EMMA

I lightly knocked on the wooden door. I saw Emma was lying on her back in bed starring at the ceiling. The right side of her body was lifeless, the right side of her face had an obvious droop, and saliva was dribbling out of the corner of her mouth. She could no longer speak and was able to move only the left arm and leg. Her left arm and leg were continuously moving from one side of the bed to the other as if she wanted to tell me something. There was no order to her movements and appeared to be random although I sensed it showed frustration. She looked at me as I was assessing her. Emma was 84-years-old and suffered a stroke during the night.

I watched her face as I asked her questions and talked to her even though I knew she could not speak. I knew she could understand me because of the way she moved her eyes after speaking to her. By only watching her eyes I could tell a part of Emma was still inside but unable to get out.

“How are you?” I asked Emma. She looked at me as I was asking the question. Then her eyes pointed down and to the right and back again. I had the feeling she could understand me but was unable to express herself. She was trapped inside her own body.
“Emma. You had another stroke last night,” I told her. She starred at me and then her eyes looked down. She knew she had a severe stroke and the quality of her life had taken a drastic change. She would no longer be able to get out of bed by herself, feed herself, toilet herself, or do any activities of daily living. She grabbed my hand. I held her hand with my right hand while putting my left hand over hers. I stood there for several minutes.

“Emma. We are going to need to evaluate your swallowing,” I told her. She looked at me as I was still holding her hand. She pulled her hand away.

“We need to see how well you swallow and change your diet so you do not choke,” I told her. She looked away. I finished my assessment by listening to her heart and lungs. I heard coarse crackles at the bases. I was scared she had already aspirated.

“I am going to call your daughter today and tell her what had happened last night. I will let you know what she tells me,” I told Emma. Her eyes looked down and away from me as she moved her left arm and leg from side to side.

“What a terrible thing to have to live through,” I thought to myself. There was nothing that could be done except keep her comfortable. I walked out of the room towards the nurse’s station where I would write orders for speech therapy to evaluate her swallowing and a chest x-ray to see if she had aspirated during the night. I also wrote for an order to get her up in a chair and put her with other residents three times a day. I did not want her to be left alone in her room all day long. Emma was also at risk for skin breakdown since she could not move herself in her bed and was totally incontinent of urine and stool. She needed to be repositioned on a regular basis.

It was time to contact her daughter who lived in Colorado. These phone calls were difficult but needed to be done. I would bring up hospice for her mother. Emma could have another stroke at any time. My goal was to make her as comfortable as possible.

I contacted her daughter Betty and told her what had happened to her mother during the night. Betty had a difficult time with the news but tried to maintain her composure while we were on the phone. I explained her mother was paralyzed on the right side and could not speak anymore. Betty only listened. After talking to her for fifteen minutes I felt it was time to bring up hospice. Getting news of your parent’s failing health is difficult for anybody. The mind doesn’t know where to go and the decisions that needed to be made were difficult because some of the decisions were discussing end of life issues. There always remained some hope no matter how severe the situation. Betty needed to think about hospice. Her mother would not have to be moved and hospice would come into the facility to take care of her and keep her comfortable. It was too much for Betty to deal with all at once. I told her I would call her the following day. She told me thank you as she severed the connection.

Emma was already a DNR (do not resuscitate) which was arranged while she could make the decision. She also requested no tube feeding if she was unable to eat. The speech therapist evaluation determined Emma needed to be on a pureed diet with honey thickened liquids to prevent her from aspirating although it was still possible. Her chest x-ray was negative. The staff was getting her up in the chair with the other residents three times a day. After a week and several more phone calls Betty could not decide whether she wanted her mother to go on hospice. I wanted to give Betty time to process everything she had been told but also wanted the best thing for her mother. I contacted her regularly to see how she was doing.  

Emma began to not accept food or her medications even after much coaxing and creativity by the nursing staff. They could not get Emma to take anything orally. So far she had not eaten or taken fluids for three days. My gut feeling was she had given up and did not want to live anymore. It was time once again to call Betty. She needed to know her mother was no longer accepting food or drink. I left a message for Betty to call me on her answering machine. I hoped she would get back with me the same day.

Betty did contact me the same day. I told her about her mother not accepting food or liquids. She started to cry. I knew she felt helpless being so far away and unable to be with her mother due to her own health problems. She then agreed to put her mother on hospice. Betty told me her mother was very strong minded and probably had given up. She wanted me to tell her mother she loved her very much.

Hospice was arranged the same day. I told Emma that Betty told her she loved her very much. Her eyes looked glassy and starred straight ahead. She no longer looked at me while talking to her. Emma had given up.

Emma refused food or liquid for seven days. She was showing signs of dehydration. Emma was not as alert as she once was and slept most of the time even though she was put in the chair three times a day using a Hoyer lift. I kept in touch with her daughter on a regular basis.  

I received a message three days later that Emma had passed away at 8pm while in bed. The nursing staff and hospice nurse knew she was close and stayed with her. Emma did not die alone.