Healing in the Dying Time

Joan Furman, MSN, RN, AHN-BC, CET III Presented to Nashville Psychotherapy Institute January 9, 2009

Flow

Be, as water is, without friction. Flow around the edges of those within your path. Surround within your ever-moving depths those who come to rest there— enfold them, while never for a moment holding on. Accept whatever distance others are moved within your flow. Be with them gently as far as they allow your strength to take them, and fill with your own being the remaining space when they are left behind. When dropping down life's rapids, froth and bubble into fragments if you must, knowing that the one of you now many will just as many times be one again. And when you've gone as far as you can go, quietly await your next beginning. © Noel Frederick McInnis

The names and illnesses of clients and sometimes their sex are changed in the case studies I will present. Unless otherwise specified, much of the material in this presentation is derived from my book, The Dying Time: Practical Wisdom for the Dying and Their Caregivers. (Crown, 1997).

Why on earth anyone would spend so much time on death and dying? As a young adult, I chose nursing as a profession and was exposed to dying and death before I turned 20. During undergraduate school, I lost many friends in Vietnam, around one a month. At 22, I had my own near death experience where I realized I had witnessed my own resuscitation from above the bed, and I had the ability to observe, sense, perceive, to evaluate the techniques being used and experience other thoughts and feelings while not inhabiting my body. This is described in The Dying Time in detail. I never shared that experience for 15 years after it happened until people started describing near death experiences in the literature. I had assumed it was some sort of aberration or hypoxic hallucination. And finally, my childhood sweetheart’s plane crashed in Vietnam the night before he was to come home. Without all of these experiences, I learned about death and grief at profound levels and came to wonder how most people learn about death?

Socrates said:

“Death is one of two things... Either it is annihilation, and the dead have no consciousness of anything; or, as we are told, it is really a change: a migration of the soul from one place to another.”

He also said:

“To fear death is nothing other than to think oneself wise when one is not. For it is to think one knows what one does not know. No one knows whether death may not even turn out to be the greatest blessings of human beings. And yet people fear it as if they knew for certain it is the greatest evil.” And Jules Renard said similarly: “We are ignorant of the Beyond because this ignorance is the condition of our own life. Just as ice cannot know fire except by melting and vanishing.”

From my experiences, I learned early the survival of consciousness, the impermanence of all things including life and the depths of grief. All of this happened before I was 25.

I felt a commitment to life’s transitions as a nurse practitioner in newborn intensive care and later the AIDS epidemic. I have attended about 2000 births and have provided care at about 1100 deaths. I wrote my book because I wanted to make dying less frightening, mysterious, and out of control, and more peaceful, loving and safe for everyone in my care. At one time my practice was about 80-90% clients with life threatening illness, dying and bereavement. Today those folks comprise only about 5%.

The theme of this whole year’s topics has been “Healing Separation and Restoring Union: Within Individuals, Between Individuals and Between Individuals and That Which Sustains Them Spiritually.” Congratulations to our co chairs for this theme. Obviously this speaks dearly to me. But what does healing and restoring union have to do with dying? The word healing comes from the Anglo Saxon “haelen”, meaning to make whole. It has nothing to do with curing. Healing can and does occur through the final breath of life and possibly beyond.

I am reminded of a client I’ll call Mark who, raised in a conservative family was dying as a gay man. His mother was distraught over her fear of his last breath being followed by burning in hell for his sexual orientation. She loved her son very much and although he knew her fears, she kept a quiet anxiety about them at his deathbed. As he was approaching his final breath, he turned purposefully toward her, smiled and looked directly into her eyes. Until his breathing stopped, he smiled. She said, “Oh honey, I can see it. You’re just fine. Thank you for letting me know.”

Healing can and does occur for the survivors even after the loss.

Today I’m going to talk with you about four things:

1. When Illness Takes Over: Deciding about Curing or Healing when it’s the end of the journey.

2. Helping your clients find meaning and purpose in life:

3. Helping Clients Finish unfinished business

4. Helping Clients Find Meaning in Death

When the dying time begins, the question you can help clients explore is regarding the goal:

When Illness Takes Over: Deciding about Curing or Healing

Medical care of people with life-threatening illness can have two goals: curing and recovery, or comfort and spiritual and emotional healing. Continued life is the goal of the first, and graceful and meaningful death the goal of the second. If there is to be any dignity and meaning in the death, then a shift to the second goal will become appropriate at some point.

While most people indicate that they wouldn’t want to end their lives on a respirator, it must be borne in mind that this journey is never a leap from perfect health to the hospital bed. There will be a thousand perfectly rational and logical decisions between the two. Before your terminally ill client gets on the road that leads to the intensive care unit, you can help prepare him or her to explore the map with the physicians and nurses. Ask where the proposed treatment will lead, and not to be satisfied with evasions or “Let’s wait and see.” As humans, we are inclined to believe that one more treatment, a few more days, will allow us to turn the corner. Just where the road will lead once past the corner is frequently unclear. Knowing the desired destination can make the journey much easier, and you can help your client find the right route. This only really works if you don’t see death as a failure or more politely put: giving up.

Most of the modern treatments that turn into nightmares for the dying are perfectly appropriate when the patient is expected to recover. The use of a respirator to get a person through open-heart surgery, or past the trauma of an auto accident, is entirely justified. The use of intravenous feeding to rest the digestive system during infection is completely appropriate. What may NOT be appropriate is using these same treatments or painful and invasive diagnostic tests when your client is clearly dying of a disease the physicians know they cannot cure. For example, pneumonia has long been known as the “old man’s friend.” It is a complication that can usher us quickly and relatively easily toward our death when a terminal illness or very advanced age is present. It can be treated with antibiotics, and occasionally with a respirator, and your client can survive the episode and then later die of another complication, which may be more painful or distressing. Even intravenous fluids are now considered unhelpful in the final few days of life when the body naturally and painlessly dehydrates from lack of interest in fluids, and in fact, this state, called “terminal dehydration”, assists the dying by providing chemical changes that reduce pain and anxiety. So you can see it is so important to explore your own feelings about death and your own desire to pursue staying alive more than living, as Patrick Swayze told Barbara Walters the other night in his interview about his cancer diagnosis. If you believe that keeping up the fight at all cost is the right thing to do, you may inadvertently convey that to the client or family.

One client, I’ll call Mary was worn out from chemotherapy, radiation, more chemotherapy and then a bone marrow transplant. Through a discussion of this topic, Mary decided that after the living hell of 6 torturous weeks in isolation, in intractable pain, that if she suffered another complication that could be “treated” that she would decide to let nature take its course. In this case, the family was on board. That’s not necessarily true for others. (Often we see the son riding in on a white horse from Seattle who aims to save Mom when Mom and the rest of the family have reached a peaceful place of letting go. That is often why unnecessary artificial continuation of life happens because that son may be the one who brings a lawsuit.) Mary developed a rapidly progressive metastasis to her lungs that resulted in acute respiratory distress, but she had planned with her physician to administer enough morphine that she would not be afraid of the sensation of air hunger. We gathered her husband and high school age children into her hospital bed and they lay with her as she quietly took her last breath, having told them of her love and smiling the whole way. I will never forget the beauty of that moment. I was filled with the same awe and touched as deeply as any birth I had ever attended. It was as though she had given birth to her children and they and her husband were helping her give birth to her now formless self. As in most experiences of this kind, when the life force left her body, everyone became distracted. Often gatherers at the bedside stare at cardiac monitors or the rise and fall of the chest and then seemingly get distracted or lose focus when the life force departs. So much of the wonder of death defies words or even conscious or logical thought.

Steven Levine in his book Unattended Sorrow (Holtzbrinck Publishers, 2005) and Carol Orsborn’s Speak the Language of Healing (Conari Press, 1999) refer to life threatening illness as an initiation. Illness creates panic and a loss of control. In the midst of strangling fear, people can learn to love themselves, to redefine themselves. Life threatening illness brings to the surface what may have lingered there for decades and the client may have to “confront themselves and choose between self-mercy and self-doubt.” (Levine p. 203). As Zen masters ask “What was your face before your were born?” we may all have to ask: Who am I if I’m not a therapist, if I lost a child and am no longer a parent; if a spouse dies and I am no longer a husband or wife; if I used to be strong physically and now all my strength is needed for activities of self care even on a good day; if I was an avid reader and my illness takes away my sight? If I have diabetes and my musical fingers have to be amputated.

Terminal illness creates crisis at physical emotional and spiritual dimensions unlike most anything else we ever face. It even raises questions of our own identity.

Helping your clients find meaning and purpose in life

Life review is a gift you can give your clients. Without fanfare, you can begin to ask questions that address finding meaning in the life that will be shortened.

Ancient Egyptians believed that upon death they would be asked two questions and their answers would determine whether they could continue their journey in the afterlife. The first question was, "Did you bring joy?" The second was, "Did you find joy?"

The great Buddhist teacher and author of The Tibetan Book of Living and Dying, Sogyal Rinpoche said:

Normally we do not like to think about death. We would rather think about life. Why reflect on death? When you start preparing for death you soon realize that you must look into your life now... and come to face the truth of your self. Death is like a mirror in which the true meaning of life is reflected.

A couple of years ago, I worked with Michael, a man who was dying of lung cancer after years of smoking and living hard. He had worked through his guilt about his addiction to nicotine being the probable cause of his death, but he had not yet made peace with his life, which had been full of parties and travel and over-exercising his ample talent as a wine connoisseur. He had only a fleeting relationship with depth and was doing some last minute searching for meaning in his life before it was over. I shared with him the Leonardo daVinci quote: As a well spent day brings happy sleep, so life well used brings happy death, and asked him what he thought. With big tears in his eyes, he said that was all he needed; that he knew for sure he had used up his life well. Michael died a content man.

I can’t say it is always that simple.

Stan, who had been born with multiple deformities and had undergone a lifetime of painful surgeries, was caring for his beautiful younger sister who was dying of AIDS. Maggie had never been accepted by her family because of her various lifestyle choices and compulsions and their particular religious beliefs. She was bed-ridden and Stan was trying his best to provide for her physical care. Stan usually acted very efficiently, a bit cold, and although he never said anything negative, had an angry edge to his voice. Maggie was too sick to do much more than receive care. She talked with me about how difficult his quiet hostility was, but couldn’t see any choice but to tolerate it.

One day in his exhaustion, Stan blurted out, “At least you could have taken care of me. I didn’t ask for what’s wrong with my body.” With his own shortened life expectancy, Stan apparently had counted on Maggie’s being there to help him when he might need her later. In fact, the whole family had planned for Maggie to be her brother’s caregiver when his dying time came. While Maggie might have been devastated by this remark, she felt a peculiar relief that finally Stan had said what she knew he and the rest of the family were thinking. They fought and argued and cried, fought some more, and finally came to a peaceful resolution with each other, their love winning out over their antagonism for each other’s values. Stan later told me that he had not stopped blaming her for her illness, but he decided to stop punishing her for it. Acceptance of Maggie’s value and dignity as a human being would have been the next healthy step, but this was as far as this family could go in healing.

Helping Clients finish unfinished business

Richard was a twenty-nine-year-old man I cared for for several years with a chronic debilitating illness. He felt sick all the time and struggled to keep working because he loved what he did. In September of that year, after another hospitalization and fifth brush with death, he was in my office discussing how many more life-threatening situations he might survive. He knew and accepted that he was going to die of his disease, but wondered why he hadn’t so far and when it would eventually happen.

I asked him, “What do you want?”

He answered, “I want to be thirty.”

I got up from my chair under the rather silly pretense of looking up his birthday on his chart and took some deep breaths to keep from sobbing in front of him; and then I said, “Well, Richard, your thirtieth birthday seems to be coming up on November 29th. I think you can be thirty if that is what you want.”

Richard entered the hospital with another infection on November 26th. He was very quiet and withdrawn, in fact, disinterested in people and events going on around him. I left town for the Thanksgiving holiday, aware that his birthday would occur over the weekend. I arrived back in town on November 30th, the day after his birthday, to find that Richard had just died quietly, surrounded by his family and friends.

I have also known the dying to wait until after a favorite holiday or anticipated trip. Or they may die before the winter holiday season if it was historically a depressing time for them. Men often die before a birthday, and women after. One elderly and very ill client defied all predictions of his truly imminent death when he found out his first grandchild was due in eight months. He lived long enough to hold his granddaughter and even to see her smile.

But sometimes unfinished business is more challenging to negotiate as a therapist. Not much is uglier than unfinished business and bitterness in the family during the dying time. First of all, you can help families not say all the wrong things. Here’s a list I’ve heard, literally:

1. Don’t cry. You’ll make yourself sick.

2. See it as a challenge.

3. Cheer up. It’s not the end of the world. (I heard that one from a doctor to the mother of a dying 30 year old).

4. Time heals everything.

5. I know what you’re feeling.

6. It’s God’s will.

7. She’ll be better off dead.

8. You shouldn’t feel that way.

9. Be positive. Be brave. Be strong...[be anything so I will feel better]

10. You should have seen the way poor Anne died. This is nothing.

The dying time creates opportunity to heal unfinished business, but it also creates more unfinished business because of the suffering the family endures. Family caregivers suffer enormously and their healing can also be a challenge.

My co-author of The Dying Time, David McNabb was caring for his partner who was dying of AIDS and this is a quote from our book:

“David: Danny and I had been together for 17 years and had known for many years that we were HIV positive. When he started to get really sick, it didn’t come as a surprise for either of us.

For a period of about six months, his anger got the better of him, and he took it out on me as the most convenient target. On top of all my increased responsibilities around the house and his care, it seemed impossible to please him. Formerly, he was one of the sweetest, most emotionally stable people I knew. Although we had never talked about our loss of each other, now we found it impossible to get through the day without at least one shouting match.

This was finally resolved a few months before he died. Friends had told him that he was being too hard on me, and then one day, it just became too much. I took down the suitcase and I said, “That’s it. I’m leaving. I can’t take this any more!”

I started to throw things in the suitcase, right there in front of him. Then I became so overcome with emotion I just ran out of the room, went into the living room, and collapsed on the sofa in tears.

In a few minutes, he shuffled into the living room, and came over and cradled me on his lap. He stroked my hair and said, “Everything is going to be all right. I’m so sorry I hurt you.” I said, “Danny, nothing is ever going to be all right again.” After a while, I calmed down, and then helped him back to bed. He never yelled at me again.”

Four years later, I took care of David throughout his dying time and experienced his outbursts. This demanding anger on the part of the dying person is a very common experience and we can help caregivers by giving them permission to set limits on their tolerance. Caregivers need support to help them normalize their experience, to stay connected to the dying person and to stay connected to themselves, a daunting challenge when they alternate between the emotions David expressed and the secret desire to have it all over with, even fantasies of hastening death.

We can teach healthy self-care and give permission to ask for help and take breaks. I encourage regular breaks early on because the dying often demand 100% care by one person and having other people come in regularly establishes a pattern that can make it more acceptable. We can encourage a good support system, time to meditate and reflect, keep a journal, watch a funny movie, take walks outside, maintain some normal interests, and eat healthy foods, engage in a regular spiritual practice and find ways to be touched, such as a massage, especially if the dying person was their primary source of touch. Many caregivers become ill, overweight and emotionally and spiritually separated from themselves and we can help so much by just giving permission to remember to stay connected to the self.

And lastly about finishing business, help the dying and their families accomplish what I call “The Big Five”: I am sorry; I forgive you for; thank you for; I love you (if it’s true) and goodbye. That is not as easy as it sounds because people usually fear that such final talk is premature, even when death is imminent. The bitterest tears shed after death are for words left unsaid. We can help with that even if the opportunity is lost before the death, by asking survivors to write these Big Five, or ask them to speak it to a prop such as a piece of fabric or stuffed animal or index card or empty chair in your office. This omits the healing that could have occurred for the dying person, however. They may have wanted to say the Big Five too and just needed it facilitated. We can do that.

Helping Clients Find Meaning in Death

Death is a great teacher and provides opportunities for healing and connection. Like birth, it takes its time, it’s often slow and it’s big and sometimes it’s messy and painful. As a therapist, you may find yourself at the deathbed of a client. As you all know, hearing is present even to those in coma, so I encourage family to continue talking to and around the dying as though they are listening. Touch is also important and you can encourage families to put a hand on the patient’s hand or a foot or on the heart or crown. Giving permission to touch the person whose life is ending is a gift you can give to the family as a therapist. Attending the death is a gift you can give yourself. It will change you.

Angie, a ten-year-old girl who was dying from complications of a disease called scleroderma, loved it when I used the touch therapies with her, particularly Reiki. In the hospital during the evening of her death, she was restless and fearful. She was aware that the end of her life was near and was worried about whether she had been good enough to go to heaven. I had been keeping my hands in place and encouraging her parents to do the same, and talking with her about safety and peace.

During one of the interruptions, when we had to step back to allow a nurse to do a procedure, even though Angie had hardly spoken at all that day, she opened her eyes and said, “Don’t stop. That feels good. It feels like the angels are here.” We held our touch to her until she smiled, looked up at the ceiling and took her last breath.

This smiling and looking up is a phenomenon I’ve witnessed hundreds of times in the last moments of life. Each of us may have a spiritual orientation that helps us interpret events like that.

Rumi said, “Die happily and look forward to taking up a new and better form. Like the sun, only when you set in the west can you rise in the east.”

White Eagle, a Native American said, "You live on earth only for a few short years which you call an incarnation, and then you leave your body as an outworn dress and go for refreshment to your true home in the spirit." The Christian tradition might interpret Angie’s and others’ smiling as they leave as seeing God or the gates of heaven. Many of my clients of varying faiths and no faith have told me they see a light. Even my 17-year-old cat Gigi stared peacefully at the corner of the ceiling while she was being euthanized.

Mary Oliver said in her poem “When Death Comes”:

“When death comes like the hungry bear in autumn; when death comes and takes all the bright coins from his purse

to buy me, and snaps the purse shut; when death comes like the measles-pox;

when death comes like an iceberg between the shoulder blades,

I want to step through the door full of curiosity, wondering: what is it going to be like, that cottage of darkness?

And therefore I look upon everything as a brotherhood and a sisterhood, and I look upon time as no more than an idea, and I consider eternity as another possibility, and I think of each life as a flower, as common as a field daisy, and as singular,

and each name a comfortable music in the mouth tending as all music does, toward silence,

and each body a lion of courage, and something precious to the earth.

When it's over, I want to say: all my life I was a bride married to amazement. I was the bridegroom, taking the world into my arms.

When it is over, I don't want to wonder if I have made of my life something particular, and real. I don't want to find myself sighing and frightened, or full of argument.

I don't want to end up simply having visited this world.”

Libba Gray, a dancer and actress who was dying of breast cancer, wrote a few weeks before her death:

“When I die I will dance just above the horizon with everything patched and mended where nothing hurts anymore and breasts and legs break through clouds to the beat of thunder and the shine of lightning where blue jays wing pirouettes with sparrows and rainbows ring my wrists and head and dolphins will rise up leaping and somersaulting all around me ocean waves will clap wildly while I bow and the mountains bow and I blow kisses to the earth and give God permission to draw the curtain all the time shouting -- "it was good Lord it was good."

Libba Moore Gray

Ultimately we fear death because we fear being forgotten. In Jewish tradition, you live as long as someone remembers you. We can help clients and their families create lasting memories through journaling, shooting video, writing letters to present and future family members, and actively creating a meaningful memorial service. Countless songs have been written about this concept of being remembered, seeing beyond form, such as this one of Josh Groban’s.

Remember Me performed by Josh Groban lyrics by James Horner and Cynthia Weil

Remember I will still be here As long as you hold me In your memory Remember When your dreams have ended Time can be transcended Just remember me I am the one star that keeps burning so brightly It is the last light to fade into the rising sun I’m with you whenever you tell my story For I am all I’ve done Remember I will still be here As long as you hold me In your memory, remember me I am that warm voice in the cold wind that whispers And if you listen you’ll hear me call across the sky As long as I still can reach out and touch you Then I will never die Remember I’ll never leave you If you will only Remember me (Remember me) Remember I will still be here As long as you hold me In your memory

I’d like to close with some concluding words from The Dying Time that ironically have been quoted all over the internet in the literature of each of the world’s great religions. I guess I didn’t offend anybody with this part:

The circle of life is eternal. It begins where it ends and ends where it begins; birthing and birth, growing and life, dying and death, birthing into new expanded awareness, new lives replacing those departed. Every day, in all life forms, as one leaves, another is born; as one phase of life passes, life surpasses itself. Death closes and thus completes the raw beauty of the circle as we are capable of seeing it while we are still alive.

However, in the midst of the tragedy of losing your own life or the life of one you love, it may be hard to conceive of a circle, of anything continuing or continuous. Your loss is too close, too tragic perhaps, to even comprehend the circle of life. It may simply feel like a horrible and useless tragedy, or you may consider it as tragedy in the epic sense.

The word tragedy conjures images and feelings for all of us. If we look at Shakespeare, we see parallels to the real life drama of the dying time. In these epic tragedies, there are three consistent characteristics. First are the noble characters whose lives cause them to be raised above the common concerns and normal life. In facing your death or in being a caregiver, you encounter and handle challenges far beyond what you believe yourself capable of, far beyond common concerns. Second, there is a tragic flaw that overcomes the hero and kills him; the hero always dies. For you this manifests not as a flaw of character, but of the physical body, causing imminent death. This physical flaw that cannot be overcome must be faced and accepted, and ultimately all must surrender to it.

The third characteristic of tragedy is the catharsis which arises from the realization that the world is a better place for the hero having been here. The way in which you face death leaves your special mark on the world. It empowers others to learn and grow. It engenders closeness and intimacy within the circle of family, friends, and supporters by allowing them to participate in the dying. The caregiver, too, helps a loved one who is dying in many ways that make her world better by allowing her to be in charge of her living and dying.

Each divine creation is both noble and beautiful and therefore the subject of tragedy when life is lost. In true tragedy, everyone experiences the full range of genuine caring to alleviate suffering, and expresses a life-changing emotional commitment to the one who is dying.

I would like to close the circle with the words of Goethe: “Every moment Nature starts on the longest journey, and every moment she reaches her goal.” The dying time is a time of living and learning and reaching for new goals. As you choreograph your final act or help the one you love, who is dying, I hope that you hold on to the light that you experience and that you emerge as the life that surpasses itself.

References

1. Furman, Joan and McNabb, David. The Dying Time: Practical Wisdom for the Dying and Their Caregivers. (Crown, 1997).

2. Levine, Steven. Unattended Sorrow (Holtzbrinck Publishers, 2005)

3. Orsborn, Carol, Kuner, Susan, Quigley, Linda, and Stroup, Karen. Speak the Language of Healing (Conari Press, 1999)

4. Sogyal Rinpoche, The Tibetan Book of Living and Dying. San Francisco: Harper San Francisco, 2000.

Guided Imagery for Creating a Safe Place

Instruction

Use this guided imagery or visualization to create a safe place. You may create this on your own or ask your therapist or a friend to read it to you. If you tend to dissociate when you do a relaxation exercise, you might want to ask for your therapist's help. Either way, I suggest the following process:

1. Read through the script and decide if it sounds okay to you.
2. Make a recording of the script. (It is much easier to relax if you are listening to your voice or the voice of a safe friend rather than trying to remember what was written.)
3. As you record, remember to slow down and lower your natural speaking voice. Leave pauses at the ends of phrases and sentences. Leave longer pauses where you are imagining doing something, such as standing under a waterfall. Talk in as soothing a voice as you have, as though you are calming and soothing a little child. If you want background music in the recording, choose something that is very soothing and won't change beat, tempo, or pitch. Be sure that the music won't stop in the middle of the recording.
4. It will take about 20 minutes to record the imagery. Turn off the phone and be sure that you have a safe and quiet place to record. Remember: speak slowly and pause frequently, at least at the end of each phrase.
5. After you have recorded the imagery, practice the visualization several times, until the pattern becomes clear in your mind and your body responds automatically. If, at any time, you feel unsafe, open your eyes, stop the imagery, and reground yourself in today. Get up and do a nurturing activity. Call someone on the telephone and tell them what is happening. You are safe and you have control today.
6. After you have practiced the visualization, you can follow the abbreviated version when you are feeling the need to go into safety. Sit or lie down in your usual position for the visualization. Allow your body and mind to remember what to do. Begin to breathe as you do in your safe place, and take yourself to your safe place.

Imagery for Creating a Safe Place

Allow yourself to be in a comfortable position, either lying down or sitting up. If you're sitting up, place a pillow behind your back, and allow your neck and your back to be nicely supported, not leaning back too much if you have difficulty staying awake. Remember that if you feel afraid at any time, just open your eyes and ground yourself in today. You are safe and you are in control today.

Begin to take a couple of long, deep breaths all the way down into your diaphragm. [Inhale.] Hold it, and as you exhale, let go of the tension. [Exhale] Letting go.... Take another deep breath all the way in. [Inhale.] Allow all the tension to move into your lungs, and then let it go, [Exhale.] just begin to let go.... And if you're still feeling tense, repeat that process a few times as you begin to let go, begin to relax.... Create a silent and healing space around you.... Focus only on your quiet breathing and the sound of my voice. . . allow yourself to begin to let go, to create a healing time, a time of peace and safety.... I'm going to count from seven to one. And with each descending number, you'll find yourself becoming more and more relaxed. Relax your body, relax your mind, focus only on your breathing and the sound of my voice and letting go. Seven.... Relax your feet and ankles. Allow your feet and ankles to become very relaxed. Wiggle your toes to let the tension out.... Allow this relaxation to drift up into your calves and your knees, relaxing those muscles in your legs, even relaxing the bones.... Allow the relaxation to drift up into your thighs, relaxing those muscles in your thighs. And gently relax your hips and your pelvic area. Relax your lower abdomen all the way to your navel.... Relax your lower back. Six.... Let the relaxation gently drift. Let it drift up into your solar plexus area and into your chest and your lungs, just letting go.... Let the relaxation surround your heart and your lungs, and relax. Notice how gentle and quiet your breathing is becoming.... Let the relaxation drift around to your back. Relax each bone in your back, and all the muscles and all the nerves, as the relaxation fills your shoulders now, gently spilling over your shoulders and down to your elbows.... Relax your forearms and your wrists.... Relax the palms of your hands and your fingers. Five.... Relax your neck, all that tension that holds your shoulders up, tight, around your ears. Let your shoulders drop now, and let the tension go.... Allow the relaxation to drift up the back of your scalp and into your head.... Each breath allows you to become more and more relaxed. Let the relaxation drift into your eyes, and your nose, and your cheeks.... Your mouth becomes so relaxed, your tongue relaxes enough to drop away from the roof of your mouth. Your jaw drops just a little.... You're so relaxed. And going deeper, you relax. Four.... Three.... More and more relaxed.... And two.... Scan your body for any remaining pockets of tension. And let go.... And one.... You find yourself in a safe place outdoors. Perhaps it's not a place you've ever seen before except in the beauty of your own mind. You see a place outdoors that is beautifully safe.... Allow the images to come.... For in this place of safety, only you are allowed. In this place of safety, no one can come without your invitation. In this place of safety, you are always at peace.... Allow the images to come.... Notice the color of the sky at your favorite time of day. And in this place, at this most perfect time of day, at the season and the temperature that you like on your skin, allow your senses to become more and more alive. Look around at the surroundings and allow yourself to see; if not with your eyes, then sense with your heart.... Each time you come to your safe place, you may develop it and allow it to become more and more beautiful. Allow yourself to see what is here today.... Notice the color of the trees or flowers or grass, or perhaps sand or water. Let the colors and textures come alive for you in this beautiful and safe place.... Listen to the sounds of safety.... Perhaps you hear birds or splashing or the sound of wind in the trees or the grass.... Allow yourself to create a place of safety and peace that is always yours, always safe.... And breathe in the safety. And breathe out the fear. And breathe in the safety. And breathe out the fear.... As you breathe in, you can even smell the smells of safety.... Perhaps salty air, or the sweet smell of a flower.... Breathe in the smells of your safe place. It's so safe here that you can even taste it as you lick your lips. Let yourself bask in the safety and the peace.... Allow yourself to walk around, to be in this place, to notice more and more, to create more and more in this place.... Perhaps you would like to build a shelter of some kind, a cottage, a cave, a tent, a tree house. And if it's already there, you may add to it.... Plant flowers, adding a splash of color. Add special places or rooms to your safe place.... Create anything that you would like. [Long pause.] Create special places for special kinds of feelings that need to be healed, special places to wash away fear and pain.... Create a waterfall or a pool of healing water. Stand under the waterfall to wash away the fear.... Let the healing waters wash away what you'd like to be finished with. Each time you come to the waterfall or the healing pool of water, you can wash away more and more of the past.... Each time you come, you are cleansed and rejuvenated, the shame is washed away. Wash away the pain. Wash all of it away, as you are ready. [Long pause.] When you are finished, step out of the water and you will find a robe or a towel to dry and warm yourself.

Now allow yourself to continue walking around your safe place.... You find a place for a healing garden, a place that is just for your healing. You can plant anything you would like.... You can plant wishes and dreams for the future. You can plant seeds of your healing. And you can weed out what you want to be finished with. Take some time to work with your garden now. [Long pause.]

And now, find your favorite place in all of safety. Walk around until you find just the right place. [Long pause.] Sit down, and get comfortable.... Breathe in the safety and the peace. Breathe out the fear.... Breathe in the safety and peace. Breathe out the fear.... Breathe in the safety and peace. Breathe out the fear.... And just be in this place as you breathe and heal.... Stay in this place as long as you would like.... And when you are ready, simply count yourself out by counting from one to five. When you reach the number five, your eyes will open. And you will be awake and alert, and feeling safe and at peace. One.... Two.... Three. Take a deep breath.... Four.... And five.

Short Version of the Guided Imagery

Begin to breathe in the safety and peace. Breathe out the fear. And breathe in the safety and peace. And breathe out the fear. Each time you breathe in, relax your body. And each time you exhale, let go of tension. Breathe in relaxation. Breathe out tension. With each breath, count from five to one.... If you need more than that, begin at seven or ten, counting to one.... Make each breath a number. Each exhale letting go. As you are counting, as you are breathing, allow the image of safety to fill your mind.... You are there, in safety, in peace. No one can be there with you without your permission. Focus only on breathing, on counting, on imagining your safe place once again. Allow your vision to come alive as you breathe. Remember and focus on all the images in your safe place.... Breathe in the peace and the safety. Breathe out the fear. Allow your senses to come alive again in this place. Remember how it looks. Remember all the detail -- the color of the sky, the grass or trees or sand or water.... Remember your place of safety and how very beautiful it is.... As you continue breathing in safety and breathing out fear, remember the sounds of your safe place.... Remember how beautiful it smells.... Remember the sights -- glance around at your house or structure of safe shelter, and see your waterfall or pool of healing water.... And over there, see your garden.... And remember, remember the beauty and the peace and the safety.... Sit as long as you need to, breathing in safety and peace. Breathing out fear, as long as you need to.... Do whatever else you need to do in your place of safety. Spend as long as you like.... And when you are ready, simply count yourself out by counting from one to five. And as you leave the place of safety, bring with you the knowing that you are safe, you are at peace, and everything is going to be all right.

How to Stay Healthy as a Nurse

One may wonder at the title of this article why I would write about nurses staying healthy, when nurses are obviously experts at helping people stay healthy. The simple answer is, we are not healthy. I am not speaking of blood pressure here; I am speaking of health in the holistic sense. What do I mean by holism? "Holism", "healing" and "health" come from the Anglo Saxon word "haelan," meaning "to make whole." It is a process of bringing parts of oneself (physical, mental, emotional, spiritual) together at deep levels of inner knowing, leading toward an integration and balance, with each part having equal importance and value. As wounded healers, the first step in deciding an approach to your own healing is to find what good health is for you individually.

Beyond your physical regimen of health, include certain esoteric items such as:

• A searching for your reason for living. Finding your "destiny" is easy. Look around you at all the absurdities in the world, pick one, and work on it.
• A seeking of four very important kinds of power:
  • power of freedom: Check your feeling of freedom in work, relationships, and personal life.
  • power of action: See that you have impact on your life, in the work place, in relationships.
  • power of giving: Have something to give and do it. This is not the same as "I'm dying to take care of you."
  • power of joy: Change whatever stops the joy. You need it.

How does the mind work with the body for health and healing? Nurses have always known that our emotional health and physical health are interrelated. This is much more than "thinking positively." Emotions, beliefs, and desires actually have a role in extending life. Psychoneuroimmunology, the effect of personality and stress on immune function, is a term we hear now even in the newspaper. The immune system, the body's defense system, once thought to be important only in prevention of infection, is becoming a household word now, not only because of AIDS, but also cancer, chronic fatigue syndrome, multiple sclerosis, recurring yeast infections and herpes. Biochemically, we know how stress, fear, and anger travel through the body and eventually exhaust the immune system. Then with exposure to something we wish we did not have to catch, our immune system fails us.

Practically speaking, if your imagination is filled with old hurts and pity; if your desires are filled with fear; if your expectations are filled with anger; if you are riddled with the anticipation of error or humiliation, it is hard to reduce stress, live life, or have fun, much less prevent or heal a disease that depends on immune function. So what is a nurse to do?

• Work on your emotional healing. Ask yourself frequently, "How do I feel about this?" Express emotions responsibly. If it is not responsible to blow up at a co- worker, blow up in the privacy of your home, alone. Don't stuff the anger. Don't reward unhealthy cooperative behavior in yourself or others. Be assertive, not aggressive.
• Constantly work to stop errant or negative thoughts such as "I'm so stupid."
• Learn to love yourself. If you cannot stand in front of a mirror and genuinely feel love for yourself, and even say so, find out why not and heal the pain. Self loathing never leads to good health.
• Release yourself from what you or others think you "should" be:
  • "I should be Super Nurse who works overtime to the detriment of his/her own lifestyle, with dangerously high patient assignments."
  • "I should be 115 pounds."
  • "I should have 17 year old thighs."
  • "I should like or love ___________."(fill in the blank).
  • "I should be a person who doesn't make mistakes."
  • "I should do everything perfectly".

Stopping "shoulds" is not the same as being irresponsible. Change your responsibilities if they have you faking any part of your life. Your body knows.

• Keep a journal. We know it helps improve immune function.
• Finally, take responsibility for your body, not blame if it breaks down. See your health care provider as a consultant in your health, not to be told what to do. Many feel responsible for not polluting the body of Earth, but continue to pollute our own bodies. Many take better care of our clients, children, cars, homes and yards than we take care of our physical, mental, emotional and spiritual health. Healers, let us heal ourselves.

Visiting and Helping the Dying

Have you ever wondered how you might be helpful to someone who is dying? Or how to say or do the right thing for that person's caregiver? You may ask, "Is there anything I can do?" And predictably and untruthfully, the answer you hear is, "No, not right now." As a counselor, I am often asked how to be a helpful friend to a terminally ill person, whether in the hospital or at home. Here is my list of helpful guidelines, based on many years of observing exhausted caregivers and visitors who wish they could help:

1. A visitor is anyone who is not one of the primary caregivers.
2. Do not visit without calling ahead unless you have been asked to do so.
3. Ask about a convenient time to arrive, and stick to the schedule.
4. Ask about how long a visit is welcome and leave promptly. If you are not given a length of time to stay, look for the earliest signs of fatigue and then leave.
5. Offer to give the caregiver a break while you are there.
6. Ask the sick person how she is feeling. Remember that the most supportive thing you can offer is your full attention.
7. Ask the caregiver how she is feeling.
8. Recognize that the sick person's world is very small, perhaps only one room.
9. Don't lie. Gentle diplomacy without dishonesty helps create trust.
10. Check your emotional baggage at the door. A very sick person is not likely to have the strength to hear about your problems.
11. Leave news of world tragedy outside the room. If she is watching it on TV, use the time to learn what her feelings about it are, not to expound your own.
12. Surround this person with positives rather than negatives. This is not to suggest denying what is happening. Pollyannas and hopelessly moping visitors are both irritating. Honest concern works best.
13. If you love this person, say so. Love heals the soul. And there's magic in the telling.
14. Don't offer unsolicited advice. If you think your idea would be especially helpful, ask if it is wanted.
15. Even if you can only stay a minute, sit down so that you are nearer the eye level of the person in bed. Sitting near the head of the bed and holding her hand make a brief visit seem more meaningful as opposed to waving from the door.
16. Visit alone rather than with a lot of other friends. The temptation for visitors is too great to talk among themselves and over the bed, and the sick person often feels overwhelmed and left out.
17. If the sick person seems more interested in TV or dozing, ask if she wants you to stay. If she does, stay even if you're not "receiving" anything from the visit. Sometimes your silent presence with or without touching is all that is necessary.
18. Be willing to listen even to the silence.
19. No moralizing, judging, criticizing or blaming.
20. Never minimize the person's feelings as in, "You're not thinking about this properly...", or ""Don't you realize...", "You have to stop feeling this way...", or "Don't cry/don't feel bad..."These are ways to protect your feelings, not hers.
21. Don't assume the person wants or is able to recover or does not want to recover, and allow her the dignity of having those feelings without arguing or minimizing the situation with statements such as "Oh, you'll be better in no time. I'll see you on the golf course."
22. A very ill person spends a lot of time thinking about her condition. You
23. can find out if she wants to talk about it by asking.
24. Crying is okay for everybody.
25. Avoid more than two visitors (in addition to caregivers) in the room at one time.
26. If the sick person is entertaining you as a guest, let her know gently this isn't necessary.
27. Know who is in charge in the sick room and defer to her judgment.

Things Visitors Can Offer to Do

1. Sign up for a block of caregiving time.
2. Organize friends to bring meals, share overnight care, and send letters.
3. Bring pictures, decorative items, or any supply that is needed.
4. Welcome gifts may include a stuffed animal, a journal, bath powder, music tapes, mints, incense, flowers, rented movies, a gift certificate for a massage for either the sick person or the caregiver.
5. Offer to clean the house, mow the grass, water the house plants, take the car for service, walk the pets, write the checks, write letters, take the children for outings
6. Remember your talents: fixing things, singing, crocheting, painting pictures, taking photographs of friends.
7. Hug the caregiver and offer encouragement. Hug the one who is sick. Hug yourself for caring.
8. When the loved one is gone, offer to help take things home from the facility or return the sick room to a normal room in the home.