Tuesday, February 23, 2010
So there I sat, flipping through the songbook, singing songs for two pts who were mentally in another place, and a third pt who would’ve smiled if I played Schoenberg or Metallica.
I was concerned that our little pt with the crossed arms. Last time I saw her she was so happy to hear the music and smiled so sweetly. I went over to her and sang unaccompanied by her side. I gently touched her arm, but she only tightened her grasp around herself. She squeezed her eyes tighter than they already were. I thought maybe my singing was that awful that I made her squeeze her eyes shut and pull away from me, but she was in that sort of mood when we first arrived, so I’m hoping it wasn’t my singing… However, if it wasn’t my singing, then it probably means she was upset or in pain, which is even worse than her hating my singing.
I returned to the piano and flipped through the songbook some more. As I flipped past the last page of the “Traditional” section, I panicked. I had entered the children’s section of the book! I don’t know what else to sing! That’s when I found “It’s A Small World.” I thought this was perfect since Disneyland is only a hop, skip, and a jump away. I opted out of playing anymore piano, and just turned around and sang directly to the pts. I asked them if they had ever been to Disneyland. No answer. The dear pt who was continuously smiling was wearing a Winnie the Pooh sweatshirt, so I asked if she had ever been there. I told her that Winnie the Pooh was there, and Tigger too; as well as Mickey Mouse, Minnie Mouse, Cinderella… our silent pt looked at me as if I was naming famous Norwegian scientists, or other names she’s never heard of… and my other pt was just as closed off as before.
“…it’s a small, small world!” I said to the pts, “Isn’t it a small world? It’s amazing how you can find similarities with almost anybody. See, you two both decided to wear pink today!” No response. I gave up. I thanked them for letting me play music for them today, and said individual good-byes to our two pts. I told our little Japanese pt that I hope she gets lots of rest today. Then I left (even though I felt like I was escaping!)
When I found the MT, she was just finishing with her pt as well, so good timing on that front! We went to the office upstairs, charted on our pts, and went on our way. I thought it would be easier playing for the pts with dementia, as they are probably less quick to judge, but boy was it hard! I felt so foolish! I want to say I made a positive impact on their day, but I don’t know if I really did… with no feedback at all from the pts, how do you know if you made a difference?...
Since we’ve had a lot of new admits in the past couple of days, I went off on my own (eek!) to see a pt we’ve had for awhile, who is now actively dying, while the MT went to see our new admits. So back to the SNF we were at yesterday I went. I honestly was not nervous at all to go see my first pt by myself. She was pretty unresponsive the last time I saw her, and I figured she’d be in a deep sleep, so all I would have to do is play some soft music on the guitar for her to help her be at peace, and to know that someone was there for her and to comfort her. Well, to my surprise, the pt’s family was there gathered around her. “Oh, you’re going to play music? How nice!” the pt’s daughter said. “Now do you do this as volunteer work?” “No,” I said. “This is my job… or at least will be. I’m a music therapist. It requires schooling and a degree.” She looked lost for words for a moment. “Oh, how nice,” she said with kind sarcasm. The pt’s son found me a chair and placed it by the pt’s bed. I sat down with my guitar as her family anxiously stared at me, full of pleasant curiosity. All I could think about was choosing songs the family would approve of and calming the pt, while still defending my profession and proving that no, this isn’t just some volunteer gig! I finger-picked some through some chords till I found a key that would be good for “Amazing Grace,” my new go-to song. I could hear the family behind me keep saying, “Oh isn’t this so nice?” And of course, more family members arrived, as if I wasn’t nervous enough already. I haven’t been playing guitar much lately, so the strings felt like they were resting on my bones. So much for these callouses that do a whole lot of NOTHING! After some “Peace Like A River,” I threw in some “Kum Ba Yah” and privately dedicated it to my dear Uncle Tommy since it’s his favorite music therapy song.
After about five more minutes of playing, I got out the songbook and gave it to the family. I said they could pick out a song that they think she would like. The son asked if I knew any Italian songs (if you knew the pts last name, you’d know they were obviously Italian.) I told him that other than that song they always play at the Olive Garden, my Italian repertoire is rather limited. He laughed and said it was okay. (Note to self: learn some Italian songs!) The daughter said she liked Christmas songs, and suggested “Silent Night.” Thank you! A request for a song that’s easy, and that I know all the words and chords for!
After a couple Christmas tunes and another run through “Amazing Grace” upon request of the daughter, I gathered my things and went on my way. Before I left, I told the family that if they needed anything to not hesitate to call us, and that we’re here not just for the pt, but for them as well. They graciously thanked me, and I graciously left, glad for it to be over.
I don’t want to come off like I don’t enjoy music therapy. It’s not that at all. It’s just nerve-wracking starting out, and I’m not very confident in my skills as of yet. I actually didn’t think I’d be seeing pts by myself till the 3rd or 4th month, so the fact that I agreed to going alone surprised even me! But anyway, just please know that when I say I was glad to leave a pt, I’m just relieved to not be under pressure anymore. I really do enjoy playing for the pts and interacting with them, and I can’t wait for the day that I feel confident in what I do and the pressure and nervousness goes away.
So, now to an in-service and IDG meeting, the fun part about this job :-P
Monday, February 22, 2010
I spent most of the morning on the phone with IS/trying to log onto my new mini HP laptop. Everything has its own password and code and this and that and nothing was working! I think I’m at least closer to having everything figured out technologically speaking.
After messing with computer logistics for over two hours, the MT and I went to see a pt who is now actively dying, upon request from the nurse. This pt is the mother of the pt we saw on Friday (we sang Christian hymns with her; she is being ‘graduated’ from our services.) The pt’s niece and daughter were present. We sang as many spiritual tunes we could think of. The daughter even sang with us, beautifully harmonizing on the spot. We sang “Amazing Grace,” “Swing Low, Sweet Chariot,” and a few others. I sang “I Can Only Imagine” since it was a Christian song I knew pretty well. (I didn’t realize how fitting the lyrics were to a hospice setting until as I was singing it to her! “Surrounded by your glory, what will my heart feel, will I dance for you Jesus, or in awe of you be still, will I sing Hallelujah, will I be able to speak at all, I can only imagine…”) The MT asked the niece if we could sing “Jesus Loves Me,” and the niece told us that she’d love it – she used to sing it all the time to her grandchildren. The MT then dedicated the song to all the pt’s grandchildren, and new great-grandchild just born today, and also, to all her loved ones.
The niece and daughter expressed their gratitude for us coming to see the pt. The daughter showed us the pt’s bible. On the back page, she had written a list of songs which the daughter believes is what her mother wants played at her memorial service. I wrote the songs down for us to reference later, and the MT offered for us to learn some of the songs for the next time we see them.
The two talked to us about looking at death in the light that the loved one is leaving this world to go to a much better place; that their mother/aunt has been waiting for this moment for 70+ years – to be with God in Heaven. It’s obvious that this family’s particular coping method is focusing on their faith, and that their loved one’s soul will be taken somewhere perfect, and it will be better for her to be in Heaven, with all the loved ones who have gone before her. In contrast, the MT believes that the pt’s other daughter, our former pt, is coping by believing her mother’s personality has already left; that all that’s left behind at this moment is a body stricken will illness. Since she herself cannot be there to help take care of her mother in her final days due to the limitations her own illness places upon her, she chooses to believe her mother mentally isn’t there anyway. The MT and I are not ones to judge whether the pt’s persona is still present or not, but she did open her eyes a number of times while we were playing music for her, and the nurse claimed the pt still responds to questions being asked. All in all, everyone we’ve seen, family and pt, seem to be coping in some way or other.
Although I’m still uncertain as to where my own personal faith lies, it seems a little too ironic and pre-conceived that within the same family, a baby enters the world right as a loved one passes on… a beautiful work of choreography on God’s part from the Christian voice within me.
Around 12:30 we visited a nursing facility where we currently have three patients. The main gathering space was brightly lit by large chandeliers and natural sunlight. In the far corner of the room was a beautiful upright piano, of which I had the pleasure of playing. As I sat down on the wooden bench, I flipped through my book of classical music. I soon realized how many songs I’ve been meaning to learn, but just never got around to it. – How I wish I would’ve spent more time expanding my repertoire! Luckily I found two songs easy enough to sight read, and one that I actually have been practicing on and off for about 3 years. As I was playing Bach’s “Prelude in C”, a woman walked over to me and asked when I was going to play some Rock ‘n Roll. I told her, “Oh, that’s next week!” and she laughed and walked away. As I was playing the second piece, she walked over again and said, “Come on now, you gotta rock out!” I just smiled and continued to play. During the third song, she came over yet another time, and this time, I don’t even know what she said. Again I smiled, and continued to play.
Out of all the residents gathered there, only one was one of our hospice patients. It worked out alright though, since the MT was able to sit with the pt while I played and give him one-on-one attention.
As I played the last few notes of Debussy’s “Reverie”, I stood up, grabbed my book of classical unknowns, and gave the MT a distinct look. She knew without me having to say anything that I had already exhausted my set of songs I had prepared to play and that I was ready to move on. She said her good-byes to the pt, and we left to go see the other two pts who were in their rooms.
The first pt we went off to find was fast asleep in his bed. The MT told me he was a retired policeman and is known for his ability to firmly grasp a staff member, thanks to his prior training. She softly spoke to him to see if he would wake up, but was weary to touch him, afraid he might grab a hold of her and not let go! (Could you blame her??) We hated to have come and just leave without singing to him, so upon suggestion from the MT, we sang a patriotic tune, “God Bless America.” The MT first asked the pt’s roommate if it was alright if we sang, and he granted us permission. In fact, he sang right along with us, blundering through the words he didn’t know, proudly singing to his heart’s content. It was good to hear him singing the words to a song, rather than hearing him talk about “all the foxes” down the hall as he was saying earlier.
A full song later, the pt still didn’t budge. We let him be and went on to the next pt. This pt was also sleeping! (Afternoon naps – if it were me, I’d probably be sleeping too…) The MT knows this particular pt likes songs from The Sound of Music, so we sang an acapella “Edelweiss.” Twice through this German number and patient #2 did not awake either! Perhaps everyone had a case of the Mondays today…
We went back to the office to do some documentation, and I barely got anything done because, of course, I couldn’t log into our documentation software. After yet another phone call to IS, I managed for the first time ever to access our documentation site.
The MT called (and spoke directly to!) one of our pts to schedule a visit for this afternoon. She was the very first pt I saw here in California, and is also the grandmother of one of our HCCs. However, our plans were changed when one of our nurses called and asked us to go see a pt who was actively dying. This was the pt at our impromptu Valentine’s Day/Mardi Gras celebration who kept trying to stand up during “Stand By Me.” (Gotta love him for that.) Since we also had another pt at that particular facility who we didn’t see the day of the celebration, the MT went to see her while I saw Mr. Stand-up. I suppose I would’ve been more nervous to see a pt by myself for the first time, but the poor man was so sound asleep, he practically snored to the beat of the music. I tried everything. I played fast songs, slow songs, touched his arm, spoke to him, knelt down by his bed and sang… nothing seemed to grab his attention. That’s when I began to question myself: why was I even trying to get his attention? If the man’s tired, let him sleep! I hope that he either didn’t notice me being there, or he was comforted by my presence, and that I didn’t disturb him. I touched his hand, told him I’ll be thinking of him (since I’m torn on telling people I’ll “pray” for them since I don’t really pray…) and left to go find the MT.
When I entered the room the MT was in, she and her pt were in the middle of discussing “their favorite things,” brought on by singing “My Favorite Things” from the Sound of Music. She was a really nice lady who said she enjoys all sorts of music. When she told me she liked the Beatles I was very pleasantly surprised! The MT let me play some songs for her, and together we sang “Edelweis” (for the second time today), “All My Lovin’”, “Brown Eyed Girl” (but changed it to “Green Eyed Girl”… even though I kept forgetting!) and “Blue Skies.” She told us we should take our show on the road, so we officially named her our manager. So, if you want to book the MT and I for a show, you have to talk with our darling manager first! (And thanks to HIPAA, I can’t tell you her name, so I guess it’s gonna be quite a challenge for you to contact her… best of luck though!)
We said our good-byes and went to go chart on the pts. I got to chart on our dear sleepy head stander (my first time charting!) and the MT charted on our band manager. Then the MT helped me document on the pts in the computer, and then – home! (And lots and lots of traffic in between those two things.)
Oh, and thank you to my MT supervisor for the guitar, picks, capo, binder of 1000 songs, and carrying case! I finally got to be one of those crazy MTs walking the halls with a guitar strapped to my back :)
And another thing, one of the secretaries at a facility we went to today said "Oh, I hate when I see you guys." She said that because when we come, it means one of the patients is dying. I never really thought of it like that before... the only reason we go to these places is to serve someone who is dying... I guess if you've accepted the fact that this particular person is at the end of life, then us coming is a good thing, as we help to make the best of the time he/she has left. But if you just see us in a general sense, then I guess it's true, we're total bearers of bad news... a stigma of death and dying... Ok... I shouldn't think like that. It's not true. We're there to support a living breathing human being, and that's that.
Friday, February 19, 2010
So today... today today today... I guess I should start from the very beginning... a very good place to start...
I got to the office around 8:30am and tried to quickly finish typing my blog for the day before (oops!) After re-doing my travel logs with all my mileage on them and getting my TB test read (no TB again! -- hooray!), the MT and I left to go see three pts who lived at the same assisted living community. Our first two pts lived on the memory care unit. Our older gentleman was sleeping in his chair amongst a group of older folks learning how to make some sort of Mexican dish from one of the staff members. She allowed us to play music for the group, so the MT grabbed her guitar and went to the front of the group. I stayed back and tried to engage our hospice pt one-on-one. It took a good four or five songs for him to wake up, but when he did, he made sure everyone in the room knew! I've never heard anyone hack and cough with as much flem and fervor as this poor man did this morning. He took a BIIIGGG breath in, as if he was trying to blow out 100 candles on a birthday cake, and then out came the cough and up came the gargle of flem. Who knew one little old man could produce so much mucus...
Fortunately though, he managed to keep his eyes open the rest of the session. I'm not sure if he was hard of hearing, or what thoughts were going through his mind, but he just slowly looked around the room, fixating on one thing, and then another, and then another, but not really reacting to any of them. It's hard to describe his face in any way other than expressionless, but it was just that - expressionless. He didn't look happy, or sad, or content, or upset, angry, confused, in pain, uncomfortable... I still don't really know what to make of it... even when he attempted vocalizing, it was still expressionless jargon with his gurgley voice. Sometimes I think negative emotion is better than no emotion -- at least you're feeling something...
The staff informed us that our second pt on the memory care side was experiencing a lot of pain this morning, so she went back to her room to lie down. When we got there, she was sleeping, so the MT let her continue to sleep since she didn't appear to still be in pain.
The third pt we saw at this facility was one I saw last week. She is one of our younger pts and is no longer eligible for hospice. When this happens, we discharge the pt, but call it "graduating". But, with her goods news, came bad news. Her mother developed an infection in her lone kidney, and was given about a week left to live. She is now actively dying, and may be taken on as one of our pts. (What a unique situation -- a daughter is d/c'ed and her mother is admitted, all at the same time!)
During our visit, the pt told us that we were going to switch things up today, and she would sing, and the MT would try and follow her. She had a pretty voice, and sang a handful of Christian worship songs for us. She even suggested we use them with our other pts. Despite my experience with praise and worship music, I didn't recognize any of the songs she sang, nor did she recognize mine. We enjoyed listening to each other's though. The MT attempted to follow along by strumming chords as the pt sang, but sometimes it was difficult since the pt tended to change keys in between different parts of the song. The MT left to document on the other two pts while the pt we were with made a phone call. I stayed in the room and tried to wait patiently for her to phone her friend. I was getting a bit antsy to be honest... after the pt hung up the phone, the MT and pt sang their favorite song, which was surprisingly a Christmas carol (which happened to be one of my brother's favorite Christmas songs growing up, so it must be a good one!)
Even though she begged us to stay, at the end, she said, "Ok fine now get out of here." I think she knew she was keeping us there and that we needed to move on, but I'm certain she would've liked to have had us stay the whole day. I'm glad she is graduating though -- she was far too young to be on hospice and has a teenage daughter to take care of.
At 1:00, the MT provided me with the experience of my first national Music Therapy conference call. On the 3rd Friday of every month, all the music therapists across the country from our company call in and talk for an hour about any issues they're having, any updates, things they want to discuss or brainstorm, etc. It was quite an interesting experience... Only in the music therapy world will you hear such an eclectic conversation... we're a unique bunch to say the least. It was neat I must admit to be on a call with a bunch of other MTs who do the same thing we do here in California.
After the conference call, I received a gift -- my Blackberry and laptop mini arrived!!!! So... now I have a company phone, computer, ID badge, jacket with a logo, and matching laptop bag. I'm gonna be stylin' and profilin' with my high tech gear and my company threads :-P
On to our last patient of the day. This woman was the cutest little Japanese lady I've ever seen. AND her family was sooo nice as well. It was such an enjoyable visit. They wheeled her over to the middle of the room facing the MT and I. She stared at the MT innocently. Sometimes she'd look over at me and smile. She even winked at the MT. The cutest part about her was her laugh. She just randomly laughed throughout the whole session. Just cute little bursts of giggles. It was precious.
And now I realize I describe some of my patients the same way a person would describe a five-year-old. But I guess that's because they have a lot of similarities... it's the circle of life. You enter the world, learn to talk, smile and giggle, make others happy just by being there and looking cute... and there's this innocence about children that makes them so endearing; so easy to love... and then you become an adult, and mature, and go through life... and then when you reach the end of your life, everything goes in reverse... the innocence returns... you might lose the ability to speak... and then you exit... and, depending on your beliefs, go off to somewhere new...
When I first decided to do this internship, I thought about how all my patients would be the same... I'd just be working with a bunch of old people, and every day is going to be the same thing over and over... but it's not like that at all. Even though most of our patients are close in age, they are all so incredibly unique. Their life stories, family dynamics, personalities, abilities, likes, dislikes... everything about them is special and different... it's much better than I could have ever hoped for :)
This morning, I left around 9:00am to meet the MT at the first pt’s SNF. She was sitting in her room, nicely dressed, eyes glazed with shadow, and lips puckered in a pale red shade. Her caretaker was there by her side. The pt was so excited to see the MT since she absolutely loves music therapy. When the MT sang a song, the pt just gazed up at her, like a yearning child watching her idol, mumbling along with some lyrics here and there, some jumbled syllables. She was captivated by the music, and also having someone sing to/with her. The MT asked a couple of times throughout the session if she had any songs in particular she would like to hear, but she left the song choosing up to the MT and continued to contently listen. The MT had me play a couple songs for her as well. I can sing along and guess at the lyrics I don’t know when the MT has the guitar in hand, but as soon as she hands over the reigns to me, I freeze, and all songs except “Amazing Grace” leave my memory. I can’t think of song titles, lyrics, what chords to play… I think the older population intimidates me because I know I am still quite unfamiliar with songs they would recognize and enjoy. I could play her a Jason Mraz tune or some Coldplay, but she wants to hear songs from the 20’s, 30’s, and around that time.
Fortunately, the pt’s health has been improving, but unfortunately, she is now no longer appropriate for hospice services. The MT tried breaking the news to her, but as she was beginning to utter the words, the pt looked up at her and said, “I love when you come and sing. It makes me so happy. It really brightens my day.” How do you tell a pt you can no longer see them when they look you in the eye and tell you that?!
The MT plans on visiting her one more time before she is officially discharged from our services, but who knows what the future will bring… maybe she’ll become eligible again, or maybe she can hire the MT personally.
The second pt we saw this morning was a new admit living in a board and care. It was also a beautiful California ranch house in a nice, quiet neighborhood. The pt was reclined in her chair in the living room, with three other pt’s seated on the couch and easy chair. At this visit, we were not the only hospice workers there. Another hospice employ from a different company was there to see one of the other pts. She was unloading her car right when we got there, so we ended up entering the house as one big trio. She was the epitome of a California girl. Shame on me, I judged her immediately. It turns out that she was a bundle of energy, full of love for her pts, and the pts loved her in return. :)
The pt at this house was filled with love and emotion. She offered everyone love, and freely allowed herself to experience every second of the visit. She cried when we sang of love, shared stories about traveling around the country, and talked about her beautiful home in Texas. The people she mentioned most were one of her daughters, and her new love, “John.” She often would repeat positive things her daughter has told her, as if saying, “Well, my daughter said these things about me, so I guess they’re true.” Her daughter keeps in contact with her every day, and it really makes a difference in the pt’s life.
The second person she often mentioned was away at an activity for the day. She missed him so much and couldn’t wait for him to return. At the end of the session, she confided in me that he worries about being separated from her, because he’s afraid she’ll leave him when he’s away. She continuously told us how much she loved him, and how much he loved her in return. It was nice to see that she was able to form such a special relationship with another resident, providing her with increased support through this last stage of her life.
When the MT played a song with poetic lyrics, the pt cried. When I played piano, the pt cried. She expressed her gratitude for having music the entire session, not just at the end. We stayed with her for over an hour. She really opened up and was enjoying the music immensely.
As we said our good-byes, the pt gave the MT and I “kisses from God,” which were small kisses on our foreheads. She explained to me that the forehead is the eye of the Spirit, and that’s where you give kisses from God.
Together, we reminisced, talked about death, talked about loved ones and relationships, engaged the other pts (and the other hospice worker), held her hands and provided emotional support… she was an amazing pt and I hope I get to visit with her again!
In the afternoon, we drove to a facility about 20 miles away. It smelled awful. There, we saw two patients. The first patient was an older male, who shared a room with his wife. When we entered, the two were in their respective beds situated on opposite sides of the room. Our pt was fast asleep, but his wife awoke to our arrival. We invited her to come sit by her husband while we play some music. Already my heart was broken, walking in a room of a married couple, their beds on opposing walls. She sat by her husband and looked up at the MT, ready and waiting. As the MT began to sing, the pt’s wife joined right in, perfectly in tune. She later told us she used to be in many choirs!
The pt awoke to the music, and listened for awhile, his eyes taking long, slow blinks. He eventually fell back asleep though, and it was just the three girls singing once again.
As we packed up to leave, the pt’s wife joked about the three of us going on the road to sing as a group. She patted her husband’s leg and said, “Sorry Grandpa, we’re gonna hit the road!” The woman called her husband “Grandpa.” I thought she was just being silly at first, but she repeatedly called him “Grandpa,” or “old man”… that’s when I realized her dementia was so advanced that she could very possibly view him as an old man, while believing she is still a young woman who could very well go on the road and sing. I felt a couple tears come to my eyes. It was the most innocent yet saddest situation… the mind of a young girl, trapped in an aged body, further trapped in a room with this “old man,” the man she was once in love with. Since our pt is extremely weak himself, I don’t think either of them really notice that their relationship has changed from lovers to “old man” and young, friendly companion. All the years they spent together just seemed to disappear…
The second pt we saw at the facility and the last pt of the day was asleep in her room. The MT believes this is the pt who cursed out one of our nurses… As we began to sing, her eyelashes batted up and down. She heard the music, but did not want to wake up. We sang a few songs, but only stayed about 10 minutes. The MT tried rubbing her shoulder and offering a comforting touch while I played the guitar and sang. Hopefully the pt felt comforted by our presence and the music… I think she’s just a tough one to crack (hehe).
After pt #4 of the day, we drove back to the office to do some documentation before our psychosocial meeting.
The meeting lasted for about an hour, giving me about 15 minutes to freak out about how I have to play music tonight for a bunch of people I don’t know.
Then I threw the guitar in the back of the mom-mobile, and started off on my journey to a new city for a marketing birthday social event. Of course, the address I type into the GPS doesn’t even exist, so I decided to just drive to the road and figure it out from there. After driving past my exit that was closed and through a major intersection with broken lights, I decided at the last minute that I would search for the hospital under points of interest under my GPS. The best thing I could find was a speciality outpatient unit, so I just set that as my destination. I finally got frustrated with that, stopped at a mattress store to ask where the hospital was, drove to the hospital, called the marketer, and found out they’re not actually at the hospital, but another facility owned by the hospital. The markerter told me I was close and to just go further down the street and turn right. I drove further down the street… and further down the street… and further down the street… and finally decided I was going further down the WRONG street… I turned around and drove the right direction down the street (having to stop every 50 feet for another red light) and finally reached my destination an hour and a half after I left the office.
The marketer teamed together with a couple other staff members from the hospital facility to throw a little birthday party for two nurses. There was food, margaritas, lots of nurses I didn’t know, and a little scared MTI with a guitar. I played “This One’s For the Girls” for them, which almost completely applied, but of course, two seconds before I go to play the song, a man walks through the room.
After the song and some food and drinks (I opted out of the margarita – can’t drink and drive!) we sang “Happy Birthday” and cut the cake.
Despite the fact that it took an hour and a half to find the place and I only knew one person there, it was an enjoyable evening and all the people were really nice. They were very interested in music therapy, and now that I work for a hospice company, I can narrow down my definition of music therapy, instead of trying to describe the entire scope of our practice in two sentences. Now when people ask what music therapy is, I can say, “Well with our hospice patients, we can…” Hopefully what I said sticks in their minds and they remember music therapy and our company!
At last, 12 hours later, I made it back home. It was a long long long day, so sorry I didn’t get this posted when it was supposed to be!
But in other better news… IT’S FRIDAY!!
Wednesday, February 17, 2010
Ok, so... what I did today... attended a staff in-service where one of our HCCs gave a practice presentation on our special program we do for pts with dementia. Then saw two pts with the MT. Then shadowed one of our RNs and saw two pts with her. It doesn't sound like much when I type it here... but it was a very tiring day! But a good day. Very VERY thought-provoking...
~Presentation on our company's special program for patients with end stage Dementia
(based on book, The End of Life Namaste Care Program for People with Dementia by: Joyce Simard)
Namaste – peaceful Hindu gesture; expresses a wish to honor the spirit within
Create a calming, relaxing environment for the patient, i.e. washing feet and hands, massage, moisturizing with lotions, nourishment (treats)
Can be provided by any/all members of the care team
Candles (flameless), scents, music, and flowers can be used to create peaceful ambience
Facility staff, family, doctors, or care givers can fill out the Lifestyle Preference Appraisal form, which helps fully describe the patient’s preferences and activities. Examples: sleep habits, spirituality, religion, leisure activities pt enjoys with others, activities pt enjoys alone, favorite scents/music/flowers, fears, desires, dislikes, family members, pets, etc.
Stimulate all 5 senses:
• Smell shaving cream – reminisce about going to the barbershop
• Lavender scents – calming, relaxing
• Old Spice
• Touching/look at a colorful silk scarf – reminisce about going out dancing (while also doing exercises/stretching)
• Ponds body cream
• Blowing bubbles
• Listen to soft, calming music
• Soft speech guiding the patient through the process
• Offering lollipops or other such treats
Our first stop of the day was to see a new admission. She is Chinese and only speaks Mandarin. She was at a care facility that looked and felt much like a hospital. I believe her terminal diagnosis is debility NOS…
When we arrived, she was fast asleep. The MT got out her guitar, and sat down in a nearby chair (which adds a nice approachable, non-threatening sort of touch I think… kind of like when a server at a restaurant kneels down at your table to take your order… the person becomes literally at the same level of you.). She began to softly strum some chords on the guitar. The patient still did not awake. Her eyes blinked (even though they were already closed), and her left arm slightly twitched. The MT and I softly began to hum the melody to “Amazing Grace,” and continued on by singing the first two verses. Still, the patient continued to sleep. The MT tried one last song, “Dona Nobis Pacem”. Even still, the patient did not open her eyes.
It’s okay though… just because a patient isn’t clapping along or has a big smile on his/her face, it doesn’t mean the MT intervention wasn’t beneficial. I think especially for a pt in this sort of environment, soft singing and music can really help to create more of a comforting, caring environment. As the MT reiterated to a nurse today, hearing is the first sense to develop, and the last sense go. I like to think that even the pts who seem the most gone, they can still hear the music, and the music makes them feel secure, at peace, and that someone is there who cares, spending time with them.
We quietly exited her room and let her continue to rest. This visit would be documented as a “Music Therapy Assessment” (instead of a MT reassessment, for obvious reasons—it was the first visit.)
After leaving the care facility, we drove about 4 miles down the road to a board and care home. It was the first time I saw a home turned into a care center for patients! I think it’s a great idea. Nobody (or at least nobody I know) wants to live his/her life in a hospital (or a nursing home that looks like a hospital.) People like to feel comfortable and “at home.” What better way to feel at home than in an actual home! It was the cutest little house in a nice suburban neighborhood. We entered the home, and found our pt sitting at the kitchen table, nibbling on her lunch. Another resident was sitting next to her, happily enjoying some mint chocolate chip ice cream. Our pt had a bowl of milk (which I’m assuming had cereal at one time) and an itty bitty half of a sandwich. (Why the one resident had mint chocolate chip ice cream and our pt had a wimpy little sandwich and a bowl of milk is beyond me…) Since she was in the middle of eating her lunch, the MT decided to let her finish eating and to just return another day. She introduced me to the pt, and to the orange tabby in the corner named Charles. (Does HIPAA protect cats’ names?) The MT asked how she was doing, told her it was nice to see her, and that she would return another day to play music for her. And so, we’re on the road again… (just can’t wait to get on the road again... the life I love is making music with my friends… dah dah dah dah…….)
We left the second pts home around noon. It was then that the MT and I parted ways. She had a meeting with one of our HCCs back at the office, and I was scheduled to shadow one of our RNs.
I got in contact with the RN over the phone, and met her at pt #3’s house. This pt opted out of having music therapy, so I was a bit intrigued to meet him, and perhaps figure out why he didn’t want MT.
I drove straight to this pt’s house from the boarding care, so I arrived about 15 minutes before the nurse did. I wasn’t sure what to do, or if I was even at the right house, so I just sat in my car, roasting in the sun. I eventually got out my laptop to get a head start on typing all this blog spectacularness when I realized how much of a total creeper I must’ve looked like… there’s this girl sitting in her car parked outside my house, typing on her laptop… she must be a spy!
I swear I don’t work for the government… sometimes I wish I did! (sweet benefits!) but, I don’t, and whoever told you I do, lies.
But anyway, we were greeted at the door by a screaming tot, and a woman who was busy carrying another child. “The nurses are here!” she yelled, loud enough to be audible over top the blaring little bambino. I remember thinking to myself, “Nice! She thinks I’m a nurse too! So this is what it feels like…”
The pt’s wife came over and greeted us in the foyer. I could tell she was extremely exhausted the first second I saw her, despite the although convincing, forced smile on her face. She led us to the pt’s bedroom and proudly showed the new bed that was just delivered. Laying on the bed in a pair of flannel PJ’s, the bottoms turned inside out, was a quiet man, his gray hair pulled back into a short ponytail. Instantly I thought he looked like an aged rock star. I know you shouldn’t judge people by appearances, but the man practically screamed “Come play music with me!! I’ll play bass!” I stood in the doorway as the nurse began her assessment. She checked the pt’s vitals and asked if he had any problems. The pt’s terminal diagnosis is throat cancer, which makes it hard for him to swallow, move his mouth, or speak for that matter. He was absolutely miserable. Well really, beyond miserable. The nurse asked if he had any thoughts about hurting himself, to which he replied, calmly and honestly, “Yes.” The pt explained that he thinks these thoughts every day, and that he’s ready to go. He joked and asked for the nurse to give him morphine so he could die peacefully. He wasn’t really joking though… I wanted to jump in there and get into a deep discussion with him about why he wanted to die, and what he was feeling, but it wasn’t the proper time, and I am not at all experienced or mature enough to handle such an intensely deep conversation with someone who truly is suicidal… I did however introduce myself as the MTI, and let him know that we would be more than happy to come and play music with him. I told him it wasn’t cheesy or anything. The wife smiled and asked, “Will you rock out to some Led Zepplin?” I told her “Sure! Acoustic though.” He still said no thank you. I told him that was okay, and that if he changed his mind, just let the nurse know and we’ll come see him right away.
It was a tough situation… I was convinced (and still am) that he would really benefit from music therapy, but how do you convince someone who isn’t willing to try something new? The wife said that he even refused to see his own mother today. He’s just extremely depressed… he’s given up on life and just wants to die already. He doesn’t want visitors, or people to try and make him feel better. I remember him looking the nurse square in the eye and saying, “I’m suffering. I’m really suffering. I’m just ready to be done with this.” His emotions were so real and relatable. It made me think of times in my life when I was so frustrated that I just wanted to quit whatever I was failing at, and overcoming it took everything I had in me. This man is dying from cancer… he can’t eat or speak… he is too weak to get out of bed… it’s completely understandable that he doesn’t have the strength to climb out of the horrible trench his life has dug for him.
If that wasn’t enough second hand depression, the nurse and I joined the wife and her sister in the dining room to talk. The nurse told the wife how the pt admitted to wanting to hurt himself. She replied, “Oh, I know. And I don’t blame him. If I could help him pull the plug I would. If it weren’t illegal, I’d pay whatever I’d have to let him stop suffering.” It was after saying this that she let her guard down. Tears filled her eyes as she held her breath. She excused herself and as the nurse put her hand on hers, assured us it would pass. “Just give me a minute,” she said. She squeezed her eyes tight and held her fist to her mouth. All of a sudden, she opened her eyes, dried her tears, took one deep breath, and exhaled loudly. “Ok, see? It passed,” she said with a smile. “It comes and goes, comes and goes.” I’m hoping that she was withholding her tears due to our company, and that if she cries when everyone’s gone, that she really cries and allows herself that catharsis of emotion. I wish I would’ve said something to her… me hoping that she’ll get through this doesn’t do much help…
Laughter was the true medicine for this family. The sisters talked about their youth, and all the good times they had, and how they would always be laughing hysterically… they even joked about how cute the man who brings the medical supplies is… she said how she wanted to call him and tell him the bed he brought today broke, just so he’d come back. I haven’t figured out if humor is a lasting way to deal with something as intense as death, but for now, it seems to be working, at least for them.
Ok, so I just wrote a book on the one pt I saw who doesn’t even want music therapy… you’ll never know who or what will strike you; who will make you think…
Pt #4 of the day was at a SNF about 30 miles away, so that’s about an hour in California driving time. After driving in circles in a parking lot for 15 minutes thanks to my GPS saying “turn left in 250 ft and you have reached your destination.” With a little help from the nurse, I finally navigated my way through empty parking lots and back streets to the facility. The pt was a new admission, and sadly, actively dying. Her daughter was there with her, and greeted us in the hallway. When I introduced myself as the music therapy intern, she told me that she plays music for her mother. In the room, she had an old cassette player sitting on the nightstand. Playing was a tape recording of her brother (the pt’s son) singing Christian church hymns in their native language. He is a pastor in the town I play softball in. What better for the pt to be listening to during her last hours than the sound of her own son singing church hymns!
I asked the daughter how she was doing, and she said she was fine. She told me how she lived with her mother for 12 years (!) until her mother moved to a nursing home about six months ago. This seems to be the case for a lot of our pts… a family member ends up devoting their entire life to caring for the sick pt, and now that the time has come for the pt to die, what is the family member to do? It’s almost comparable to a veteran’s situation… you send a soldier into war where he/she wakes up every day with certain tasks and responsibilities… he/she eats, drinks, and breathes the war… then you throw him/her back into society and expect them to pick up where they had left off… these people devout years and years to caring for their loved on 24/7/365… being a caretaker becomes part of their life and part of their identity… when the loved one dies, that part of their self is taken away, and it can be a long and difficult journey refilling that void…
As I digress… despite what I delved into above, the pt’s daughter did not strike me as someone who would be dealing with this. Even though she took care of her mother for 12, almost 13, years, she told me that she knew during the 6 months she spent at the nursing home that this would happen. She seemed prepared and accepting of the situation. From the music and the fact that her brother is a pastor, I can make a guess that she finds the strength and comfort she needs by knowing her mother will be with God in Heaven. After watching a loved one’s health decline, I’m sure the belief in knowing that your loved one will be soon be in a blissful place, where everything is perfect, and life is pain-free, can be quite a comforting thing.
As the nurse and I were on our way out, the MT was on her way in. I told her how the daughter was playing her brother’s tape of Christian music for her, and the MT reiterated my feelings, that what could be better than that! Can’t beat a recording of the pt’s son singing spiritual hymns!
After a quick catch-up conversation between the MT, RN, and myself, we again parted and went our separate ways. After the hour drive home through jolly ‘ol Cali traffic, I made it home, tired as can be, and starving from my lack of lunch!
And so I leave you for today… as you can see, it was a busy, busy day, with lots to think about…
Alright, a 1hr respite then off to another fun filled softball adventure in the always recreational Irvine, CA! Go team!
Monday, February 15, 2010
Got up early and thought I was ahead of schedule... then decided to double check my email about the Homeworks Training I had to go to today and wouldn't ya know it, I read the time wrong. It started at 10:30am CENTRAL standard time meaning the training session actually started at 8:30am PST!!! I hurried up and ran to my car after lazily jaunting about the whole morning. Miraculously I arrived at work 7 minutes early (without speeding) and made it to the training session on time. Phew! So from 8:30am-12:30pm, I sat in the conference room with our new HCC and our director of education and quality as the computer trainer from our office in Illinois taught us how to do basic documentation on our pts. It was kind of neat that she was training people from 5 different states all at once. It was also nice that she would use music therapy examples and say things like, "Now for you Gina, you would go to the music therapy reassessment form here..." instead of just using all nursing examples. Our documentation program has music therapy stuff already programmed in! I just have to go to the form and check which MT interventions I used! It's so nice that they respect MT as an actual legit field of practice and provide its own place for documentation, instead of us having to use an "other" form or generic form and fill in the rest ourselves. If I use songwriting or lyric analysis in a session, I can just check the appropriate box! I guess it pays to have a MT as the Vice President of your company :)
After that 4 hour adventure through Homeworks, I got in my car and met the MT at a SNF about 12 miles away (in the direction of the beach--yay!) We went to see a pt, a very sweet man in his late 60's, with a terminal diagnosis of CHF. Sadly he has no immediate family to care for him or visit, but he does have a few very close friends who come by often. Apparently one of the friends (the one designated as a primary care giver) is over-stepping her boundaries and being a bit too forceful with her wishes, demanding that we give these supplies, and make this visit at this time, etc. etc. The MT has to see her 40 pts once every 2 weeks (which is the standards for the other members of the psychosocial team, mandated by Medicare... Medicare is yet to set specific rules for MT...) That means 40 pts in 10 working days! She doesn't really have the time or flexibility to schedule herself at the convenience of a pt's friend... unfortunately of course... but let's be realistic here. 40 pts, all within a 50-mile radius, and all in 2 weeks, every 2 weeks...
Continuing on!... this was the first time I met the pt, but the MT said he seemed a lot more tired today. He was sitting up in his wheelchair with his 02/nasal cannula. He is a conga player, so the MT makes sure to always bring a couple drums for him to play. At first, she handed him a new drum he's never seen before. He tried it out, tapped it a few times, but didn't really like the sound. She then gave him the drum he used at the last session. He hit the second drum once, then twice, then immediately nodded his head and chose drum #2 due to the better sound quality and dynamics. The MT asked if there was anything he was in the mood for, to which he responded, "a love song." The MT and I just looked at each other and laughed inside since my whole first week here was dedicated to playing love songs thanks to Valentine's Day and the two "celebrations" we were asked to play for. I went over to the MT's big binder of music and pulled out the lyrics I printed out for last week. We sang "Let Me Call You Sweetheart", "I Can't Help Falling In Love", "Stand By Me", and "My Girl" (to which the MT in the end changed it to "My guy and even inserted the pt's name). The MT then asked the pt's two friends who were there visiting if they had any songs they would like to hear. The man said he had nothing in particular in mind, and the woman requested "Ave Maria." The MT kindly offered to learn it for next time, but for now, if "Amazing Grace" would do. She agreed and we sang all four verses of "Amazing Grace". (didn't even know there was four verses to Amazing Grace! Heck now that I think of it, there's probably nine or ten verses...) In the middle of the session, one of the pts friends helped him set the drum down on the table in front of him -- poor guy was too tired to even hold it anymore. During one of the songs (I forget which one specifically) the MT asked who the pt loved, and he said he loved his two friends. Later I learned the significance of this -- the MT said that not only will the pt's friends remember that moment after the pt passes, but also, when they hear that song in the future, they will think of him -- I just thought that was the nicest thing! Sometimes you forget to think what affects a session can have on the friends and family! Hospice is very pt/family-oriented. I often think "patient patient patient what does the patient need how is he/she responding what should we do next" but everyone present needs to be accounted for. Remember, Medicare mandates us to follow the loved ones for 12 months after a pt's death! Ergo, it's not all about the pt, but about the loved ones "left behind" as well. (And our company in particular follows pts for at least 13 mos. so we can see them through the 1yr anniversary, since that time in particular can prove to be quite trying on a family. We truly are a can-do organization, and I'm proud to be able to be a part of it!)
We stayed for about 45 minutes, and left so the friends could continue their visit. The pt seemed to tire quickly (physically), which is something the MT could document as a decline, which is necessary in order for him to remain eligible for hospice in Medicare's eyes. (The MT pointed out that in a rehab/most cases, it's important to document a pt's improvement!, but in the case of hospice, a pt's decline is what's necessary to be continuously documented on paper so when the end of that 90-day (or 60-day) certification period arrives, the decline of the pt's health is proven on paper.
The second pt we went to see was only a few miles down the road. Unfortunately when we arrived at his room, he was sound asleep in his bed. Since he was snoring and looked so at peace, the MT decided to leave him be instead of wakening him for a session. She simply charted that we were there and that she stop back at another time.
From there, we stopped at a Starbucks so she could teach me a bit more about the documentation process and how to navigate the Homeworks and Calendar programs. The Starbucks was also quite conveniently located right next to the beach :)
And so, week #2 of my internship is underway. Tomorrow, 3 patients in the morning (yay!) followed by 3 staff meetings in the afternoon (boo!) You win some, you lose some :-P
BUENAS NOCHES A TODOS!
Saturday, February 13, 2010
Oh, and I also gave a presentation on music therapy in a hospice setting... public speaking --- eeeek!
Volunteer Training Day 2.13.10
Things to keep in mind:
• Validate pt’s feelings. Listen to what they’re saying. Don’t be quick to judge. Pt. has a right to how they feel.
• “Speak for yourself” by using “I” language – I feel this way, I like/dislike this vs. we feel this way, people like/dislike this, etc.
• Do not give orders or make decisions for the pt. or family
o A pt. has a right to make his/her own decisions
o Can educate pt./family and offer suggestions, insight, resources, etc., but ultimately any decisions are theirs
• Gave presentation on music therapy (and how it is used in a hospice setting.) Power point presentation courtesy of:
Rebecca Thompson, MT-BC Seasons Hospice Pasadena Office
• Never forget that the pt is still alive! Yes, pt. knows he/she is about to die, but while you’re with the pt., he/she is still a living person and should be treated as thus
o Be empathetic, but don’t pity the pt.
o Offer support and pay close attention to understand what they’re going through to the best of your ability
o Keep an open mind
o Respect what the pt. knows/has experienced/believes
• Create a legacy for the pt so they can live on in some form after they die, for the sake of loved ones (and pt’s own feeling of self-worth; I made a difference and will continue to impact others even after I’m gone…)
• Watched hospice video: Letting Go (HBO)
o Followed 3 real life pts receiving hospice services
• Young boy, middle aged woman, adult male
• Michael – mother came at the end, said father wouldn’t let her see her son, father didn’t want to traumatize daughter further, volunteer read books to daughter about death to help her cope – allow parents to make the decision on how much they include children on a death – not your place to tell a child of a dying loved one if the family chooses to keep them in the dark
• Anna – Anna and son held onto hope till the very end – mother and daughter come to turns with the terminal diagnosis – preacher came and prayed over her – if holding onto her faith and believing she’ll pull through is what gave her the best QOL, then that is her right and her decision and not hospice’s place to tell her to think or feel otherwise – if she chooses to deny her own terminal diagnosis then that is her right to do so
• Adult male – tough guy – independent – frayed relationship with wife – hospice did not judge their marriage – allowed them to feel how they wanted to about each other/his dying – eventually was able to open up emotionally, see his daughter, etc.
• Note card exercise
o Write 4 loved ones, 4 possessions, 4 activities, etc.
o Order them by importance
o One by one take them away
o Brad took 2 from us – loss of control
Some more things I learned:
• POAHC – Power of Attorney of Hospice Care
• If a pt is going to die very soon – pt is “actively dying”
• When you first enter pt room, ask if it’s a good time to visit, and if pt is in any pain
• Before leaving, assess pain again
• COP – Condition of Participation
• Pain is what the pt says it is and can be controlled in a variety of ways
• Pain tolerance vs. pain threshold
o Pain tolerance – how much psychologically you can take
o Pain threshold – how much something must hurt before your body registers it as pain
• Acute pain vs. chronic pain
• Somatic pain – sharp, dull and/or aching pain
• Neuropathic pain – burning, shooting, and/or tingling pain
• Tissue or generalized pain, nerve pain, bone pain, visceral pain
• Cultural/gender/religious/etc. differences can affect pain tolerance and response to pain
• Pain with a rating higher than 4 requires notification to nurse/IDG
• Physical signs of pain:
o Tensing muscles, loss of appetite, nausea, weight loss, does not chew or swallow properly, spits out food, change in ADL routine, sleeplessness, moaning, groaning, sighing, change in gait, unwillingness to move, facial grimace, tachycardia, rapid/irregular breathing, high BP, constant fatigue
• Behavioral signs of pain:
o Agitation, irritability, anger, resentment, impatience, anxiety, tearfulness, less socializing, withdrawn, sadness, depression, confusion
• Pain medications can cause their own side effects i.e. sleeplessness, nausea, constipation
Physiological Signs and Symptoms of the Dying Process:
• Disorientation, sleep more, confusion, talking with unseen people
• Food, liquids, IV fluids may get to the point where they do more harm than good
• Change in BP, pulse, respiration rate, body temp
• Periods of apnea
• Increase in perspiration
• Restlessness, agitation
• “Last Hoorah” – sudden significant regaining of energy and mobility, shortly followed by death
• Five Wishes + official state documents
• My wish for…
o The person I want to make care decisions for me when I can’t
o The kind of medical treatment I want or don’t want
o How comfortable I want to be
o How I want people to treat me
o What I want my loved ones to know
• Gone From My Sight: The Dying Experience by: Barbara Karnes
• Universal pain assessment tool
Friday, February 12, 2010
I'm sorry my writing is so unbelievably horrible in this blog! It's just a mess of run-on sentences and bad grammar. It's pretty much all just stream-of-conscious since I'm writing this after work and trying to get everything "down on paper" before I forget it! I hope it at least makes some sense and you can get a basic understanding of what I'm saying and all that I'm experiencing.
Oh, and if you've always wanted to visit California, now's your chance!! I'd love to have visitors! It truly is a beautiful place, and I think everyone should see Cali at least once in their life :) Every moment in life is precious. Seize the day. Get your butts out here. hehe Much love! xoxo
It's 63 degrees and sunny today here in the OC :) Let's see.... got to the office just in time for stand-up at 8:45. I thought I was going to a meeting about my internship at 9am, but they decided to just keep it a private meeting, which is fine, I respect that. So from 9:00-10:15 I looked up songs we could sing at Valentine's Day Celebration #2. I picked some Elvis, some Beatles, "Moon River," and some other tunes and printed out the chords and lyrics. Also got my TB test checked -- yay! no tuberculosis! for the 8 millionth time in the past 3 years :)
We left around 10:15am for a SNF in the southern regions of Orange County to play at a second Valentine's Day celebration. When we arrived, we stopped by to see one of our pts., said hello, and sang her a quick song since she didn't want to go to the reminiscence area and join the party. It was sad to see another young pt. She's only in her mid-50's, recently divorced, and has a 19 y.o. daughter who also seems to be struggling with some mental health issues. She was very sweet and apparently likes to sing as well!
We then to the reminiscence side where all the pts. were gathered, eating cookies and drinking punch. Again, I attempted to play some songs on piano, but I guess my skills aren't quite up to par yet. The chords I printed off weren't very accurate, and unfortunately I don't have the know-how yet to be able to figure the chords out on the spot in my head. One of these days though, when I gain more experience (and more confidence!), hopefully I'll be able to just play anything a pt. requests! Two of the pts. in this group were in our program, and even though the MT was sure to include them in our singing, she included the other pts. as well.
Our marketer dropped by to bring the nursing staff some cookies, and our social worker was nice enough to stay and listen to our music. Even though it's good business to get people on your good side by smiling, saying hi, bringing them cookies, etc., all the staff at these facilities are so nice that being friendly just comes naturally. I guess what I'm saying is, even though being extra nice is what you should be doing from a business stand-point, the kind acts shared between our staff and the staff at these facilities is genuine and from the heart (at least from what I can see!)
After we charted on the pts., we got back in the car to drive back north. After stopping for a quick bite to eat at this yummy new restaurant (I forget what it's called, but it has the most delicious chicken and rice bowls!), we went to a much smaller facility to see a new admission. He was an older Asian man just arrived at this facility after being d/c'ed from the hospital. We arrived the same time as our social worker, so the three of us went in together to meet the pt. He was laying in bed on his side, eyes closed, mouth gaped open. I sadly noticed build-up of saliva and mucus between his upper teeth and lip, and as an MTi, could not do anything about it. (Now that I think of it, I probably could have told his nurse...) I think one thing that will be hard during this internship is using my knowledge gained as a nursing assistant, but remembering not to put it into action. I'm not aloud to grab a mouth swab and perform any oral care on the pt. Anything that could be considered medical care is not something I'm permitted to do :( But anyway, the MT got out her guitar, and PIMA'd softly as the pt. slept. The social worker gently rubbed his arm. He opened his eyes occasionally, but never for more than a few seconds, and did not focus on anything in particular. The MT began softly humming, harmonizing with the simple I, IV, V chords she was playing. She then added some words. "We are here." "You are at peace." "All is well." We knew the man was Buddhist, so the MT tried to incorporate themes centered around peace and tranquility. I took over playing guitar for awhile so the MT could step out and check his medical chart. While I was playing, the pt.'s cousin and son entered the room. The social worker and I introduced ourselves, and I continued playing guitar for a little while longer. He continued to open his eyes every so often, but still, not for very long.
When the MT returned, I strummed one last chord and returned the guitar to her. Then, the MT and social worker just talked to the family, reminding them that they can always contact us, and a nurse is on-call 24/7. They made sure they knew that they were here for them, and that if they had any questions, they would either provide an answer themselves, or find someone who could. I suppose it's important to just put the family at ease as much as possible. They're going through a really hard time emotionally, and we need to be there for support in anyway.
I think the company's IDG is well-balanced in that it has a medical professional (nurse), an aide for that professional (HHA), a creative therapist to help with processing all the emotions of dying/losing a loved one (art and music therapy), a social worker to help the family find those resources for all the arrangements, finances, planning, etc., and a chaplain to talk the family through the whole process in a spiritual way.
After about an hour with the pt., we left him to be alone with his family. They said they're a very big family, and visit him in shifts, which is so nice that he doesn't have to be alone through this last stage of his life. They were all very nice and it was so sad to have to see them go through this. But, I guess in this line of work, I'll be seeing a lot of cases like this... death is a part of life... it's inevitable for even the strongest of us... at least there's things like hospice to help make the transition a smooth transition, so the pt. can die peacefully and not alone, and the family can come to accept the death in a healthy way.
And well, that was my day! I feel like I've learned so much already in only my first week here. So far, so good!
Thursday, February 11, 2010
The pt.'s mother was so sweet. She kept smiling at me and winking at me as she talked to the social worker (not in a creepy way.) She even took me back to her bedroom to show me her cat nestled under the covers (first cat I've seen since I've been in California! They do exist!) After an hour of talking, discussing, and talking to MediCal on the phone, the social worker was finally able to sign her up for financial assistance to help her afford an aide to come in a take care of her son for a couple hours every so often so she can have a break.
Thoughts/observations of the situation:
- An 85 y.o. woman should never be the sole caregiver for her 65 y.o. son!
- She didn't want to put him in a facility, so she agreed to take care of him in her own home 24/7, even though it's not in either of their best interest (can you blame her though? What mother wouldn't want to take care of her own kid, and keep him out of a facility?)
- You can not request to have a volunteer a.) come at a specified time every week for more than 2hrs at a time because they volunteer their time! and b.) our volunteers are not medically trained and cannot replace a HHA. They are simply a companion. (sorry, I've been in "volunteer training" all week!)
- If you don't want your mother to have to nurse you through hospice, don't smoke.
- The nurse assigned to this pt. provided the mother with medication for her laxatives and a back brace for her sore back. She cannot provide medical care to the pt.'s mother (unfortunately.) The mother is not our pt. All she can do is offer medical advice and maybe a referral.
- There are typically 5 stages of grief:
1. Denial 2. Anger/resentment 3. bargaining 4. depression 5. acceptance
- Grief - physical or emotional reaction to loss
- Bereavement - period of time to grieve after a loss
- Mourning - process dealing with grief
- Anticipatory grief - grief experienced in anticipation of the loss of a loved one
- Shadow grief - feelings of grief which occur on the monthly or yearly anniversary dates of the loved one's death
- Complicated grief - grief that requires processing with licensed medical professionals
- The path of grief is not linear in its progression - it goes back and forth, up and down through each of the stages, often within the same month, week, day, or hour. Unexpected "triggers" can throw a person instantly backwards to earlier stages of grieving. Grief will often appear in some way at some time whether the person wants to deal with it or not.
- Hospice Bereavement: The hospice company follows the bereaved for the next 13 months following the loved one's death with phone calls, cards from the team, home visits, short term counseling, newsletters, etc. This is mandated by Medicare as a vital part of hospice services.
- 1. Routine Bereavement - survivors are seen as probably being able to cope normally with the loss of the pt.
- 2. High Risk Bereavement - survivors may need more immediate attention and are at greater risk for needing support during the grieving process
- Every person's grief is unique; intensity and duration is unique to their personal experience, personality, and perception of the loss
- there is no proper way to greive
- there is no time limit - can last days, weeks, months, years...
- grief needs a witness - someone to hear the story of loss until it comes to a place within where it can be held without distracting activities of every day life.
- sadness, loneliness, emptiness
- loss of appetite/eating too much
- ANGER (towards the person, God, or those around)
- fear i wont' survive the grief
- despair at rapid changes
- yearning/pining for the way things were
- frustration with current situation and the need to deal with things alone
- shock (at what's happened and/or subsequent events...)
- confusion - what to do next
- numbness as protection from so much pain
- helplessness in the face of overwhelming lack of energy while big decisions need to be made
- relief - see progress through path of grief
- anxiety over "doing the right thing" and caring for yourself and your loved ones
- Ages 3-5: may deny death as a final process; see mom and dad leave during the day (death) and come home at night (ta da! not dead anymore!)
- Ages 5-9: may be able to accept the idea that someone has died, but may not understand that it will happen to everyone or even themselves
- Ages 9-10: recognize death as inevitable, even for them
- What is death?
- What makes people die?
- What happens to people when they die/where do they go?
Memo from the MT: For children’s grief, it’s important to be concrete in the terminology used to describe death. For example, some people may say “go to sleep” but that is not an accurate description of what is happening. Be open and honest in describing death to children.
Wednesday, February 10, 2010
I've been taking different routes to the office every morning, but it seems not matter which roads I take, it still takes me about 28 minutes to get to the office, which is only about 11 miles away. If I took the highway, it'd probably take 45 minutes.. oh well, that's California traffic for you!
I went in for stand-up today and was all alone except for our boss. Everyone else was out and about and participated through the magic of conference calls. The only call from overnight was for a pt. at one of the SNFs. Apparently they've been calling us for supplies every night, so we're assuming the SNF is using this pt.'s supplies, funded for by medicare through our company, for other pts, which is ILLEGAL!! (hey, get your own chucks and barrier cream!)
After stand-up, my morning consisted of signing a million new hire forms and papers, having one of the nurses give me a TB test, and getting a work physical at a local health clinic. The nurse who took my vitals talked a lot to me about why I moved to California and all the great things about living here. He gave me his phone number, but he honestly seemed to be trying to be nice and help me get acquainted to the area and not hitting on me. The doctor was the exact opposite. He was apparently from Ann Arbor, MI and moved here 4 months ago. He doesn't like how expensive Cali is, all the traffic, and how rude the people are, and is planning on moving again...
Anyway, after leaving the clinic, I went home to take a break and look up some songs for later today. I got so incredibly depressed from being alone. Sometimes when I'm not doing anything concrete or productive, the feeling of loneliness here gets so overwhelming that all I can do is cry and kick myself for ever wanting to move so far away from home all by myself. I called my boyfriend and cried to him for awhile, and finally decided that even though I'm physically alone, I have a lot of wonderful people back home missing me, loving me, and supporting me, so I should just buck up and get back to work! :-P
I left at 2:00pm to go to a SNF (or at least I think it's a SNF) about 18 miles away. Of course it took about 40 minutes to get there :) The MT and I sang some songs for the "reminiscent" pts. (the dementia pts.) before our little Valentine's Day Celebration began. There was the cutest little old Asian lady who looked like she was about 4' tall and 50lbs. She was so happy to see the MT. The MT even sang "Amazing Grace" and dedicated it to her, which put a great big smile on her face. One of the pts. there objected to our music playing but sat and listened anyway. She seemed very grumpy and moody. I was later informed that this pt. recently pulled out a chunk of the cute little Asian lady's hair, and was consequently sent to a psych facility. The fact that she was admitted back to the SNF had a lot of staff and pts. a bit perturbed, understandably. The MT sang "He's Got the Whole World," and took turns putting all the pts. and staff's names into the song. "He's got 'Susie and Jimmy' in his hands..." When she asked one of the pts. in front what his name was so she could add it to the song, he just smiled and said "I don't know!" as if it was just a silly little thing he didn't know his own name. A staff member told the MT the pts. name and when she sang the song to him, his face lit up and he clapped along happily to the song. It's the little things like this that make MT so rewarding. It's nice to see people when they are genuinely happy or feel special.
After we left the "reminiscent" side, we came back to the main lobby where many of the other pts. were sitting either talking, sleeping, drooling, or watching TV. I set up my keyboard and the MT and I traded off playing and singing love songs or older tunes we thought they would recognize. I was nervous as I only brought with me one fake book, and most of the songs in it were either Christmas or religious songs, or I didn't know them. The first couple songs I played though, one of the pts. sang along with me the whole time, which helped me to know someone actually knew what I was playing! Soon I busted into the MT's massive binder of music and chords and played some of her songs. While we were playing, the volunteer director, one of our social workers, and a third lady walked in a listened to us play/sing. I was later introduced to the lady, and found out that she is our company's director! She was the founder of the company I'm interning for! She came all the way from Chicago and she just heard me play piano! Thank god I didn't know who she was while I was playing, or else I would have been much much much more nervous :)
What I learned today:
- Always allow 1/2hr - 1hr for travel time, even if the place is only 10 miles away.
- ALWAYS try to make a good first impression. You never know when you're going to meet your company's founder and CEO!
- MT stands for Music-MARKETING Therapist. Always schmooze over the staff when you're at a SNF so they remember you. Tell them what company you're from so they know that you are the only company that offers MT and that you always come in with a smiling face and have a good rapport with the pts. This way, they can recommend your company to other pts. Ta da! More business :)
- In California, THERE ARE DOGS EVERYWHERE! Outside, inside, in SNFs, in people's homes, in cars in the parking lot, right outside your bedroom window... AND, the more you don't want them to come over and lick you, the more likely it's going to happen. Ergo, dogs love me.
Tuesday, February 9, 2010
After staring at a computer screen for hours and hours, the MT returned and we sat in on the nurses’ meeting during which they discussed their pts. and reviewed some nursing protocol. Then the rest of the staff joined us in the conference room for their weekly IDG meeting from 2:30pm till about 4:45pm. Today they discussed who has died in the past week, and any changes with the pts. with last names M-L. By doing discussing half of the alphabet per week, the pts. are reviewed bi-weekly which follows hospice protocol procedures. After all the pts. statuses and conditions were discussed, one of the directors reviewed the things the Board of Health marked them for during a recent survey/review. Basically she emphasized the importance of documenting anything and everything, so if an issue ever does arrive, it is not a facility or family/pt’s word vs. the hospice company’s, but rather, their word vs. documented proof of what was done, when, and for what reason. From working at Presby, I learned that in health care, yes, documenting is good for the sake of having references of a pt’s care history, but also, to save your own butt so you don’t get blamed for something that’s not your fault. Everyone’s accountable for every single thing done with regards to a pt.
What I learned today:
· QAPI – Quality Assessment and Performance Improvement
· CoP – Condition of Participation
· EOL – End of life
· COPD – Chronis Obstructive Pulmonary Disease
· HHA – Home Health Aide
Monday, February 8, 2010
I got to the office about 25 minutes early like a good little intern, and then sat in my car for 20 of those minutes because I was too nervous to walk in the front door by myself. But, I finally mustered up enough courage to go in, and thankfully was greeted by one of the employees I had already met (phew!)
At 8:45am, we gathered in the conference room for "stand-up," or morning rounds, which is basically a little meeting they have every morning to start the day. Between the employees present, and the ones on checking in on speaker phone (I don't know where there are that they have to be on speaker phone... so far it's a mystery...) everyone discusses any updates on pt. statuses they might have, such as recent learning of certain preferences a pt. might have, any pts. who passed away overnight/over the weekend, complaints or issues from a family member or SNF (Skilled Nursing Facility), any updates in general, etc. etc.
After morning rounds, I joined the MT at her LTC (Long Term Care)/SNF Task Force meeting on "PIP" or Performance Improvement Projects. There they discussed ways to insure that all the charts for their hospice company are appropriately kept up-to-date, and that there are no errors or necessary pages. The pt. charts should be kept as detailed but as concisely organized as possible. This way, when someone comes to review a facility, they will be able to see that their company's charts are well managed. Also, they discussed ways to educate SNFs on what their hospice company does that makes them different than other companies. After only my first few hours, I could tell that their hospice company truly was different. They pride themselves in always putting the needs of the pt. FIRST, and making sure the pt.'s QOL (quality of life) is at its highest. For instance, a pt. is not immediately taken off meds or life support just because he/she is put in hospice care. Instead, the pt. is supplied with all their medical needs (funded for by medicare) until the pt. and family has come to terms with the current situation, and is properly prepared to begin the dying process. For many, hospice implies immediately "pulling the plug," scaring away many potential pts. who could highly benefit from end of life palliative care, especially from this specific company.
After the task force meeting, I spent the next couple of hours with the volunteers coordinator. She was very nice, even though her job seems overwhelming daunting. There was trees and trees of papers to sign, forms to fill out, manuals to read... not a good day for my "Convergence Insufficiency" to say the least (I couldn't focus my eyes properly at all!) I received my first of three binders for the volunteer training process. This binder alone contains 19 sections of information and quizzes to complete. Perhaps if I hadn't just gone through this with WPIC and Children's I wouldn't be so reluctant to read the 20lb manual...
So after meeting with the volunteer coordinator, we ate lunch. The MT received a call from a pt.'s son. He gave the MT an extensive list of music his father enjoyed, but also informed her that he might not be having the appropriate emotional response to knowing his father is about to die. I guess in his eyes, his father wasn't doing much with his life anyway, so it was okay for him to die, which made him feel guilty that he even felt that way in the first place! I completely understood why he might "feel guilty for not feeling guilty" as the MT put it... it made sense to me... I don't think I would feel the same if my dad was dying, but I understand. I also think that as long as he continues to support his dad and continues to help him, it's okay that he feels that way. Maybe it's appropriate, or maybe it's something that a therapist would try to work on... I'm too new to the game to really know what is right and wrong or appropriate in the world of death and dying... but I'm sure I'll learn.
In the afternoon, the MT took me to see a pt. (who sadly was a relative of one of the employees...) We were greeted at the door by who I'm assuming was her son. He welcomed us in with a big smile as he led us to the kitchen. There sat the cutest old lady in her matching pink sweats, eating a bowl of soup with her two little dogs wagging their tails nearby. The son helped the woman over to the couch as the MT took out her guitar. The MT had visited the pt. many times before and seemed to know her well. Wouldn't you know she put me on the spot and asked me to sing a song from memory! I was dumbstruck. All of sudden, any recollection of a written song in the history of music had left my mind. Finally, I resorted to "Amazing Grace," which I hoped that I remembered the chords, not to mention the lyrics. The first verse wasn't awful, (despite the dogs crawling all over my lap and licking my hand,) but I had to seek a little help from the MT for the lyrics of the second verse. By that time, I was feeling pretty comfortable and was even debating an encore of the first verse to finish it off, but I decided 2 verses was enough, and strummed a final I chord with the cutest smile I could make, hoping that way the pt. would be more forgiving of my poor musical skills. Thankfully, she was pleased as punch with my little "Amazing Grace" rendition. However, I was still quick to hand the guitar over to the MT as I admitted to her that I didn't know any other songs (which of course is not true, but at the time, that really was the only song I could think of...) The MT took over and we flipped through her big black binder of bangin' boogies (how's that for an alliteration?!) We sang a lot of patriotic songs and folk tunes. It was nice to see the pt. singing along, although she only did minimally. She said she liked to hear the MT sing. As we were about to leave, the son came back in the room and requested "Red River Valley." As we all tried to remember how it went, we eventually burst into a spontaneous rendition of the song with missing words here and inserted la da da's there. Everyone in the room had a smile on their face, and for those 40min or so, I think everyone forgot that the nice old woman was about to die, which I think means the music therapy was effective. :)
The son walked us out and showed his utmost appreciation for coming today. He told the MT how wonderful music therapy is and how happy they are she keeps coming. It's always nice to hear that people appreciate music therapy and see first hand the benefits it has... (and hopefully they tell their friends! woo!)
And...... that was it! End of day 1, and so far, so good :)
Read below if you too want to know the difference between Palliative and Hospice care:
Since I wasn't even sure myself, I googled the difference between Hospice and Palliative Care. From what I gather, palliative care is basically "comfort care," which differs from medical care in that it may not physically improve the pt.'s health, but it can make them more comfortable. Hospice is specifically for end of life care, and provides a pt. with palliative care, allowing the pt. to die as comfortably and peacefully as possible. So, if a pt. is dying, he/she can receive hospice and palliative care, but if a pt. has a chronic condition and is not dying, palliative care is appropriate. There are other differences as well, such as how they are funded, etc., but for the sake of sticking to the main points, Palliative Care is general comfort care provided at any stage of a condition/disease while Hospice is palliative care provided to a dying pt.