The value of leaving things alone

I've noticed lately that a lot of things get better when you don't do anything about it. I'm talking about medical things, but also about just life things. What's up with that? In critical care, we fix everything RFN (right frigging now). In hospice, we don't take action about a lot of things. And you know what? Most of them resolve anyway. It makes me wonder how many unnecessary procedures go on all the time.

I've seen the following things just get better with no intervention whatsoever: atrial fibrillation with rapid ventricular response, extreme bradycardia (low 30's), multiple multiple infections of all kinds, wounds that I felt absolutely needed sutures, and a lot of alarming situations where I've thought, "in the ER, I'd have a doctor over here immediately." They just...get better.

Same with life situations. The older I get and the less likely I am to react and start frenetically trying to fix things, the fewer things I have to fix because the problem often disappears or fixes itself.

It's hard to do nothing, though, on both accounts. What nurse wants to just not do anything for a patient? I've now had to stand by a dozen times by someone I'm pretty sure is in some deadly cardiac rhythm and do nothing because we don't code people in hospice. It's a weird feeling. But as I say, now I wonder how many codes would have resolved themselves anyway that I've been in. I mean, maybe the successful codes would have resolved anyway, and the unsuccessful ones would never have had a chance to matter what. I'm growing decidedly anti-code.

Just to be clear: I am NOT anti-treatment. If someone has an infection that is causing pain or distress, by all means I want to treat it, if that's what the patient wants (sometimes they don't!). If some situation in my life is causing ME pain or distress, I want to remove the source of distress sooner rather than later.

But it's food for thought. Is it absolutely necessary to DO something about this situation?

Can I eat low carb as a vegetarian?

Operation kick-ass 2017 is in progress. I'm still doing my Miracle Mornings, astonishingly enough. In fact, I get up early even when I don't have to because I just wake up and feel like getting up. That is a miracle for sure.

Exercise is a big challenge for me, but at least I've discovered that I actually enjoy yoga. I'm stiff as a board and probably look like a total idiot, but it's the first physical activity I've found in a long time that I don't actively dread. That's an important first step.

Exercise aside, my main focus right now is on my diet. I went spelunking on the Internet and various books for ideas for why, despite doing everything I previously thought would solve the problem, my weight refuses to budge. I'm swayed by research and data indicating that sugar and white flour are Really Bad, so I've cut those out. So far I've read The Case Against Sugar and The Vegetarian Low-Carb Diet. I'm halfway through Why We Get Fat. The ideas are so hard to grasp; they make my brain hurt. But the arguments are very compelling.

I'm a vegetarian and will remain one. Nonviolence is one of my Values, with a capital V. It is however difficult to eat anything at all if you don't eat meat and seek a low-carb existence. I'm at the beginning of my journey and find that this switch is daunting to say the least. My diet has always been based squarely on bread, pasta, and rice (to say nothing of loads and loads of chocolate!), because I was raised on the low-fat high-carb idea. I have mountains of mouth-watering recipes that I no longer want to default to.

Thank heavens for Pinterest. And Paprika.

The sugar withdrawal is HORRIBLE. Horrible. The only way I'm getting through it is that it's so horrible I don't want to have to do it again. I'm exhausted in a special, "I can't keep my eyelids open" way. My entire body aches. I'm dizzy and nauseated. I'm starving as soon as I eat. My stomach is upset and I'm gassy and bloated. It's really truly unpleasant, yet all these symptoms are apparently to be expected. And I'm still eating carbs! I'm eating way FEWER carbs, but I am including whole grains and beans in my diet because (a) I have to eat something and (b) I'm not as swayed by thoughts that these carbs are harmful as sugar and white flour are. I imagine it would be a lot worse if I really did a carb cleanse.

In some ways this isn't changing my diet all that much, because I can switch white flour for some whole grains once in a while. Beans are a staple of my diet and I remain 80% convinced that their benefits outweigh their possible drawbacks. Veggies are my go-to. I'm eating a lot more leafy greens, though, because the easiest way I've found to throw a meal together is to house the rest of my food on a salad instead of on rice or pasta.

The change isn't so much what I'm adding as what I've taken out. I was shocked and appalled to discover exactly how much sugar and white flour I was eating every day, starting from my ab-fab caramel Keurig coffee every morning and continuing on to my pile of chocolate in the evenings. I've always thought sugar really wasn't that bad compared with fat so I've never restricted it. And I definitely never made any effort to restrict white flour. I ate a ton of bread, chips, tortillas, and pita/naan. My body is clearly asking me what exactly I'm doing to it right now. I can FEEL my blood sugar jumping around and trying to find a new normal!

My One Task for today is to figure out and prepare some foods I can have available when I get starvingly hungry, because I want to reach for my old foods and then feel cranky and deprived when I remind myself that these foods are not healthy for me. I have a selection of organic nuts and seeds to munch on and am tempted to buy some of the low-carb snack bars, but I really want to get away from processed food.

I am excited to see how this change affects me. I'm committed to see it through for a while until I am pretty sure I'm through the awful adjustment period, because I can see how it would be easy to mistake growing pains for possible negative effects of the lower-carb eating style. If it doesn't work for me, I will try something else, but I will not add back sugar and white flour. Those are out.

Why I have a Kindle and an iPad

My Kindle Paperwhite turned up with a giant scratch on the screen. It was actually like a huge gouge in the screen, and I have no idea how it happened because I don't typically drive over my Kindle or use it for tennis practice.

I thought I could read around it, but no. Then I thought I could just use my iPad (a baby Pro) to read on, but no. This weekend I schlepped to Best Buy and forked over the money for a new Paperwhite (and then gave Amazon $15 for a case, which I've never bothered with on a Kindle). Five minutes after I got home, the twin Kindle was up and running just like the old one, and I breathed a sigh of relief.

But I feel somehow guilty about having a duplicate gadget. How many tablet-like items does one person reasonably need (David Sparks, I'm looking at you!)? At least I bought a several-generations-old Kindle and didn't spend $300 for the Oasis, I guess. I'm writing this post to justify why I am engaging in anti–clutter reduction.

Reasons to have a Kindle even if you have an iPad:

  • Size. I don't realize I'm holding a Kindle. The Paperwhite is itty-bitty. It slips easily into my purse and doesn't drag down my shoulder, and I can hold it up to read in bed without my hands going to sleep and without needing to prop it up with a pillow. If I fall asleep while I'm reading, I can drop it on my head without risking waking up or sustaining a concussion.
  • Screen. Kindle screens don't give me a headache. I don't think they look as sharp and snappy as Amazon claims; I'd much rather stare at my crystal-clear iPad, in theory, but in practice I haven't yet experienced a headache or eye strain with a Kindle, and I read a lot, lot. iPads start making me want to take a break after an hour or so despite what I try with the brightness and so on.
  • Battery. The Kindle batteries really do last weeks. iPad batteries are no slouches, for what they're powering, but I can run down my iPad to nearly nothing on a weekend when I'm plowing through some reading, in a single day. And THEN how am I going to check Facebook?
  • Single tasking. Which brings up my next point. The only thing I can do on a Kindle is read, whereas with my iPad, despite my best intentions, I respond to those banner notifications sliding across the top of the screen. I CAN'T HELP MYSELF. Then an hour later I'm still watching guilty dog videos on YouTube. Reading on a Kindle is more relaxing for me because it gives me a break from constant connection.

I used to like the Kindle Owner's Lending Library benefit, which let Kindle owners borrow a book a month for free. Amazon seems to have replaced that with Prime Reading Eligible books, which lets Amazon Prime members read eligible books for free. So now you no longer have to own an actual Kindle to read books for free (the iOS and Android apps will work), but you do have to be a Prime member, which I am.

Amazon isn't what I'd call transparent with all these benefits. They kind of introduce them and switch them around in confusing ways. They also have the Kindle Unlimited program, because no company can live with itself nowadays without having Yet Another Subscription Program. With this subscription you pay $9.99 per month and get all-you-can-read Kindle books, as long as the books are Kindle Unlimited eligible. And there's the rub. If I want to read a book, it's a specific book that I have to hope is eligible. If I were a reader who could happily browse known Kindle Unlimited books and be happy with those, it would be a great deal for me.

Anyway, none of that is tied to owning an actual Kindle anymore, like it used to be. This is good and bad. Before, if you didn't own a Kindle device, the Lending Library was not available to you. Now, if you don't have Amazon Prime, Prime Reading isn't. Either way you had to buy an Amazon device or service, I guess.

I do read some stuff on my iPad, of course. iBooks, obviously. PDFs. Web clippings. RSS feeds (yes, they still exist, and so do people who read them). eBook formats that don't work on Kindle. If you aren't in the Amazon ecosystem, a Kindle is useless, but I've been buying Kindle books for like a decade now and have a zillion of them.

It works for me. I guess I'll keep on living in an extraneous-device household. Anyone else out there sporting another tablet and a Kindle? Why?

I'll just do it myself: Independence in home health

Scenario: your patient has an SpO2 of 48% at rest and on oxygen. Scenario: your patient's wound is suddenly giant and bleeding. Scenario: your patient is so agitated that she is trying to pull her own fingers off.

Those kinds of things sound bad. You'd go get a coworker to help you, right? You can't do that in hospice.

Independence and responsibility are things I idiotically overlooked when I started case managing for hospice, but they are at the forefront of challenges (and satisfaction) with the job.

In my job, I am frequently the only health care provider who sees the patient. That means if I miss something, it's not going to be caught by anyone else. I'm the only one who intimately knows all the medications the patient takes and knows every square inch of their skin and every crackle and wheeze in their lungs.

What's in my car is all I've got to handle anything that happens. What would you put in your car to deal with any imaginable circumstance? Sometimes I physically long for a hospital room with oxygen and suction right there on the wall, along with toys like otoscopes; a cabinet filled with bandages, Kerlix, and gauze; gloves on demand; a clean sink (with running water); and other nurses who can hold stuff for me. (Ever tried putting a Foley in a woman who can't get out of her recliner? By yourself? While staying sterile?)

In hospice, I don't have any of that. If I've done my job right, I'll have an oxygen concentrator to work with and a box of gloves in the house, but otherwise I either can't control what I'll need (e.g., running water) or it's just not feasible (e.g., I can't possibly foresee what types of dressings I'll need for any possible wound). Running to the office for supplies is almost always also not feasible. I work in rural Kansas, and it is not infrequent for me to find myself an hour away from the office (and from anything else).

This is scary. It didn't scare me at first because for some reason I didn't realize how alone I'd be. It took a succession of "oh, crap" incidents to scare me, those ones where you think, "Well, this looks bad. We should call someone." And then realize that you are the someone who's been called.

Now that I have realized how scary things can get at any moment—because forget the Emergency Department: hospice is hands down THE MOST unpredictable environment I've ever worked in—I have found a sense of challenge and achievement in the unpredictability and reliance on my own skills and experience. I have become very good at walking into impossible situations and having good assurance that I will end up figuring something out. That's pretty cool.

It's not just patients who rely on me, either. Physicians do. I often think it must be nerve-wracking for them. Here they are tasked with providing end-of-life care to people they will never even meet, and they have to rely on me, often ONLY me, to pass along accurate assessments and recommendations. If a patient is having trouble breathing, is it likely pneumonia? Or could it be their CHF? I have to decide what to assess and pass along, and I don't get to use toys like labs and X-rays to figure it out. I'm usually also the one who has to negotiate whether the patient and family will want to treat the problem in the first place, because in hospice we walk a thin gray line between treatment that increases comfort and treatment that unnecessarily prolongs life.

I negotiate a lot of what I call "curiosity treatments." These are things that would be interesting to know but in the end will not change what we actually DO for the patient: things like X-rays, chemistries, and even UAs. Getting a UA on a patient with signs of a UTI would be a slam dunk in the hospital, but in a home hospice patient, is it worth the hassle and trauma to the patient to do a straight cath? Will I even be able to get the sample to the lab in a reasonable amount of time? We often just presumptively treat that stuff because it's more timely for the patient and the results of the lab tests end up being relatively unimportant. Physicians rely on me to figure this stuff out.

Somehow this all works, I think largely because of teamwork. Perhaps ironically, the more indepently you work, the more important having a good backup team becomes. Without one I'd be truly alone.

Miracle Morning, Miracle Me: That Pesky E

I started religiously doing the Miracle Morning 16 days ago. I blogged about it on Medium already and thought I'd start blogging regularly about my adventures. I'm thinking hard on what to do with my blogging future, by the way; I don't think being a nurse blogger is my thing anymore. Anyway.

You're supposed to give yourself a full 30 days to acclimate to the systemic shock that occurs when you start getting up early and doing healthy stuff, so I'm about halfway through. I told myself I wouldn't edit the system until I'd tried it exactly as written for long enough to tell if it's doing anything.

I've changed around the amounts of time I spend on each SAVERS, but otherwise I've been a purist, and there's no proscription against changing how much time you spend on each thing anyway.

Getting up early and doing SAVRS has caused relatively little friction for me, which shocks me because I was a night owl for so long. The E (exercise) I am having more trouble with in the morning. When the weather has been nice, which in Kansas means not too far below freezing and without a whistling wind, I've had surprisingly little difficulty getting out the door for a (very slow) walk/jog to start out my fitness journey. Today it's like 3F, so that isn't going to happen.

I've supplied myself with Ways to Exercise at Home so I have T25 DVDs and a yoga app on my iPad/Apple TV. Problem is, the boyfriend and I live in the tiniest of houses, and he's working second shift right now, so there is nowhere and no way I can do much of anything except creep around in the mornings to avoid waking him up. The gym? Is 15 minutes away. With my work schedule I do not have the wherewithal to spend 30 minutes a morning just driving. That's several hours a week I could be doing something, well, something else. I drive enough during working hours.

Furthermore, I feel totally worn out starting around late morning and am starting to wonder if "exercise in the morning" is too one size fits all. Hands down I am more likely to do it I I can cross it off my list first thing. I'm not debating that. Still, at least with current circumstances being what they are, I've decided to break with my resolve and try exercising after work. I'll let you know how that goes.

Thoughts on creativity and fear

Why does anyone blog? I've reached a discouraged point in my bloggery, not because I have nothing to say, but because I've become afraid to say it. Fear has taken my voice. We live in a world in which every byte is recordable, able to be taken out of context and wielded against us. Why does anyone say anything at all in such a world?

 Crayzee day

Because of my blog, I have been threatened to be kicked out of nursing school, harassed online, and personally and professionally attacked. Some people really don't have enough to do.

Apparently I don't either, because I miss writing, and writing for people to read. Obviously nothing is stopping me from journaling and whatnot, but at some point creativity is meant to be shared. Writers write because they have something to say and humans don't typically talk to themselves only. Bloggers blog because they have experienced the "me, too" feeling that you get when you read something that really resonates with you and want to return the favor.

I'm sick of thinking, "oh, I'd like to blog about that," and then thinking of half a dozen reasons I shouldn't do it. About the only thing I feel safe writing about is my pets, and sometimes not even then. You really have to be psychotically anonymous or totally transparent these days, and I don't have the energy to go underground. I've learned that people really will go to the trouble to unearth things that I had no clue anyone would care about ever. So I have learned helplessness about being anonymous.

Some whacko even reported this blog to my professional agency, who promptly dismissed the complaint as "obviously vindictive," but that kind of thing is neeeeeearly enough to make me want to bury myself and fly completely under the radar forever.

Why nearly?

I was raised to believe that people should do the right thing, and that thing usually involved speaking up and consequences be damned. I don't think freedom of expression is served by allowing fear to stop me from keeping a two-bit blog, because that is where things start. Surely important people who actually have important things to say are lurking on the silent sides of their keyboards as well, roped by similar ghosts of dread and what-if.

When it comes down to it, all the people who have objected to things I've written have been offended by them. And you can't be offended by things that don't hit home. It's the old thing about the giraffe: if someone calls you a giraffe, you're not offended, because you know you're obviously not a giraffe.

The thing I don't understand is, if I hated giraffes, I wouldn't read giraffe blogs. When past coworkers complained about my blog, I suggested they read any of the millions of other available blogs instead. Why do people insist on gravitating toward things that upset them? I NEVER watch Fox News.

I feel like I should be able to point to some really gnarly offensive truth-seeking posts I've written that I could hold up and say, "I've gotten in all kinds of trouble for THIS REALLY IMPORTANT THING." But I've never said anything particularly important, at least not compared to things I've wanted to write and would have written if I could have. Again I point to all the no-doubt silenced voices that we could be reading, if it weren't for bullying and fear.

I think I need to have a voice for my own mental and spiritual health. I just don't know how to speak anymore.

Gadget update: buh-bye new pank MacBook

I got a new 12-inch rose gold MacBook recently but returned it and came away with a Boss Pro, which I had returned originally in favor of the Baby Pro and subsequently missed a lot.

The MacBook had issues, like, bad ones that would have necessitated a new computer swapout had I decided to keep it. Notably, the battery randomly dropped from 60% to the scary red icon, and it declined to wake from sleep without a restart about half the time. This is not convenient. I did Disk Utility stuff and PRAM stuff and all that hoodgie-boodgie stuff we do, and for my troubles I was rewarded with a flashing folder with a question mark on it.

If I loved the thing enough I would have swapped it out, but I didn't. I loved my Boss Pro before, but I had only 2 weeks to return it and thought I'd like the Baby Pro better. Having done so I figured I'd just get a slick little MacBook. It's just like a Boss Pro with a built-in keyboard, right?

It DID look slick, and the rose gold is pretty. All of My Things matched (except my watch). It worked OK for the first few days, just as I'd expect for a machine with its specs. It is CRAZY light, too. I didn't have complaints with the sound, as others have. I did have issues with the keyboard. I do much better with the iPad Smart Keyboards. They get mixed reviews, but they work great for me. The MacBook keyboard resulted in a lot of back-spacing and corrections, and I'm not sure exactly why. It looks all right, and it feels all right, but nevertheless I just couldn't type well on it.

The screen looks really nice, too. In cosmetic terms, the new MacBook rocks nations compared with the Airs or MBPs. My MBP is a bit long in the tooth but has prodigious hard drive space, so I'm unlikely to give it up until it's dead and gone. But it looks like a heavy silver brick compared with the new MacBooks.

Still and all...meh. I'm happy to have my Boss Pro with Smart Keyboard back. It doesn't run OS X, but I apparently don't really care that much anymore. There are a few tasks I need OS X for, and I open my MBP every weekend (yes, once a week) to do them. When Hazel and my complex e-book workflow come to the iPad, maybe I'll abandon the MBP, but for now I still use it for some important stuff.

So why the Boss Pro? I am a fundamentally lazy person, and this machine is made for us lazy people. You can draw on it, write on it, type on it, and watch video on it without feeling cramped. The Pencil was initially a big deal for me, but now it's receded into being a nice perk. The Smart Keyboard, I love. Either people like or hate them, and I'm in the like camp. I like just lifting off my screen and setting it back down for an instant conversion from laptop to tablet.

I now, though, have two iPads (the boyfriend got my Mini), and that seems fundamentally weird on the surface. No one needs any of this stuff, after all. I justify it because I do use all my toys, and it's really my only expensive hobby. I just want the toys. Also, after you look at the Boss Pro screen, the Baby Pro looks like an iPad Mini, and it's a wicked cool iPad. It's super light, so it goes with me, whereas the Boss Pro just migrates around the house with me. Unlike many people, I do like reading on the Boss. I just like the giant two-column spread. But you really can't read in bed with it without risking a head injury, so I end up reading about half and half on the Baby.

I have gone a week without the little MacBook and don't miss it. I like the instant-on of the iPad, and I still like the Smart Keyboard better than that butterfly keyboard on the MacBook. I thought I'd use the MacBook like an iPad with a built-in keyboard, but it wasn't very good at being either a laptop or an iPad-equivalent.

Regarding connector gate, I didn't care about the lack of ports. Almost everything I use connects wirelessly (largely, my printer and my ScanSnap). I back up using Backblaze and Time Machine. I bought the dongle to plug other stuff in to the MacBook but never ended up opening the box.

What I did care about was the lack of the nice snap-off charging cable. My MacBook Pro has been spared from an untimely death a few times because the charging cable just snaps off when someone pulls on the cable ("someone" being me meandering into it and tripping on it, usually). The USB-C port is a tight fit and that cable isn't coming away without some effort. Granted, the battery should last so long that it doesn't spend a lot of time plugged in, but I just didn't care for it, especially since the MacBook I had experienced battery issues and did need to be charged during the day.

So really, for people on the fence about whether to get a little MacBook or a big iPad, I vote for the big iPad. They end up costing about the same if you get a Smart Keyboard, a Pencil, and the larger capacity on the iPad vs. the bottom model of the MacBook. When I swapped I ended up with about $150 back and half the storage space, and I'm okay with that. Better to have something you use constantly and love.

Nurses week: an honest reflection

Not that other posts are dishonest, but I feel contrary. Am I proud to be a nurse? Absolutely. Would I do it again? I can’t answer that. After all, if I’d known then what I know now, I wouldn’t know what I know now.

Nursing has changed me profoundly. I can say that without reservation. I have become more fully human and had experiences that most people never have. I have more stories than I could ever capture about which you’d say, “you can’t make this stuff up.”

I have cried with happiness and with empathy. I’ve been there when people come in to this world and, far more often, when they leave it. I feel a deep sense of connection with the lives I come in to contact with and a deep sense of honor and pride that I am good at what I do. I derive integrity from it. I start every day saying “I’m going to be the best nurse I can be today,” and I usually am. That’s job fulfillment right there.

I have made the closest friends I will ever have. Sharing trauma, death, and plain hard work with people will create bonds like no others.

I never feel like I’m doing pointless work. When I was an editor, I felt as if I was spending my life working hard on things that no one would ever read, and I felt empty and frustrated. Now I feel empty and frustrated for different reasons, at least. I know that what I do matters to people. Even the stupid pointless bureaucratic tasks I spend so much time on matter because they’re necessary for patient care.


I have also experienced life-shattering betrayal of those bonds with other nurses, because lateral violence is a real problem.

I have been so exhausted I couldn’t drive safely, on a regular basis, and I have realized that I’m doing hard manual labor daily without the chance for adequate food and water intake. I have felt like I was too drained to go on living. I just can’t give any more, sometimes. I’ve started IVs on DOA babies and made dozens of phone calls bearing bad news. Compassion fatigue is a real problem.

I have been smacked down after doing my level best for patients simply because doctors think I’m automatically an idiot for being a nurse. I know I am seen as an inferior being, a pawn, disposable. I have been yelled at because of unbeatable power differentials. Lack of professional respect (between professions and within this one) is a real problem.

I have watched this profession deteriorate over 10 years as nurses have to do more with fewer staff, and I have watched patients suffer for it. Understaffing is a real problem.

Nursing isn’t so much a job as it is a lifestyle. It isn’t so much a healthy lifestyle, either. There are good reasons why mental illness and substance abuse are issues in our community.

So yes, I am absolutely proud to be a nurse, and I hope we all use this week to pat each other on the back, because we need that. But I’m using the week for some real reflection on where I am in my life because of this professional path, and it is by far not all positive.

Psychiatric History - Can I still become a nurse? | allnurses [rant]

My question is this. Is it even possible for me to become a nurse, and gain licensure after two psychiatric hospitalizations. My psychiatrist thinks I am doing quite well, I have spoken to lawyers, and the BON rep in my state both said I should be able to gain licensure if I earn it.

Allow me to rant about this (quoted from Reword it to "can I be a nurse if I am diabetic? I've been hospitalized for DKA several times." Or "I spent 6 months in the hospital when I had breast cancer. Can I still be a nurse?"

This is the same thing. Why are we even talking about it? Why is it an issue?

If you do your job, it shouldn't matter what MIGHT happen. I've seen nurses flip out completely who do not have a psych history, possibly because they needed treatment and didn't seek it on account of fear of retribution. So this is a serious problem in this profession.

I've also worked with doctors who openly discussed previous addiction issues. They seem to get away with it. I've never heard a nurse admit to same, although statistics show I must surely work with a bunch of them who have those issues. Is there a double standard there too? Are doctors allowed to be depressed or anxious or bipolar?

Now, if you have a history of getting homicidal and violent, nursing is not the profession for you. But I've worked with nurses who even have shizophrenia and did fine. These things are conditions that people can work with, just like diabetes, heart disease, and everything else. I even worked with a narcoleptic nurse once. You'd think that might disqualify you, but our manager worked with her, and she was a fantastic nurse.

I can't rant enough about this so I'll try to shut it down...but just one more thing. I'm sorry to break it to people, but those nurses who call in with migraines all the time or are always late or always call in on the equivalent of their Friday mornings? There's a good chance they're dealing with psychiatric or substance abuse issues, and they will not get the help they need because they're afraid. It has to stop.


Why do we call it "actively dying?"

I'd always heard the phrase actively dying and never thought much of it until I started seeing a lot of people die in hospice. I'd seen plenty of death in acute care, but following the process through provides an entirely different perspective. In the hospital, particularly in the ER, I saw the last bit of the process, and sometimes it was as fast as a few minutes (think aortic dissection). It's not that simple.

The first thing I learned was that alive/dead is not the easy dichotomy that you would think it is. Either you're dead or not. But I go uncommonly religious and tell people that the Bible says it's "the hour of our death" for a reason. In the ER, I saw one person during my entire time there be pronounced and then sit up and pull her tube out. Now I know to give it a while before pronouncing.

The next thing, and the topic of this post, is that I started to learn about the process itself. Dying, I thought, is a passive thing; it's something that happens to you. Not at all so. It takes a lot of energy (from both the dying person and her loved ones). Anyone who has ever sat vigil at the bedside of a dying person will know what I mean.

It happened to me with my dad. We sat and waited and found ourselves wishing he would just pass because it looked like such a struggle for him. We were exhausted. We hated ourselves for wishing he would go, for any reason. We told him it was okay to die. We told him we loved him a million times. Why was it taking so long? Was he being stubborn? I didn't know. I don't think we slept for days.

He, like many of the moribund, unbeknownst to me at that time, was actively dying, and that's normal.

What's so active about it? I wish I could tell you what was going on inside the consciousness of the dying person, but by this stage, usually the last 72 hours of life, nobody knows. I do know that many of my patients while still responsive often say things like, "why am I still here? Why can't I just go?" A few have outright shored themselves up and decided to pass, right then, and couldn't do it simply through power of will (seriously, "OK, I'm going to die now," with eyes squeezed shut).

Is there an internal debate? Is it simply physiological? Is it a necessary biological process like birth, in reverse? I wish I knew.

The body is busy during the actively dying phase. I think of it like a powerful jet engine going through the postflight checklist, system by system. Things stop working when systems shut down. Muscles stop: first the big ones that move arms and legs and then the little involuntary ones that move food and water along. So the person stays in bed and does not want to eat or drink (please don't water-log a dying person...they don't appreciate it).

Inevitably in this process, then, dehydration sets in. Vital signs get weird: typically, heart rate goes up, temperature goes up, and blood pressure goes down, just as they would with regular dehydration. Think of a radiator without as much fluid going through it day by day. It heats up. Most often actively dying people are not sick from an infectious process that can be treated to reverse the process. They're just working on dying.

All those fancy respiratory detectors and regulators we learned about in physiology seem unsure what to do with this new information, so their little dials spin and breathing changes. Spin, spin: breathe really fast. No spin: stop breathing. For a while the systems kick in from time to time and breathing begins again. Eventually, they don't.

Breathing also requires the help of some pretty big muscles, notably the diaphragm, and as I've mentioned those are shutting down. Breathing begins to therefore look labored. I don't know what this experience is like from the inside. People don't look bothered by it (the dying people, not the onlookers), and we give medications for air hunger just in case they are.

Finally, the heart, also a muscle, is winding down before it stops. Heartbeats become fast, thready, irregular, slow, hard to hear or palpate. What with all these circulatory shenanigans involving blood pressure and heart rate, the little bitty blood vessels on the periphery close down because the body shunts blood centrally. This, along with decreased efficacy of breathing, leads to cold, dark hands and feet (and, sometimes, nose) and eventually mottling, that distinctive pattern that appears on the feet, knees, dependent areas, and eventually anywhere.

Then there is the issue of swallowing, that hugely complicated and coordinated effort that we all do without any conscious thought, if we are lucky. Remember, muscles aren't working. When that happens, secretions pool in the back of the throat, causing the notorious death rattle. Sometimes we give atropine or scopalomine for these secretion noises, but I don't like it because we are just dehydrating the person even more.

My point with this incredibly unscientific recounting of dying is that there is a lot going on here. People don't just lie there and die; they are going through quite a lot physiologically. I often think of it as reverse labor. Everyone has a different experience of it, and the body has its own timetable.

Also, I should say that I believe these natural signs of the progression of death should not be personalized, meaning I believe that the apparent labored breathing, fever, and so on are typically not as bothersome to the dying person as they are to those observing, particularly when the person is being medicated. I'm all for medicating people if there is any sign at all that they are suffering.

Finally, part of the active dying process really seems to be mental or spiritual. Those who see a lot of death say things like, "what is he waiting on?" and then postulate things such as (a) waiting for a family member to come, (b) waiting for a family member to go, (c) waiting for everyone to gather around, and (d) waiting for everyone to leave. It sounded bizarre to me at first, but now I do it to because I've seen so many people apparently duking it out until something happens: a visit. A holiday. An anniversary. Some people will tough out a death vigil for days, and then when the person sitting vigil finally falls asleep they go ahead and die.

Again: there's a lot going on there. And that is why we call it active dying.