What happened

Mom agreed last week to start taking morphine if the doctor and hospice could put together a drug cocktail that would limit the side effect of stomach cramps and itching. With the use of diphenhydramine hydrochloride, that shouldn’t be a problem. The hospice nurse was supposed to bring the drugs and instructions for administering them. I was there to transcribe the instructions or at least be another person besides mom who understood the instructions. Dad doesn’t get complicated instructions. Mom can’t retell them very well, even though she understands them. Hospice nurse didn’t show. Turns out Tuesday was her day off and she had rescheduled mom’s visit for Wednesday but didn’t tell mom. I left around 12:30 after waiting a few hours and calling a few times before finding all this out. Anyway, this is important (in my head at least) because mom wasn’t on morphine and my understanding of later events was colored for a time not knowing if it was mom’s condition, or her taking of morphine that was causing her to be non-responsive.

At 9 o’clock the evening caregiver called. After she fed mom, mom had regurgitated most of her food. This is something that had been happening for a couple of weeks, but on a smaller scale. All mom had told me though was the new food formula didn’t agree with her. I suspect it was more her body just rejecting food at all. I’m not a doctor though, so that’s a judgment call I’m not qualified to make. Tuesday night though, a fair amount went up far enough and back down into her lungs. They had suctioned what they could from her throat, but mom was having trouble breathing and was in distress. The caregiver told me it was the end. I discounted that pronouncement though because she’s seemed a little too ready in the past for things to be the end, when they weren’t. But it still was serious and I grabbed a book and some stuff to stay the night, and headed over.

When I arrived mom was sitting on her chair leaning forward, with a distinctive gurgling sound emanating from her throat as she breathed. She sounds like that when she needed to be suctioned of saliva, but this time they couldn’t reach it. Dad was on his knees in front of her hold her head up. She felt like she couldn’t breathe if she leaned back in her normal position.

They’d called hospice, and the on-call nurse was on her way. Though they were in the middle of another emergency so she wasn’t there yet. She came and helped us dose morphine. It would help mom breathe and make her comfortable enough to sit in her normal position. She told me that it was possible the aspirated fluids would cause pneumonia, which would pretty much be fatal to mom. So I was prepared for this to be the start of the end. That wouldn’t happen overnight though. I expected the night to be rough, and mom’s breathing to really start to decline over the next few days.

After a second dose of morphine at midnight, mom finally was able to go to sleep with the BiPap machine on. The caregiver took up a seat around the corner in the TV room (she can hear mom from there and can watch her from behind). Dad crashed out on the couch across the room, though he only lightly dozed. I went in to the guest bedroom, where I read Brokeback Mountain and then turned out the lights. I got about 2 hours of sleep.

At 3 am the caregiver woke me. Again it was the end, according to her. She wanted me to call Joe. She and dad had taken off mom’s bipap because she was essentially choking on the air. It should self-adjust to her breathing, but it could no longer do so. Her inhale would stop as soon the air started going in. Mom was mostly coherent. She was having a fit like normal when she was extremely uncomfortable but couldn’t explain why or how to fix things. She wouldn’t really communicate anything except that whatever it was we were doing wasn’t working. She spelled out “UP” to me with her foot. She wanted to go back to the forward position she’d been in when I arrived at 9. Dad can’t make out what she’s saying when she spells with her feet, and lots of times I can’t either. But I got that, and she relaxed when I said it. We got her leaned forward. However, she didn’t respond to anything else we asked. She could hear, but didn’t do anything more than move her feet in response, and not in a coherent way. In other words, she moved to indicate distress but not communication. She was so anxious that responding with “right foot yes, left foot no” wasn’t working. I then went in to the hall and called Joe. I told him Mom was not responsive and he should come up.

I called Elaine to tell her mom’s condition and to give her a chance to say goodbye over the phone in case it was the end. But she didn’t answer. I called Dan, and after the grogginess left him held the phone to mom’s ear. She wasn’t moving except occasionally in distress at that point. Then Joe arrived. He called Elaine but no answer, and then Elaine’s husband with no answer. They called back shortly thereafter though. Phones had been recharging in another room. Held the phone up to mom’s ear and they both said good bye. We told Elaine we thought mom could hear but weren’t sure. He asked mom to wiggle her toe if she could hear, and she did, which was the first time since 3 that she had done anything responsive. So we held the phone up so Elaine could talk some more since we knew mom could hear.

At this point I still wasn’t certain if it was the end, or if her being non-responsive was a result of the morphine. Morphine can make you sedated when you first take it, and that could easily be the reason why she wasn’t responsive. At 6 I called hospice because I wanted guidance. I knew there wasn’t really anything they could do to fix mom, though. The regularly scheduled visit was supposed to be Wednesday, and I asked her to get them to move it to first thing. They said they would. They would likely put mom on a morphine pump. At this point, I expected that mom had very little time left, but I wanted an idea of how much and an idea of whether she would be lucid at all again. That was essentially what I wanted when the nurse came.

After talking with hospice, we leaned mom back somewhat, but not as far back as she normally sat with the bipap. THe closer to supine she was, the harder it would be for her to breathe. Her diaphragm works against gravity in that position rather than orthogonally. So we didn’t go as far back because I didn’t want to hurry her death. But we couldn’t hold her head up anymore as we were getting very tired. So we went back just enough that her head leaned back against the back of the chair, and then used a piece of cloth to hold it in place.

The morning caregiver called at 5:45. I suspect she wasn’t going to come in, but Dad said mom was dying and so both her and her mom came (her mom is another one of our caregivers). We alternated holding mom’s hand and waited. This period feels busy, but I can’t recall what happened, if we had anyone come by or talk on the phone. The fourth caregiver also came in. I’m glad she did, and she was there almost until the end. She’s passed all her tests to become an LPN, but just hasn’t received the certificate yet. She’s the most medically qualified of the people we hired. Rock steady as a caregiver as well. Oh, the next door neighbor came by and held mom’s hand for an hour or so. She and mom were good friends. She then went to work, but they told her to go home at noon because she was so distracted. We sent the overnight caregiver home. Told her that she needed some rest if she was going to come back that night. She made me promise to call her after hospice arrived and told us anything.

At 8:45 the hospice nurse called. She had ordered the morphine pump and was waiting at the pharmacy for it. She expected that to take a half hour, and another half hour after that to get to our house. She arrived just before ten. She installed the pump and explained everything to us. She took mom’s pulse, temperature, measured her breathing. She told us that typically people in mom’s condition live another 12 to 24 hours. Not a few days as I thought might be the case with pneumonia. She might have some lucid moments but that was not guaranteed. Likely she’d aspirated so much fluid that the remaining space in her lungs couldn’t absorb enough oxygen, particular since her muscles couldn’t move her lungs very well either. Her heart rate would accelerate as her breathing weakened trying to make up for less oxygen in the blood. And then it would lessen as lack of oxygen affected the heart itself. Her extremities would turn blue and the color change would travel from the ends toward her torso.

Before she arrived and told us that, I called Jason. THe plan had been originally for him to come up and we would work on his resume. THen my grandparents wanted to visit and so Jason would drive them up (mom gets upset when they drive) and they’d visit mom while Jason and I worked on his resume. I told him mom took a turn for the worse, though we didn’t know much at that point. But things obviously had changed from Monday’s plans. I wanted to make sure he was okay with the changed conditions. I told him mom was unconscious and had been nonresponsive since 4:30 or so. My grandparents might be upset. So I wasn’t sure if he wanted to drive people he barely knew into that situation. He was willing.

We called both Elaine and Dan to tell them. I left mom’s around 11, headed home for a quick shower and supplies. I expected to hold vigil at mom’s overnight. I called my grandparents on the drive back and explained mom’s changed condition. They took the news pretty well, though I didn’t give them the time prognosis. And I also called the overnight caregiver. I got back to mom’s around 12:30.

The hospice nurse had left by then. The hospice social worker had also arrived and left. The caregivers had moved mom from her chair to her bed. I can’t remember the reason.

We were still alternating people holding mom’s hand. Her breathing was very irregular at that point, and her legs were blue up her calves. Someone from the church came and prayed with mom. The rest of the family were talking, holding conversations, keeping the room as pleasant as possible. Jason arrived with my grandparents. Mom’s breathing stopped, and Joe held her hand as her heart stopped. It was 1:50.