I recently had one of those rare days of picking up a shift on the Palliative Care team at our local hospital. At the end of that day I knew I needed to write about it. So now I have and I want to share it with you.

We begin our day by standing in on the Critical Care rounds, hearing about each patient and what the plan of care is for the day ahead.

We are a small hospital by many standards. All 10 of the ICU rooms were occupied, some with patients more critically ill than others and one by a child, barely 3 years old. We were not asked to get involved with any of them so we started by visiting patients who had been seen by the team the previous day who were in the less critical rooms. 

As we walked to the room of a 52 year old gentleman with advanced liver failure the provider on the team filled me in on how she had left things with the family the day before. The plan was to get him to his daughters home and admit him to hospice. His daughter and her mother, the patients ex-wife, had been caring for him up until his admission 2 days prior. Yesterday, when he'd had his initial consult, he'd been talking and answering questions appropriately, seeming to understand what was happening. 

When we entered the room the daughter was standing by his bed and he was half in, half out of the bed, his belly fully and uncomfortably distended, he was deeply jaundiced, hands and feet slightly swollen, on his back snoring loudly. His head had lolled off the pillow and was cocked at what looked to me like a very uncomfortable angle, opposite the direction that his legs were hanging off the other side of the bed. He had several days growth of beard and his hospital gown was tangled around him. His nursing team was there preparing to move him to another room. The daughter could have visibly been wringing her hands and she wouldn't have looked any more distraught. She seemed young and clearly relieved to see a familiar face from the Palliative Team visit the day before. The two nurses told us not to mind them, to just pretend they weren't there but that was impossible. The room was very small and for every move they made, one or both or all 3 of us had to make an opposite move. It was momentarily chaotic and personally uncomfortable. 

Not long after we arrived the nurses excused themselves and just asked to be notified when we were done.

The clinician I was working with told the daughter that the case management team was working on getting him home and admitted to hospice all at the same time but that we still didn't have a firm commitment from hospice that they could admit him. The daughter was so gracious and gently explained that she would be with him wherever he was, that she wanted to care for him at home and if he needed to stay here until that could happen, that would be alright as well. I told her we were not 'kicking' them to the curb, that we would never ask someone to leave who could not care for themselves without knowing they were going to an environment that could provide the necessary care. Her shoulders visibly relaxed and she let out a big sigh of relief. We explained what we were seeing and said our top priority for this day would be his comfort. 

The clinician then very compassionately said she thought he would probably die in a few days to possibly a week.The daughter accepted that information and just rested her hand on her father's head. I did not speak into that because I have learned over the years that it is a slippery slope but my gut said this man was going to go very soon. We were happy he was being moved to a larger room, a room that we often try to put end of life patients in for the comfort and ease of the family as they gather. The daughter had mentioned that her dad's two older sisters had traveled from Mexico and would be here shortly. We notified the nurses and as they were moving his bed to his new room and the daughter was quickly scooping up items from around the room to move with him, we assured her that we would be checking in frequently with updates and just to see how they are doing.

We ordered a comfort cart for his room and I asked the daughter about her dad's spiritual life. She said they were Christian and she was calling their minister to come offer him an anointing. 

I left them then and went on about my day, doing odds and ends, connecting dots, arranging for things that might make our patients stays a bit better.

One of those was calling my husband to ask who I needed to call at our local fire station to see if there was a chance they could bring one of their fire trucks to park outside of a little boys room with their lights on. Greg sits on our rural fire board and I knew he would know who I should start with. 

I had had a random exchange in the hallway with him and his parents as they were walking around looking out windows and I had asked if he might like to have a visit from a fire truck. This was the 3 year old from critical care. It was a bit tricky to arrange because there were tests being done and his parents wanted to keep him to as normal a schedule as possible which also meant a nap from 1-4 but we got it done and they said they'd come at 4:30 sharp. It's one of so many reasons I love living in a small community, being able so easily to help make simple things happen that feel like magic to the ones on the other end. 

At about 3:30 I was sitting by the fireplace in the lobby just off the elevators on fourth floor chatting with this little guys mom, when the daughter of the man I spoke of earlier walks by crying. A tall young man has his arm around her, she and I make eye contact, I stand and she falls into my arms sobbing quietly that her dad has just died and she was going to the lower lobby entrance to bring her aunties upstairs. I told her I'd meet them in his room. I excused myself and walked the long hall to his room. The see-through shades had been lowered creating a soft glow of late day sunlight. The room was quiet and felt peaceful. There were two other people. One was a young man on his phone and the other was a woman I thought might be the ex-wife. Almost immediately the daughter came back with two small beautifully weathered older women, both of them crying. She had her arms around them and walked them to his bedside. Then she came to the window across the room where I was standing. The young man she'd been walking with was still with her and she introduced him as her son, the oldest grandchild of the man who had just died. I laid my hand on his arm and said “I'm so sorry”. Then I asked him, “Were you close?” and he gave one of those laugh/cries and said, “Absolutely. He was my guy. He practically raised me”. I said, “I'm so glad you were here with him and here for your mom” and he said he was too.

We are watching and listening to the 3 elders around his bed. These three women who all just lost someone they have long history with and deep affection for.

I marvel at their ability to express grief through keening and rocking themselves. It was such an honor to be there to see that. 

The daughter and her son are quiet. We are watching the 3 women and I ask the daughter if it is alright for us to talk a little bit. I assured her and her son that there was no need for me to do anything for the 3 women, that they were doing exactly what they needed to do. She acknowledged that she agreed with me and said it was fine for us to talk quietly.

The daughter and her son were the only english speakers in the room. 

She looked exhausted and lost. I asked her what her dad's wishes had been, what he would have wanted her to do now. She said that he had told her many times, “Do not take me back to Mexico. It's too exspensive and too risky for you.” She asked me if I knew what the rules were and how difficult it would be and I said I didn't but that the poeple at the funeral home would know. I said I would imagine he would need to be embalmed and that I was sure taking a body back to another country is always possible. She was watching the women at his bedside, weeping and laying their bodies across his. She told me that he was one of 9 kids and that all the rest of them were in Mexico and she cried out that she couldn't just show up with a box of ashes and say “Here's your brother”. This young woman's angst was raw and real. I told her that no one needed to make any decisions about anything right that minute. That she and her family could stay with him as long as they needed to. I would let our staff know that they aren't ready to make decisions because they didn't even know which funeral home they might want to call. She thanked me and we turned our attention to the bed again. I asked if the two sisters were older sisters and she said they were the two oldest ones of the 9. That they had cared for him since he was born and she was so happy for them to get to be here with him. Assuming from that, that they had bathed him as a baby, I asked her to ask them if they would like to give him one last bath, to clean his body one more time in preparation for whatever is next.

She approached them and spoke to them in Spanish and they looked over at me eagerly shaking their heads yes, yes. Chills ran down my arms to my toes. After some more words were exchanged the daughter came back to me and said they would very much like to do that and had asked if all the tubes could be removed first. I said I'd check but couldn't think of any reason under these circumstances that we couldn't disconnect his IV's and remove his cathter.

I left their room and told his nurse what they'd like to do and asked about what they'd like to have done first. She jumped right up and said oh yes ma'am we can do that and asked two care attendants who were there to please get some towels and wash cloths, a razor and anything else they might need. 

Back in his room, things were quieter and while his nurse tended to the sister's request, I stood by the daughter again leaning against the window. She was crying quietly and said, “None of the rest of his family ever got to say goodbye. How can I just take a box of ashes to them?!?”. I looked over at the women preparing to bathe her father and said, “You know, I'm going to go out on a limb here but you could document what is about to happen. You can take pictures or even make a video of these two loving elders and your mom bathing him. Let them see this incredible thing that is about to take place. Then, perhaps going to Mexico with just his ashes will feel like enough.”.

She smiled and said “Yes. Thank you. I will do that”.

I knew that they would take this time to do some critical and necessary emotional work and I wanted so badly to be a fly on the wall and watch it unfold but I excused myself, partly because it is an initmate and private experience and partly because my phone had been vibrating in my pocket all through this exchange. I say my goodbyes, offering my condolences once again and I leave. The calls were from the fire dept saying they were leaving the station and on their way.

I walk to ICU when suddenly all the fire alarms in the hospital go off. A text comes immediately saying they will be delayed with the surprise while they sweep the hospital to be sure there are no fires, which there were not. I explain all of this to the parents of this sweet child and we all do our best to distract him from the fact that he is in the hospital, tied to an IV, doesn't feel very well and now is being asked to wait, (not a toddler's strongest suit) when all of a sudden a huge ladder truck roars into view and stops right below his window, with all of it's lights going. The driver comes around the truck scanning the fourth floor windows until he sees the reason he's there. 

A small hand in a big window.

This was such a touching way to wrap up a fully incredible day. Watching that little hand waving, as much to the truck, as to the man driving it. So, I'm backing away to leave when the door to his room opens and TWO firemen enter. They fill the room. One is dressed in official clothes like dress blues but the other one is dressed in full fireman stuff. The only thing missing was an oxegyn tank on his back. He kneels down by the couch our patient has been standing on to see out the window and starts talking to him, telling him about being a fireman, showing him his uniform and his hat. I was so overwhelmed with gratitude for the generosity of thoughfullness they were showing to this family. And probably overwhelmed with the situation I had just left. All I could do was stand there with tears running down my face. A very mixed bag of tears.

The firemen only stayed a few minutes. It was perfect. I walked them out, thanking them over and over again.

This actually isn't the total end of the story but it's enough for now. It's enough to show the depth of compassion people are capable of when someone simply makes them aware of a need.

A larger room for a dying man.

A cart with food and water for his family.

Warm water and towels for the sacred ritual of bathing the one who has died.

A visit from a fireman to help ease a child's anxiety.

I know I have a privileged life. Living where I live. Loving the people I love. Being loved by the people who love me. We do not live in a big city where too many people can become invisible. We live in a place where I often say, this is what Hillary Clinton meant when she said, “It takes a village”. This is a village I hope I am part of for a long long time.