Ian West

Cast of characters Palliative Care Team RN – The purpose of this registered nurse (RN) is to offer palliative care to the Oncology Hospice Patient. For the purposes of this play, the RN is a male. Hospice Nurse – The Hospice Nurse offers hospice care to the dying patient whose prognosis is poor. For the purposes of this play, the Hospice Nurse is a female. Grieving spouse – This character is the partner of the dying patient. The grieving spouse is a husband of the dying patient for the purposes of this play only. He is also referred to as spouse in this play. Dying patient – The health condition of this character is detrimental. He is being offered both palliative care and hospice care by a dedicated palliative care team and a hospice nurse. The dying patient is the wife of the grieving spouse only for the purposes of this play. He is also referred to as patient in this play. Student nurse- This character is currently taking a nursing program and being trained to be a certified and licensed nurse in future. For the purposes of this play, the student nurse is a female. Synopsis A dedicated palliative care team, a hospice nurse and a student nurse give their all in dealing with the symptoms and examining the prognosis of the Oncology Hospice Patient. The interdisciplinary team is committed to improving the quality of life of the dying patient and her family. SETTING: The play takes place in an Intensive Care Unit (ICU) of a major hospital in with one of the best health systems in the U.S. The hospital is divided into five major wings. The ICU is located at the right side of the second wing which deals with Oncology. AT RISE: Four ergonomic chairs, two at each side of the ICU bed, to be occupied by other characters other than the dying patient who helplessly lies in her death bed. Lights are turned on as it has just turned dark. The dying patient’s condition seems critical but rather stable. The whole ICU is normally silent. Palliative Care Team RN: ”How are you feeling now? “ He honestly asked the patient. Dying patient: Unfortunately I am feeling worse than yesterday. My body has not responded as expected to the chemotherapy procedures that were carried out on my tumor yesterday. (He replied while in pain) At this very moment, the student nurse gives strange looks to the Palliative Care Team RN in dismay) Student Nurse: At what stage is the dying patient’s cancerous disease? (She directed the question to the nurse while wondering how the patient was able to speak so well regardless of the pain she was going through) Palliative Care Team RN: We can conclusively say that the illness is at a life-threatening and incurable stage. Neither can chemotherapy nor medication of any kind cure the disease. (He affirmed his statement) Grieving spouse: (He shockingly looks at everybody around the ICU bed. He is out of words. Within no time, he gathers enough courage and enquires from the nurse) did you just say the disease is incurable? Palliative Care Team RN: I sympathize with you but that is the truth. However we will deal with the symptoms of the disease, reduce stress and improve the quality of life of the patient and his family. You should not feel worried; we will handle this situation to the best of our ability up to the end. Grieving spouse: (nodding his head in agreement) that sounds encouraging. Thank you for making it clear. After a lengthy conversation, the Palliative Care Team RN and the student nurse leave the ICU to take a break and may be a nap for next day’s work leaving the patient in a stable condition under the care of her spouse for a short period of time. Next day in the morning hours, the Hospice Nurse is accompanied by the Palliative Care Team RN and the student nurse. They enter through the front door of the ICU as their patient’s bed is just next to the front door. Palliative Care Team RN: Good morning. (He greets both the patient and the spouse while wearing a white lab coat) Grieving spouse: Good morning sir. We feel encouraged by the support offered to us by the hospital and more specifically, the three of you. You are so dedicated to your noble work. The Hospice Nurse introduces herself to the dying patient and her spouse. Hospice Nurse: Good morning. I have been working as a senior hospice nurse in this hospital for the last twenty years. (The patient looked at the Hospice Nurse with sleepy eyes) Student Nurse: I can see the health condition of our patient is worsening day after day, sorry to say. What can we say about his prognosis? (She directed the question to the Hospice Nurse) Hospice Nurse: We can say that the patient has a poor prognosis; meaning that the chances of recovery are minimal. Student Nurse: It is good that you've made it clear to us. (The patient together with her spouse clearly heard the conversation between the student nurse and the Hospice Nurse but did not make any comment) Palliative Care Team RN :( He assesses the respiratory rate of the patient) the respiratory rate of our patient is very fast. She must be in pain. Out of the assessment I have done to our patient, She is experiencing hypo-perfusion meaning the blood flow in the body is low. We understand that the disease is life-limiting but be assured that we will work towards complex symptoms relief and relief of pain to improve the quality of life of our patient and family. The Hospice nurse is now sensitive about asking end-of-life questions to the patient. The nurse also plans to ask the patient about advance directive. Hospice Nurse: (She directs the question to the patient) The first thing I would like to know, is about your advance directive. Who would you want to make important medical decisions for you if you were to become really sick and unable to speak? Patient: I would suggest my lovely husband. (She replied miserably) Hospice Nurse: It is good you made a good and close suggestion, your spouse. That is agreeable as per the hospital’s terms and conditions. The hospital respects the end-of-life wishes of every patient and we would respect your wishes as well. I hope your spouse agrees with you. Spouse: I agree to make medical decisions for my partner in case she is unable to. The three nurses, the Palliative Care Team RN, the Hospice Nurse and the student nurse, collaboratively do some medical assessment to the dying patient. Palliative Care Team RN: We will have to do some sequential assessments to our patient. Let us first assess her breathing pattern. The student nurse passes the exhale-meter to the Palliative Care Team RN which he uses to assess the respiration rate of the patient. Palliative Care Team RN: From the assessment, I can confirm that our patient has cheyne stokes respiration, she is breathing abnormally. The patient’s blood pressure has increased and consequently, the heart rate has lowered. This indicates close to end of life. Hospice Nurse: (As she agrees with the Palliative Care Team RN) we have to continue doing a series of assessments so we can offer the best treatment. The next assessment we are about to do is Gastrointestinal assessment (GI) to assess whether there are any abdominal abnormalities. The Hospice nurse carries out the GI assessment to the patient with the help of other nurses. The grieving spouse is only helplessly watching what is happening. Hospice Nurse: We can confirm that the patient’s abdomen is abnormal. The belly has swollen and is extremely big. The patient can no longer perform body functions such as urinating. The student nurse passes the foley catheter to the Hospice Nurse. The Hospice Nurse passes the flexible tube through the urethra into the bladder to drain urine. The Hospice Nurse also notices that the urine output of the patient has decreased at an alarming rate. Palliative Care Team RN: We will now do an assessment on the Right Upper Quadrant (RUQ) of the patient’s body. We will assess the liver, right kidney, large and small intestine. Again the three nurses do the RUQ assessment and conclude that the body organs mentioned above are almost shutting down. This makes them conclude that the patient may be approaching her end of life. Hospice Nurse: The liver cancer has metastasized to the lungs which worsen the condition of our patient. The tumors will now spread to the lungs and that implies the disease is at an advanced fourth stage which leaves the patient at a critical state. Any treatment can only slow the growth of the disease and reduce its symptoms. The student nurse vividly remembers what she learnt about metastatic cancer back in medical college and confirms what the Hospice Nurse just said to her and the Palliative Care Team RN. Student Nurse: ”Why is the skin color of our patient turning yellow? “She directed the question to the Palliative Care Team RN. Palliative Care Team RN: We call that jaundice. It is a condition of a seriously ill patient and mostly signals liver disease and in our case, liver cancer. Among other symptoms, the patient is experiencing nausea. Student Nurse:” We should administer Glycopyrrolate and antiemetic drugs to prevent nausea.” She suggested. Palliative Care Team RN: Yes, that is a really good suggestion. The drugs will prevent the condition. The grieving spouse helps the nurses to administer to drugs to the grimacing patient. At this stage the Hospice Nurse faces the patient. Fortunately, the patient looks ready to answer any questions posed to her. Hospice Nurse: What do you think about the end of life? Dying patient: I know my health has worsened and am ready to accept death. Hospice Nurse: Who would you want to be your caregiver during your final days? Dying patient: My spouse. Hospice Nurse: What treatment types would you want? Dying patient: I would want any treatment as far as it makes me comfortable and out of pain but not a ventilator. Hospice Nurse: who do you want to make medical decisions for you if you are unable to speak? Dying patient: (The patient turns around the bed from side to side. She stammers in an extremely low tone) I… I would... I would still sa… y… my…my spouse. The DNR (Do-Not-Resuscitate) and DNI (Do-Not-Intubate) forms are brought to the patient to sign which she comfortably signs with the help of her spouse. Signing of the two forms respectively guarantees that Cardiopulmonary Resuscitation (CPR) cannot be carried out if a patient stops breathing and no breathing tube to be placed in a patient’s body but only administer cardiac drugs if necessary. Hospice Nurse: ”The patient in her final days of life. ” (She told the grieving spouse with a steady eye contact.) Grieving spouse: ”I agree with you . “He firmly agreed with the Hospice Nurse. Days are now gone with everyone monitoring the patient in her death bed. Everybody who has been serving the patient in whichever capacity seems to help the patient in the dying process and help her die with dignity. Student Nurse: ”Are there chances of our patient recovering? “ Hospice Nurse: Yes, but very minimal. Palliative Care Team RN: In my experience as a nurse, the highest percentage of patients in stage four of cancer, barely make it alive. Grieving spouse: (while looking at her beautiful partner in the ventilator) I would request that you do everything possible to save my partner. Hospice Nurse: Be assured we will do everything in our ability to save her. We will do the very best to offer treatment according to the medical assessments we carried out to your loving wife. The Hospice nurse held a therapeutic communication with the grieving spouse. The spouse seem encouraged by the words from the Hospice Nurse. The nurses continue giving medical procedures according to the assessments previously carried out. Chemotherapy was one of the medical procedures to relieve the pain in the tumors. Suddenly the chaplain appears to offer spiritual support to the grieving spouse, the patient who is in a deplorable state and the nurses as well. Palliative Care Team RN: We would like welcome the chaplain to make his remarks. Chaplain: I have really followed the case of our patient here while in the city church. We have always prayed for her together with other believers in the church. It is our hope that the patient’s condition will improve and she will recover with the help of God through our committed nurses. Grieving spouse: Thank you so much Chaplain for your words of encouragement. We all hope that my wife will recover anytime soon so we may reunite. Thank you also for your support together with other believers in terms of prayers and financial support as well. Hospice Nurse: We are very grateful for your visit here in the ICU. You have been a source of encouragement to us and our patient. We hope for best to our patient. The Chaplain said a prayer and left wishing everybody well while taking care of the patient. Palliative Care Team RN: Our patient is responding well to all medical procedures we have been carrying out. Intensive care will improve his condition. It is in the morning, days after the chaplain had left the hospital. Nurses are attending the patient as it has been their usual routine. To their surprise, the patient was able to clearly speak and that might be a good sign of recovery. What a shock this was to everybody including the nurses. Everyone tend to believe that the patient had defied all odds to recover from the life-limiting illness. Hospice Nurse: (Sitting down from where she was giving medical procedures to the patient for a while) this must be very good and hopeful news to this hospital and the world at large. Our patient has recovered from the life-limiting illness. The patient was able to hold a conversation with the Hospice Nurse. Her skin color had drastically improved and her health condition was better. Palliative Care Team RN: I am equally delighted with the recovery. Statistics show that only 10% of patients recover from stage four of metastatic cancer. We can count our patient today as a winner. (He also sits in the chair next to him) Student nurse: I am out of words to describe this experience. It is a milestone in my training as a nursing student. It is good that our patient has recovered from this serious cancerous disease. Thank you so much for the knowledge, skills and attitude that you have instilled in me for the period I have been in this hospital. Dying patient: Thank you to almighty for the cure. I also thank you all for your selfless efforts to fight for me till the end. I have come turned from a dying patient to a lively being. (She laughs while looking at everyone around her ICU bed) Spouse: I would say I am the happiest man on earth right now. I say a big thank you to each one of you. Palliative Care Team RN: I know the process has accumulated a lot of hospital bill. Consider all the bills paid in full. I have volunteered to pay the full hospital bill. The Palliative Care Team RN, the Hospice Nurse, The student nurse, the grieving spouse leaves the ICU unit through the front door with their faces very happy. THE END