that about?) - and the New Management hasn't even been sworn in yet.

As for the immigration issue, I have one word: COVID. Uncontrolled immigration into Southern California and other areas of the Southwest US, already a hotbed for COVID infection: what could possibly go wrong? Or to put it another way, how is our already overloaded health system supposed to cope with this? No one has thought to ask that question so far. 

I'm going to sign off for now and try to find something else to think about.

Labels: Medicine, Politics, Random Thoughts

Another Mystery Series

Over the past ten days I have taken advantage of being in quarantine by reading my eyeballs to stubs. One of my favorite websites, Ace of Spades, has a weekly book post from which I have benefited many times: the book recommendations are always worth paying attention to. Recently someone on the site mentioned the Liturgical Mysteries series by Mark Schweizer and I wholeheartedly recommend these books.

The series is set in a small town in the mountains of North Carolina and narrated by Hayden Konig, the town chief of police who doubles as the organist and choir director at St. Barnabas. In his spare time the chief, a rabid Raymond Chandler fan, bends his efforts to writing hardboiled mystery novels. He even went to the effort of purchasing Chandler's typewriter at auction, refurbishing it and using it to write. There's just one problem: He's a terrible writer. 

The books are great. Vivid characterization, scathing religious satire, hilarious town developments, terrible puns and erudite musical and theological references which sail right over my head - they have it all. It is rare that I laugh out loud when I am reading, but every book in this series has made me do exactly that. And the mystery portion of the plots are really good. Do give these a try - you won't regret it. $2.99 apiece on Amazon, if you have a Kindle.

Labels: Books, Episcopaliana

Labels: Los Angeles, Medicine, Science, The Doctor's Life, Twenty-First Century Crap