They get the job done

7Jul - by Sandy and Harry Summers - 0 - In MAGAZINES

Powerful New Yorker piece highlights the work of a veteran hospice nurse

The long 2016 report by Larissa MacFarquhar describes the work of hospice nurse Heather Meyerend, who provides skilled physical and psychosocial care to patients and family members in South Brooklyn. What may be most striking to readers is Meyerend’s expertise in the nature of dying.

July 2016 – The issue of The New Yorker dated July 11 & 18, 2016, included an extraordinary long piece by Larissa MacFarquhar about the daily work of Jamaica-born New York hospice nurse Heather Meyerend. Alternately headlined “The Threshold” and “A Tender Hand in the Presence of Death,” the piece describes Meyerend’s work generally and follows her with some specific patients, most of whom have lived a very long time. MacFarquhar charts in great detail what the subhead describes as Meyerend’s “physical, psychological, and spiritual” care. So the article gives attentive readers an unusually good sense of the nature and value of home hospice care, with some descriptions of the nurse’s technical skills, although that is not the major focus. Eugene Richard’s photos reinforce these themes, showing Meyerend examining or supporting patients, stethoscope around her neck, for example “assess[ing] the pedal pulse” of one. Considering its subject matter and length, the report is remarkably free of stereotypical angel imagery. There is the one headline’s reference to Meyerend’s “tender hand,” and the piece also stresses the importance of Christianity in Meyerend’s life and work—she spent time at a seminary—elements that may lead some to associate nursing with unskilled devotion. But the piece makes clear that Meyerend only shares overt religious activity with patients who make clear they are interested. The article spends a lot of time on what the dying process is like in hospice, the experience of patients and care givers during the final days, hours, and minutes. On that subject, it is clear that Meyerend is an expert. One minor complaint: The piece describes U.K. hospice pioneer Cicely Saunders as “both a doctor and a social worker.” In fact, Saunders began her career as a nurse, and it was in that role that she developed her ground-breaking ideas on palliative care. But it was only after she went to medical school that her ideas gained wide attention. The article’s failure to mention her nursing status is unfortunate, especially since its focus is a nurse. In any case, we thank MacFarquhar and The New Yorker for this powerful and generally very helpful piece.

The work

The patients

The work

Roughly half of the long piece consists of general descriptions of hospice and Meyerend’s practice, as well as her professional and personal background. The report notes that Meyerend, who it calls Heather throughout, was born and grew up in Jamaica. Heather’s mother eventually brought her to Brooklyn, apparently after Heather had finished high school. Heather planned to go to college to study English literature and become a teacher, but through prayer she decided she should be a nurse. Upon graduation, she skipped medical-surgical nursing, “where the prestige, the difficulty, and the excitement were,” but where care also seemed less personal. She went directly into home care. After several years as a visiting nurse, she seriously considered overseas missionary work and enrolled at a California seminary, where she “met and married her husband, a white man from Kansas.” They looked for a placement overseas but did not get one, so they moved to Brooklyn and became pastors; Heather also taught Latin at a school attached to the church. Evidently at some point after that, she became a hospice nurse. She was attracted to the extended physicality of the care, the chance to help make a wound heal, and even more, to touch patients in a comforting way—the piece spends some time on the importance of touch for her, linking it in part to the lack of such physical expression in her family.

The report also gives an extensive account of Heather’s general practice as a hospice nurse, including what she does, what she thinks, and descriptions of hospice that seem to be based mainly on her input. No other health professional is quoted or even cited. Heather practices in the neighborhoods of South Brooklyn, where she visits 16-20 patients per week, in care relationships that may last days or months. The piece says she feels it is a privilege to be there near the end of life when patients are at their most vulnerable. Some hospice workers, it says, feel that “working with the dying is the closest you can get on earth to the presence of God.” The piece says that unlike hospital nurses, Heather is “purposely inefficient.” She “takes vital signs, she checks that there are enough supplies and medications in the house, she asks if old symptoms have gone away or new ones developed.” But she stays much longer than that requires, perhaps managing “a complicated medical situation,” or, at the other end of the spectrum, household tasks, “which is the hospice way.” She chats with the patient, touching the patient’s skin as she evaluates. Of course, none of this is really “inefficient”; Heather is doing more than the listed tasks.

The piece says that “the first modern hospice was founded in 1967, in London, by Cicely Saunders, who was both a doctor and a social worker: she wanted to offer homelike care that aimed to provide comfort and serenity rather than to prolong life.” But MacFarquhar does not mention that Dame Saunders began her career and work in hospice as a nurse. She developed ground-breaking ideas and practices as a nurse. It was only after she became a physician that her work gained wider attention and acceptance. In fact, a 2005 article about Saunders in the British Medical Journal indicated that a physician colleague had advised her to become a physician: “His opinion was that people wouldn’t listen to her as a nurse, that doctors desert the dying, and that she could best help dying patients by becoming a doctor.” That is a telling illustration of the undervaluation of nursing, which continues to this day–as this piece’s failure to mention Saunders’s nursing status shows. In any case, hospice has always been and remains mainly a nursing endeavor. Fortunately, the piece as a whole makes that pretty clear.

Hospice grew in the United States after Medicare began to cover it, and now about twice as many people die in hospice as in a hospital. As the article explains, hospice takes a holistic approach and tries to care for not just the patient, but also the family. It addresses a range of physical and mental needs, providing a team that may include social workers, music therapists, and bereavement counselors.

MacFarquhar takes readers inside Heather’s experience, and although the piece does not say so directly, it’s clear that the work requires advanced psychosocial skills. The article explains how alert Heather is on the first visit so as to get a sense of the often-complex family dynamics, including what to say and not say. Patients and their families vary greatly in how they try to handle illness and how they treat Heather. Sometimes an adult child (usually a daughter) becomes consumed in the role of care giver: “It was people such as these whom Heather would mention to the social worker on her team as at risk for a particularly protracted and difficult bereavement.” If patients seem to be hanging on, tormented, Heather might ask if there is someone from their past life they need to see to help relieve the distress. Some patients are haunted by things they had done or experienced. Some are rarely visited because they have treated others badly. Some die alone and angry. Heather briefly explains her view of Hell, and of life choices that may lead us to God, as opposed to “money and power.” Patients ask Heather how much time they have left to live, and she carefully gauges what they are ready to hear. Relying on Heather, the piece describes how the end of life approaches and how people react, including the “agitated delirium” some patients experience in which “specters” from the past appear, some welcome, some not. Heather can tell from physical changes, including breathing and skin color, when death is imminent. She alerts family members.

If Heather was there when the end was very near, she would ask if the family wanted to gather together in the room. Then she would hang back, leaving the family to say goodbye. If the family were Christian, and if they had talked about that before, she might ask if they wanted to pray together. If the family were not Christian, she didn’t want to impose her beliefs, so she prayed silently in her head: God, here is this person, have mercy on him.

Loved ones can react very differently: “But fairly often a former spouse is taking care of the patient, because there is no one else to do it, and that person may not feel too much.”

When the time seems right, Heather begins the postmortem rituals. She shines a flashlight into the patient’s eyes to see that the pupils no longer constrict, and, if they do not, she closes the eyelids. She checks the pulse at the wrist and neck. She listens to the chest, and looks at the hands to see if they have changed color. She asks the family if there are people they need to call—other relatives, a priest, the funeral home—and if they aren’t ready to do it she offers to do it for them. She phones the hospice doctor to confirm the time of death, and the doctor writes up the death certificate. It is illegal to transfer medications from one patient to another, so she goes to the patient’s fridge and retrieves any leftover drugs and destroys them, with bleach, or coffee, or dirt.

Occasionally a patient’s death gets to Heather, as in the case of a relatively young mother who had struggled with drug abuse. Heather reportedly does not fear her own death, believing in a better afterlife and trying to do her best in this one, “so that when she came before God he would say to her, as she had read in the Bible, Well done, good and faithful servant.”

These general descriptions present Heather as a skilled, autonomous health professional, with a special focus on psychosocial care. There are also limited indications of her physical skill, such as in the examinations of patients and the “postmortem rituals.” And the brief description of medical-surgical nursing as challenging and exciting is good. But what will likely stick with readers are the descriptions of Heather’s expertise when it comes to the physical, emotional, and spiritual dynamics of death, which the piece presents in a dramatic yet often blunt and matter-of-fact way. Heather coordinates care with social workers, the piece suggests. Despite the elements related to her faith, it’s unlikely that readers will see her as a low-skilled comforter in accord with the traditional “angel” stereotype. The piece makes clear that her faith plays a role in her work, but it does not suggest that it’s essential for nurses to have a particular religious orientation or that Heather ever pushes her faith on others. The other biographical details also have helpful features, in particular the notes that Heather was academically oriented enough to consider a career teaching literature and that she actually did teach Latin at the church school.

The patients

Much of the article focuses on five specific patients. These parts are less about Heather, but they reveal elements of her care, especially psychosocial aspects. In discussing cancer patient Carmela, the piece describes Heather taking vital signs, assessing the patient’s dizziness, discussing her blood pressure and medication. Carmela says she wanted to be a nurse when young, but her mother said no. Heather observes: “And those were the days when you did what your mother told you.” Carmela talks about having visions of Jesus. Heather asks how Carmela prays about her cancer, and the piece notes: “Heather is a Christian, but she’s careful not to talk about her beliefs unless a patient asks her or it’s obvious that the patient is a Christian, too.”

In discussing a patient identified as “Mrs. Sejdaras,” the article describes Heather shining a small flashlight into the patient’s mouth “to check for thrush.” Heather also tries to reassure the patient and her daughter, who both seem distressed because a physician apparently said the patient had a limited time left to live. Heather and the patient discuss the patient’s nightmares and the morphine she is taking for pain, which makes her groggy. Heather thinks that a reduced dose might make sense and that adding Ritalin might give the patient more energy while she is with her family during the day. So she “call[s] the hospice doctor and request[s] a prescription.” Then: “Mrs. Sejdaras wrapped her arms around Heather’s neck, and Heather kissed her goodbye.”

With Mary, a patient with dementia who rarely speaks, Heather speaks mainly to her daughter Barbara. Heather asks how Mary has been eating. Heather examines her and finds a lot of stool.

Heather pulled on a pair of rubber gloves. Stool removal was a fairly regular part of her work, and she didn’t mind it. It brought the patient such relief that it was actually quite gratifying to do. And it was not the most distasteful of her tasks. A fungating wound could smell far worse than stool. Sometimes the stink of a wound was so foul that she had to excuse herself and walk away so the patient or the family wouldn’t see her gagging.

The piece’s discussion of the patient George is mostly about the immediate aftermath of his death. Heather arrives soon afterwards; George’s widow Anna had first called her church and hospice. The piece describes the work of the two clergy members who arrived in some detail, including prayer with Anna and Heather. The piece also notes Heather’s emotional support for Anna and a home health aide, both of whom have been crying. In response to Heather’s discreet inquiry, the aide notes that George’s body does not need to be cleaned, as is sometimes the case upon death. Heather examines George and “gently close[s] his eyelids.”

The last patient is Ruth, who is almost a hundred and six years old. Apparently based on past experience, Heather is unsure of the level of Ruth’s orientation, greeting her: “I’m Heather, I’m the nurse!” For months Ruth has reportedly been “inert,” lots of sleeping, not speaking, barely eating, but just a few days earlier, “she had come back to life,” surprising Heather. Ruth’s home health aide Indira reports that Ruth now wants to get married. Ruth offers some apparent non-sequiturs.

“Who’s going to take the gasoline?” Ruth asked. “The gasoline? Not me!” Heather said. Next, Ruth sings, “Summertime” and “Old Man River.” “That was great!” Heather says. When Ruth suddenly becomes “teary,” Heather comforts her: “It’s O.K., we’re here,” Heather says. “We’re right here with you.” Indira gives Ruth a Kit Kat candy bar, which is her favorite food. “Beautiful!” Ruth says to Heather. “You’re happy?” “I’m happy,” Heather tells her. “Yes, I am.”

These accounts include some very helpful elements. Heather checks vital signs; monitors specific symptoms (e.g., thrush); adjusts medications, including through advocacy with other practitioners; and performs other tasks that require skill and, in the case of the cleanup activities, inner strength. (Stool removal is also a critical assessment opportunity for a skilled nurse, although we’ve rarely if ever read that in a mainstream press article.) But again, what is most striking is Heather’s psychosocial care, as she engages with each person involved in the process according to their status and needs. She checks on patients and care givers alike, with discretion as needed, jokes with patients when that is appropriate, and provides key emotional support.

This piece is not mainly concerned with showing how expert Heather is at the kind of things that commonly appear in media depictions of modern health care, like research or surgical wizardry. But it does present her as an autonomous central player in a process that makes a great difference in the lives of the dying and their loved ones. We thank MacFarquhar and The New Yorker.

See A Tender Hand in the Presence of Death, by Larissa MacFarquhar, from the July 11 & 18, 2016 issue of The New Yorker.

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