CRITICAL INCIDENT REPORT

Student: Chap. Julio Arce Supervisor: Mary Carole Nelson Date: Feb, 2006 Unit #: 3

Lianne (not her real name) was a peculiar patient that caught my attention even before I met her. I reviewed her Case Sheet as I walked up to the familiar Hispanic Assisted Living Facility (ALF) where her family had admitted her. She was young: only 58 years old. Since I was 50, age like Liannes always catches my attention, now. Her diagnosis was multiple: she had end stage cardiovascular and cerebral vascular disease, with a history of seizures, dementia, psychiatric treatment, and multiple hospital admissions. She had less than 6 months to live. When I entered her room and saw her, she caught my attention even more: she looked a lot like a very close friend of mine. My first visit was totally based on chart information from our hospice chart and the ALFs chart on her, because she was unconscious and lethargic due to the medications administered during this time. I sat alone, on a chair by her bedside, reading her chart, documenting, and periodically observing her. She slept restlessly. There was a picture of her on her nightstand probably a few years old. She was heavier then. Now, she was extremely thin, bony, and pale, and I would later note these expressive large blue eyes deeply set under her blond brows. She looked younger than her age, and younger than her picture even though she was graying. She had been a schoolteacher. She had a Masters degree in education. She grew up in Minnesota and had been in Florida for years now. She had been in the ALF only about four months before she came on hospice. It was a little odd also that she was in the same room in the same bed as another patient I had about 2 years prior. That patient had been elderly though, and after she died, her family asked me to do her funeral. I had come to this ALF since, but always to other patients in other rooms. Being back in this room brought back memories. Even the same roommate of my elderly patient still slept in the other bed. Lianne was not religious and her Case Sheet only identified her as, Catholic other. That was a general description usually given when no one in my hospice team or the ALF staff really knew what denomination she belonged to. But in later conversations with Lianne, she told me she was Methodist in her Faith Tradition, albeit nominal. Her charts warned of violent emotional outbursts and combativeness. I was quietly glad she was unconscious, and I silently prayed that I would be able to help her in the future. I found out her husband visited on Sundays and the ALF staff gave me an impression that he was not too involved in her care. In talking to ALF staff, and talking to her husband on the phone, they both mentioned that Lianne no longer had friends. She had driven everyone away in her illness and dementia. The staff said that her husband had already divorced her. That was not true, technically, I later found out. I noted that he lived way down southwest of the county. There are good English speaking ALFs there, and I wondered why he chose to put her all the way up here in the northeast end of the county, so far

away, in a Hispanic ALF? Liannes physical care in this ALF did not impress me: she was not as clean, or as well groomed as she could have been. I surmised that she would need emotional support in her care, so I filled out a Care Plan for emotional reaction as well. On my next visit, about a week after, she was awake. She was quick to accept me and we hit it off from the start as chaplain and patient. I noted more how she reminded me of my close friend even their voices were very similar as well as their personalities. Lianne was an extrovert with a good sense of humor and energetic personality. I noticed some mental confusion, but it was subtle and she and I communicated with hardly any problem. For the next few visits, about a week to 10 days apart, I got to know her better, but each time, I also noted worsening dementia. The ALF staff said, she liked American food and had a good appetite. The staff would give her those pre-cooked microwave-heated hamburgers with juice in a box with its straw, anytime she would ask for one. I would bring her some McDonalds or a Starbucks tea and we would visit together like friends. Even though she ate, she was still losing weight due to her illness. I would hear from my hospice colleagues who also took care of Lianne, and ALF staff, that she would get violent and combative and that her seizures were increasing. So the doctor increased her medications and we were back to square one where my visit was just me, by her bedside, holding her hand as she slept restlessly. She was never at peace. Her closed eyes were always moving as well as her body. At times, she would jerk. As I held her hand, she would dig her nails into my hand; she did this up until my very last visit, the day before she died. I realized later that she was having multiple mild seizures repeatedly. She was always friendly and gracious to me. She never got combative or violent with me. Every time she saw me, whether alert and awake, or drowsy and lethargic, she would smile and greet me, or try. She would tell me, I like you so much. I noted how my smiles affected her positively. After awhile, her speech became what we term, nonsensical: unable to express a clear thought. Yet, we would still talk for long periods. I would catch the drift of her meaning by her gestures and tone of her voice. At times, it would be through parts of her disjointed sentences. Other times, it was just nonverbal communication. I seemed to somehow understand her even by the look in her eyes. She got more emotionally delicate as time passed. She would cry more and talk less. At times she would stop talking, sort of roll up into a ball by putting her arms around her legs, and stare at me for fairly long periods of time with a look of worry. It got sort of like spending time with a frightened child. It was during this time that she told me, almost pleading, that she did not want to die. She got thinner and she developed bedsores. Towards the end, she could no longer talk. Only once did I see her get color back into her face, warmth in her hands and a peaceful glow in her face. For just that little while, she looked healthy and normal. She started to decline and she was sent to the hospice Unit once, for pain management. She returned and continued to decline. One week before her death, she got so bad that she was showing signs of actively dying (change of breathing, apnea, change in level of consciousness, stopped eating and drinking, etc). So I talked to the nurse and called my

Team Manager, to suggest around the clock care. I also called her husband and when he came over, we talked about the signs. He completed her funeral arrangements. It was then, that I got to know her husband a little better. He was a little introvert and passive, and a nice man. He had unexpectedly lost his mother two years prior. He was still grieving for her, as well as showing anticipatory grief for Lianne (grief from anticipating a death). Nevertheless, he was a private man and remained aloof. The last weekend of Liannes life, I went to see her and she was back: she was alert, awake, talking, though somewhat nonsensically, and all smiles. Later, I found out from the staff that her husband came by that same day, after I left, and they had a wonderful time together. The following day, Sunday, she was again in an altered state of consciousness and put on around the clock care. I saw her Monday and she was in and out of consciousness (though mostly out), restless and again showing signs of actively dying. I spoke to her softly, administered the sacrament of the Healing of the Sick and prayed for her whispering in her ear. As I sat on a chair by her bed, I held her hand. She dug her nails into my hand so hard that she left marks, but I didnt let go of her hand. Finally, I leaned over to her ear and whispered good-bye. I told her she was dying. I told her that I had enjoyed our visits and I thanked her for her friendship. I told her God loved her and so did I, and that I would miss her and that I wouldnt forget her. Then I left. The next day, at 9 am, my pager went off and it read that I had to go do a death visit: it was Lianne. She had died at 8:35am on Tuesday exactly 5 months in our hospice program. I was at peace. I was expecting it. I did not cry. I prayed. I wondered on my way to the ALF, if she would still be there, as I sense how some patients remain even after physical death. But she was not there, just her body: she had left. I took care of calling her family, the funeral home, and disposing of her medications. When I disposed of her medications, I was surprised by the quantity of psychotropic medications she was on as our patient. It had not occurred to me that maybe I had never known her straight. I saw her husband again and I met his twelve-year-old daughter (Liannes step-daughter). Liannes body showed signs of a restless death, though her around the clock nurse said she went peacefully. Her eyes were open and her empty corpse did not look like her at all, nor did it resemble, even remotely, my close friend whom Lianne reminded me of either. It looked like a stranger.