The Making of a Nurse

by Tilda Shalof

  Phoebe, for example, is a born-again Christian and one of a small, but growing, group of nurses who speak openly about their religious beliefs and allow them to pervade what they say and do as nurses. “If I say ‘praise the Lord,’ or ‘God bless you,’” Phoebe said, “it opens a door for some people.”

  I have seen how a simple, well-placed comment like that from certain nurses did provide valuable opportunities for patients and families to find solace and communion. Many times I came upon Phoebe and other openly religious nurses praying with patients and families at the bedside. But some people maintain there’s no place in nursing for this kind of religious ministering, that nursing should be non-denominational and unaffiliated in order to avoid bias, prejudice, and especially, coercion. Justine used to tease Phoebe about her religious fervour. Once, when Phoebe said, “The most important things in life are God, my family, and my job,” Justine sidled up to her and poked her in the ribs, “Did you say dog?” She’d further deflate Phoebe’s evangelical zeal by reminding her once again that she was one of the few people on the planet who didn’t know who Elvis Presley was or tried to get a rise out of her with a comment like, “Come on, Phoebe, which is more important, how frequently couples pray together or have sex together?” which would make Phoebe blush and fall silent – until the next time.

  Justine was raised a Catholic but the only “religion” she practised was Compassion. She was guided by what she believed was the kindest course of action. One of the last patients she took care of in the ICU was Mr. Housden, an elderly man with Alzheimer’s disease who came from a nursing home. He’d been found slumped over in his wheelchair, lips blue, and vital signs barely detectable. He was intubated and brought to the icu. After a few hours, a resident came in and probably had no idea what he was getting into taking on a nurse like Justine.

  “I want to have a look at his numbers,” he said politely as he took the chart.

  “I hope you’re going to look at the patient, too,” Justine shot back.

  After reviewing Mr. Housden’s chart, the resident stood at the patient’s bedside, staring up at the cardiac monitor, thinking out loud. “His pressure is low and his heart is beating fast and irregularly. We need to give him fluids and maybe shock his heart back into a normal sinus rhythm. He may be intravascularly depleted. He looks dry.”

  “He’s not dry, he’s dying.” Justine held her patient’s hand and looked at him in dismay and then glared at the resident with disdain. “This poor man is trying to die.”

  “Yes, and I’m trying to figure out what’s wrong with him.”

  “I’ll tell you what’s wrong with him. His diagnosis is imminent death from old age.”

  “Yes, and there’s a chance we can save him from that.”

  “From what? From dying a day or two later?”

  “You never know, he might get out of here. We’re here to save lives, aren’t we?”

  “These heroics are cowardly.”

  “This man is probably someone’s loved one.” With his fingers he landmarked the man’s neck in the place he planned to insert a central line. Should he try for the subclavian vein and probably win praise from the staff physician or go for the easier internal jugular?

  “I hope no one ever loves me this much,” Justine said bitterly.

  A few hours later, after lots of drugs and electric shocks to his heart, they managed to get the patient’s heart in a slower, regular rhythm, but now his blood pressure was low.

  “The systolic is still in the double-digits,” said Justine, taking it manually with a blood pressure cuff. She went off in search of Old Father Powers who made rounds in the ICU every evening. He had watery blue eyes and big black glasses that always slipped down his nose as he checked the patient board for Catholic-sounding names. He jotted them down and then blessed the whole board of names, just to be on the safe side. Justine went over and gave him a bear hug. “The chaplain was here earlier for another patient and now you, Father,” Justine said. “Is the big guy gonna show up next?” The priest chuckled but as he drew closer to the patient, he became solemn. “Is he alive, Justine?”

  “He’s hanging in there, Father, just barely. He must be waiting for you.”

  “This is going to give the wrong impression,” the resident whispered to Justine while the priest administered last rites.

  “Which is what?” Even Justine could be made incredulous.

  “If the family shows up, it’ll make them think he’s not going to make it.”

  Justine looked at the blood pressure at eighty systolic, his heart rate fast and irregular. She ignored him.

  The resident got hold of a nephew over the phone and by default (as there were no other contenders), he became “next of kin.” He hadn’t been in touch with his uncle for years and said he wouldn’t be able to come and see him. “Please do everything you can for him. He’s a great guy.”

  We’d seen every type of family: families who came every day and those who didn’t come at all. There were families who didn’t wish to be present at the time of death and those who wanted to be there only at the time of death. Some families called in frequently, but couldn’t bear to visit. Nothing infuriated Justine more than when patients died alone.

  But this time Justine was fuming about more than that. “It is inconceivable that someone would die of natural causes!” she exploded at the resident when he came back from speaking to the nephew.

  “But we can do something for this guy. We can fix his cardiac rhythm and if he’s got pneumonia we can give him antibiotics. We can cure that. He may also have congestive heart failure, so we can give him a diuretic to pull off fluid and decrease his central venous pressure.”

  “Say, are we doing all of this for you to get in lots of practice so that when someone we can really save comes in, you’ll know what you’re doing? Is that it?” Justine wanted to know.

  “Try thinking outside of the box.” The resident started gathering together the supplies he would need to put in a central line, because he could see Justine wasn’t going to help him. “Don’t write him off because he’s old. Doesn’t he deserve a chance?”

  “Every organ in his body is shutting down, including his brain! DNR* is not some sinister plot to deal with the sick and infirm. Sometimes it’s the kindest thing.” She stomped off to cool down at the nurses’ station, leaving him to do the central line insertion on his own. Later, when it was time to give her patient his antibiotic, Justine headed over instead to the huge box of pastries at the nurses’ station left there by a grateful family, syringe in hand. “I’m going to inject it into this blueberry Danish. At least it’ll improve its nutritional content because it’s certainly not going to do my patient any good,” she said. Of course she didn’t go ahead with that outrageous plan, but returned to her patient and gave the drug as ordered. At the end of the shift, I found her sitting beside her patient’s bed, looking despondent. “I hate seeing people suffer unnecessarily. I hate keeping the dead alive.”

  We tried to cheer her up. Laura reminded her that at least it was better than the family that requested we keep their elderly grandmother alive until after her grandson’s bar mitzvah and only then withdraw treatment, or the woman who wanted us to maintain her husband on life support just so that she could continue to collect his pension cheques.

  Mr. Housden lasted two more days until life support was withdrawn and he died alone.

  These situations upset us all and we each have to deal with them. That was Justine’s turn and I was positive I saw something change in her that day. As it turned out, not long after that she made the decision to leave the ICU and a few years later left nursing altogether.

  MRS. ROSE GREEN was an Orthodox Jew, and I was assigned to be her nurse more frequently than any of the others. The nurses in charge must have figured I would have a special connection with her or that I’d understand her better than the others. I did come to understand her but it wasn’t easy. I had to work at it.

  Mrs. Green
was in her mid-sixties and had five children. Her husband and sons wore long black coats and hats and had side curls and long beards. They stood at the foot of her bed, swaying back and forth as they recited psalms of healing and prayers that called upon the “Great Resuscitator” to bring about a “renewal of body, a renewal of spirit.” For years, Rose had suffered from lupus, a disease of the auto-immune system, and consequently developed diabetes and chronic obstructive pulmonary disease (COPD). Despite a dysfunction in almost every organ system in her body, she coped as best she could, kept active, and managed to stay out of the hospital until eventually she was admitted to the ICU in respiratory distress and kidney failure. We got her through that crisis but a few months later she returned, this time requiring a longer period of dependency on the ventilator. Her chronic illness continued to flare up for the next two years, with the intervals at home getting shorter and the ICU stays getting longer and more difficult.

  “Ha Shem wants me to live,” she told me during one of those stays in the ICU. She used the general term “the Name” as she would never use the actual word or write it any way other than in short form, as “G-d,” because if that piece of paper were destroyed, it would be a defilement. “It’s not up to me,” she said with a shrug of her shoulders. “I am here to serve Him.”

  A year earlier she had been diagnosed with breast cancer. It had spread to her lungs and she underwent a mastectomy and had chemotherapy. “Now, I have two reasons to wear a wig,” she confided in me. It was a comment she probably wouldn’t have made to other nurses, but she knew I’d understand that the wig or scarf that she always already wore was a sign of her religious observance, a symbol of her modesty. A woman’s hair was only to be viewed by her husband. When she was well enough, we talked about many things. Most of our patients are unconscious or just too sick to converse with us to the extent that I could with Mrs. Green, and I relished the opportunity. I also sensed she liked having me as her nurse because it gave her the opportunity to explain the importance of the woman’s role in keeping a kosher home and welcoming the Sabbath on Friday evenings with the lighting and blessing of the candles. She herself could not light real candles while in the hospital because of the fire hazard, but electric candlesticks were plugged in for her at the precise moment of sunset so she could recite the blessing and they were not to be touched until sunset the following evening. When she was well enough, she could eat but was suspicious of the food provided by the hospital. The label that read “Kosher Style” upset her.

  “Food is kosher or not.” She pushed the tray away. “One can’t be a little pregnant, nu?”

  “What’s unkosher about clear fluids?” I picked up the can of ginger ale, the bowl of broth.

  “Jell-O, for example, is never kosher.” She pointed at the offending plastic cup. “Gelatine comes from horses, an unkosher animal because it does not regurgitate its cud and has an uncloven hoof. Even juice may contain particles of unkosher substances or may not have been properly prepared in a kosher facility.”

  “Why is there such a preoccupation about food?” It was something I’d always wanted to know.

  “Keeping kosher elevates the daily act of eating into a spiritual experience.”

  I thought of how often I grabbed something to eat in the car or stood with the refrigerator door open, in search of a snack. Mrs. Green explained that by keeping kosher one is reminded of the efforts that went into preparing the food and how the kosher method of slaughtering was humane and paid respect to the life of an animal that is providing sustenance to human beings. Through the mundane, we understand the holy, she explained. Through the daily, we connect with the eternal. “When I was a little girl, if I dropped a slice of bread on the floor, my mother taught me to pick it up and say a blessing. Bread is a symbol of life, and we must always show respect for life above all else.”

  Mrs. Green survived crisis after crisis and numerous resuscitations, but each recovery actually turned out to be a setback because it left her in a worsened physical condition. Her body was deteriorating, but her mind was fully lucid and intact. In fact, the very first thing she did upon opening her eyes every morning was to begin to move her lips in recitation of her daily prayers of gratitude and thanksgiving, to the “True Judge and Redeemer.” On more than one occasion she stated her wishes unequivocally. She wanted doctors and nurses to do everything possible, each and every time, to bring her back to life.

  “Even if that quality of life is compromised?” a resident asked her.

  “Who is to decide what is an acceptable quality of life?” she asked in the Talmudic style of answering a question with a question. “How can any life be deemed not worth living?”

  Here, finally, was someone who could tell us what she wanted. To me, privately, she added, “He keeps bringing me back, doesn’t he? I was dead and he revived me. Ha Shem took me right to the edge and said no, go back. There must be a reason.”

  The only authority she answered to was the word of “Ha Shem,” as interpreted by the scholars who wrote the Talmud. She and her husband, Mordecai, consulted daily with their personal Rabbi and relied on him to interpret the laws they lived by.

  Mrs. Green continued to have numerous admissions to the ICU and each time, I was assigned to her care. I didn’t mind, but it did present me with certain challenges the other nurses didn’t have to face. One quiet Saturday morning in particular, I was doubled with two stable patients, Mrs. Green and the patient in the room beside hers. I sensed Mrs. Green wanted to ask me for something but was hesitant. “Everything okay?” I asked her.

  “Could you please ask Noreen to make me a cup of tea?”

  I reminded her that I was her nurse and would make it for her myself.

  “No. If Noreen is too busy, please ask Tracy to do it for me.”

  “Just a minute while I finish giving these meds,” I said, “and I’ll plug in the kettle.” Why was she so impatient? Then I understood. According to her beliefs, I would be desecrating the Sabbath by boiling water, thereby using energy to transform matter. Even opening the refrigerator for the milk and inadvertently activating the light bulb inside was prohibited on the Sabbath. She would be transgressing by causing me to sin on her behalf, I explained to Tracy, who made the tea.

  The next morning, I was taken aback when her night nurse told me that the Rabbi had visited her, late at night after sundown, at the end of the Sabbath. “He asked her for a donation to the synagogue. He said he would say extra prayers for her and asked for a cheque for that, too.”

  “I guess she can spend her money this way,” I said slowly, thinking it over.

  “Yeah, but I don’t feel right about it,” the other nurse said, and explained her uneasiness. “She’s vulnerable. It’s like she’s at his mercy. The Rabbi was worried that her cheque might not be accepted at the bank, so he wanted me to witness her signature, but I refused.”

  “Yes, it does sound like they might be preying on her, as well as praying for her,” I agreed. “It doesn’t sit right with me, either.”

  “She’s angry at me for not signing and feels her independence has been taken away. She told me you would sign it because you’re Jewish, too.”

  But Mrs. Green didn’t get a chance to speak with me about the matter because that day, once again, her condition suddenly worsened. This time her heart went into atrial fibrillation that caused her blood pressure to drop. We had to shock her heart many times that day and eventually managed to bring it back to a normal sinus rhythm. But there were ominous beats on the monitor, and I brought the crash cart into the room, just in case.

  During rounds, Dr. Sandor put out a question that made us all think. Which was the bigger fear if we were to be hospitalized – that too much would be done or too little? That we would be over-treated with unnecessary tests and procedures or under-treated and important things missed? Most of the doctors said too little and most of the nurses said too much. Perhaps we trusted the system more than we should, but if so, then they, not enough.
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  Dr. Sandor has always been committed to making us scrupulously accountable in our practice. He has raised many questions over the years as well as a few eyebrows. He infuriates us, challenges us, and always makes us think. “Do you remember Mrs. Ford?” I asked him recently.

  “That was an important case.” He looked at me intently to assess if I realized just how important.

  It had happened years ago when I was still fairly new to the ICU but even then I recognized its significance. Mrs. Ford was a sixty-five-year-old woman with ALS*, also called Lou Gehrig’s disease, a slow, debilitating neurological disease that left her body paralyzed, but her mind awake. She was “locked-in,” unable to move or speak, yet fully aware of her situation. Dr. Sandor told her she could choose the date and time of her death. Her family gathered around her bed. She said goodbye to everyone. We started a morphine infusion until she was drowsy and at the same time slowly decreased the ventilator settings and the oxygen until she became comatose and then died.

  “How were we able to do that for her?” I asked. To this day, I’ve never really understood it. It seemed so radical to assist a patient to choose the day and conditions of her death and to watch her go from fully awake to drowsy, to unresponsive, to dead in a matter of hours.

  Dr. Sandor calmly explained. “In the case of Mrs. Ford’s death, we were, as always, guided by the patient’s wishes. At all times, we kept uppermost in mind the reasons we were giving the narcotic and we stayed focused on our goal of maintaining the patient’s dignity and comfort.”

  “I’M CONCERNED THAT your patient is allowing a religious authority to make decisions for her,” Dr. Sandor expressed to me privately, after rounds, away from Mrs. Green’s bedside. We were sitting at a long boardroom table in the glassed-in fishbowl, a.k.a. the “think-tank” behind the nurses’ station.

  “She did express her wishes, when she was last able to communicate,” I said.