Posts by Eric Harris-Braun

One gorgeous October day after the next comes and goes, and the moon now wanes after filling the eastern sky with magnificent moon rises these past evenings. Ellen has endured increased pain and discomfort, and her caregivers adjust this and that to find the best way to ease her journey. We wonder how much longer she can persevere and whether we have done an adequate job in helping her complete what she needed to get done and in giving her permission to let go and die.

We caregivers have collected a range of tools, some of them from those who cared for our dear friend Azim in his final months earlier this year. These live primarily on the Harris-Braun dining room table and include a white binder, a purple pen, a clipboard that often is upstairs close to Ellen, the game ColorKu, and the sunflower blanket. Here’s how they serve us, in reverse order:

Sunflower Blanket - We wrap ourselves in its warm embrace when we want peaceful, relaxing time on the porch and it’s chilly outside.

ColorKu - This game provides all the benefits of Sudoku - calms and focuses the mind and helps one decompress emotionally - but also is readily tackled with two or three players who see things differently and delightfully come up with solutions for the next move. Plus ColorKu’s brightly painted wooden balls please the eye and cheer the soul. With 104 puzzle cards on five levels of difficulty - the top ones being “tough” and “extreme” - we can go for it, if we’re up for a challenge, or stick with a more soothing “easy” one. Our game skills have grown and we’re regularly tackling the tougher puzzles with success. (We’ve learned the hard way that it helps if you start with the right colored balls in the exact slots shown on the puzzle cards.)

Clipboard - The clipboard goes back and forth but mostly can be found on the bedside table upstairs near Ellen. It holds a chart on which the person at her side can track her sleeping and check timing of medications and comfort measures to ensure they are administered relatively close to “on schedule” - sometimes a challenge, as we don’t want to wake her to give her meds.

White Binder and Purple Pen - The front cover presents Key Information. Inside the front cover are Important Documents like Ellen’s MOLST, and the sections include emergency protocols, medication information, the daily care checklist, the log, the list of folks in the rings around Ellen and contact info, and more. The contents of the binder grow steadily as we add a care checklist each day and caregivers get more comfortable with writing anything and everything in the log that might be of use to other caregivers.  It turns out the log serves other purposes, one of which is to help an individual caregiver decompress after time with Ellen, even dump out one’s thoughts and feelings in a cathartic way.

Oh, and then there’s Being Mortal: Medicine and What Matters in the End, by Atul Guwande, a timely gift from Birdie to Ellen and Eric last year, with Ellen’s penciled notes throughout.

… Spee over to Eric …

One thing I struggle with is that “charting” (of sleep times and med times, and other details of care) creates a map of a territory. On the positive side, this map helps us navigate the territory of caregiving, of sharing and coordinating information among caregivers so that, for example, we don’t give Ellen too many or too few meds. But, all maps have the property of both being incomplete and also modifying and feeding back on the territory they map. For example, the map can distance us (as caregivers) in sometimes subtle ways. One way is simply in that we spend time on the map that we might otherwise spend observing or engaging with “territory” itself. So in the most pathological case, because what we measure for this map is sleep and meds and a few other bodily functions, then the map could come to fill our entire consciousness of what Ellen “is.”

I find myself needing to tread this one carefully, holding the map for what is is - a tool - but always focusing on the territory first. For example, where/how does our map indicate our progress, as caregivers, in letting Ellen go?  Does the map itself, in fact, act as an unwanted tether? All territories, despite all the maps we make, remain a mystery.  Thank goodness.

Here’s a famous picture of Ellen using midwife caregiving tools.

This week continues the pattern of quiet.  Many hours of resting, drifting, eyes opening to acknowledge who’s sitting with her, sometimes a smile, and always response to what’s funny. And the big blessing, much less pain.  Some discomfort, but usually shifting and adjusting this or that makes things ok.

But the real story I want to share is generosity.  Earlier this week, Ellen acquiesced to being carried downstairs in the wheelchair and joined the crew for regular Tuesday family dinner.  Even though we toned down the usual rowdiness, it was clear that it was all a bit too much, and she didn’t even want anything to eat.  But she did it as a gift to us.  When we left the table, I asked if she would like to go out to the porch: nod.  After wheeling her out and sitting there in beautiful moonlight and breeze, just the two of us, just gorgeous, I realized that I hadn’t done something for her, by helping her out there, but rather that she knew I wanted that moment and was giving it to me as a gift, as she was ready to be back upstairs, tucked into bed.

As you know from earlier posts, Ellen has suffered some form of cerebral damage, either from the various therapies (radiation and chemo) or from a tumor (14 brain mets) that makes sentence production difficult.  The first half of a sentence usually gets out fine.  Examples are “can you get me…”  or “we need to…” or “remember that we should…” but the clincher, the thing that would tell us what she wants done, or how make things better, just doesn’t come, or comes out wrong.  At first, this was deeply, deeply frustrating, but this week I see a generosity settling in, toward those of us trying to help by guessing and getting it wrong (which doesn’t actually help because more words in the space just confuses things, so we’ve learned not to), but towards herself too.  Here’s a quintessential example from yesterday:

She said: “Can you please get me,” pause, “a white,” pause, “tripe?” And then, almost immediately, this beauty: “Boy, it would be funny if you really got me that!”  I never figured out what she wanted me to get her, and when I’ve asked her again if she’ll tell me, she gives me a sly grin and a head shake.  Hah!  More gifts.

Here’s a picture from the archives (2012) that reflects a bit of that humor and generosity.

Ellen is having quiet days generally.

One nice change we’ve seen since a week ago is Ellen being more active and alert and doing a bit (a bit) less sleeping and resting with eyes closed.  Perhaps this is because it’s now been a month since she’s had a chemo treatment.  She’s also doing a bit more talking but the sentences are rarely complete and the meaning not clear most of the time.  We’ve tried offering Ellen pen and paper to try writing to complete sentences but found she had the exact same difficulty as with speaking.  So instead we’re all getting better at asking yes/no questions when Ellen’s wanting something, e.g., “Is it something to eat or drink you want?  No.  Is it something like clothing or bed clothes?  No.  Is it something in the bathroom? Yes!”  All those years of 20 questions put to good use.  But its also clearly very frustrating for Ellen, so we try to keep the questions to a minimum.

Ellen needs someone close by at nearly all times, either in the room with her or maybe in Eric’s office next door.  When she makes a move to get up out of bed, it’s good for someone to spot her.  The last 4 or 5 times she’s been unable to get to her destination (unknown to us) and sinks down onto the floor, then manages slowly to get back in bed, asking for no help but usually accepting some eventually.  You won’t be surprised at the determination she’s showing.

Ellen continues eating and drinking in very small amounts.  This morning she enjoyed more bites than usual (4 instead of 1) of a melon from our own garden.  She’s chosen to take reduced amounts of her prescribed medications, maybe because of difficulty with getting them down and keeping them down.  When she doesn’t get the later meds, night-time sleep is interrupted, but usually she gets a long, good night’s sleep.

With hospice care came additional equipment and medications, mostly to have on hand for possible need later. Elizabeth, Ellen’s fabulous nurse, continues to come (as she has for months already under the palliative care program), but now is coming twice a week.  No home health aides are needed at this point, which I’m sure makes Ellen happy, as she much prefers care by her family and a few close friends, mostly midwives.

There’s a kind of peace and quiet that’s blessing this house in these days.  Lots of sitting and being.  Less doing and solving.

Here are some pictures of Ellen from years past, just for fun.

Niece Natalie with Ellen many years ago…

Jess, Ellen and Will at the bottom of the Grand Canyon (2014).

On a hike in Vermont (2012)

Jess, Ellen, Eric, and Natalie and Cake!

Jess, Ellen, Eric, Jens, and Kathryn plus Will’s leg.

Two days ago was Ellen’s 50th birthday, a bittersweet marking on the calendar of her life.  How immensely grateful we are that she was born on that special day in 1966.

Gina baked and brought over the spectacularly delicious chocolate cake you can see in the photos.  Ellen did enjoy a bite of the cake, which is saying something as she’s choosing to eat less and less.  Ellen was alert and smiled quite a bit as we serenaded her, and we read her birthday wishes she’d received, and heard her birth story from Kathryn, a tradition in our family.

Yesterday, Ellen was officially admitted into hospice care.  Many people want to come say good-bye to Ellen and we are sadly saying “no” out of respect for Ellen’s clear instructions not to have visitors.  We have been flooded with offers to help in so many ways, and we thank you, even though we find we need little more than to be with Ellen on her journey.

Your love surrounds Ellen and us powerfully - thank you so much.

Things have shifted quite a bit for Ellen in the last two weeks, with notable further cognitive decline (mentioned in her previous blog post) and turning inward.  Ellen spends most of her day resting with her eyes closed and will open them in response to a greeting and sometimes engage a bit with whoever has appeared, although often she is not lucid and/or not able to get out the words.  Hand gestures and facial expressions are becoming important modes of communication.  However, from a few on-point contributions she’s made to conversations going on around her, we can tell she’s listening and still has her sense of humor.  When Spee told her, “I’m just removing this bug from your grapefruit juice,” she replied, “That’s probably the only protein I was going to get today.”

Indeed, Ellen is eating and drinking very little now.  In recent days, she seemed to have less pain, discomfort, and nausea, which is a relief.  She does get up and around a bit, although her mobility is decreasing steadily.  On the list of “no longer doing” are using the computer, looking at her phone, reading, and getting tasks done like putting stuff away in its place.  However, when something is out of place, she’s still pointing and giving us a meaningful glance and is clearly satisfied when we take the appropriate action.

As of three weeks ago Ellen started a “chemo holiday” as the side-effects just became too much to bear.  This last week we’ve had lots of discussion about starting hospice soon, which will probably happen early next week.  Those of us caring for her have been reviewing her “Five Wishes” document (advance directive) about end-of-life wishes for how she wants to be made comfortable, how she wants people to treat her, and what she wants her loved ones to know.  She wrote, on the one hand, “As I am dying, I want people to be informed as to what is happening.  Clarity and frankness about the situation as it unfolds is very important to me.  My loved ones and friends should be able to find out what is going on with me, to the extent that they want to know,” and, on the other hand, “I hope that my loved ones can come to remember me for what I was like before I became seriously ill, rather than just remembering the last part of my life.  I want them to remember me living rather than dying.”

We are grateful for all the thoughts, care and holding in the light that we feel from all of you coming our way.

-Eric & Spee

When your wife has stage 4 metastatic breast cancer, and has been hospitalized once for an upper extremity DVT, once for pneumonia, another time for malignant pleural and pericardial effusions, has had small pulmonary emboli, and then gets diagnosed with leptomenigeal carcinomatosis, and you also live in a world that has Google, so you can type in those terms (or worse click on the links some idiot put in a blog post) and get very detailed descriptions of these diagnoses and, more importantly, their prognoses, then, despite the doctors not coming right out and telling you so, you kinda have to face it that the most likely hand you’ll get dealt this year is to watch her die. Not just the mostly likely hand, but the most likely 99 hands.

We’ve tried from the start (of the stage 4 diagnosis), before the more in-your-face evidence (which for me was the hospitalizations) not to live in denial, and not to keep things from our two teenagers or our family or community. To make decisions taking this possibility/probability into real account. But this turns out to be much more difficult that I expected.

So this post is about a concept called Death Straight Talk (let’s call it DST. That way it sounds like the more familiar “DNR”). There are three arenas in which I want to talk about DST: 1) the medical world, doctors, nurses, and Medicine as an institution; 2) family, friends and community; and 3) the metaphysics of probability and how we think about our future. So here we go.

1) DST in Medicine: Hospice operates on an agreed-upon basis of DST. The idea is that “there’s nothing left to do” to prolong life (meaningfully), so shift the medical care to comfort, pain control, and getting the most of out each day. A Do Not Resuscitate (DNR) order is another form of DST in medicine, where the patient gets to issue a token that goes in their chart saying something like, “Look, I’ve thought this through and I’ve come to the conclusion that death is preferable to life after resuscitation, so let me go.” These are both DST items that have been embodied in institutional practice, the first at a more macro level, because, it turns out, Hospice care ties in deeply to the structure of how and what things get paid for and who gets to decide. (This in itself is worth a whole other post, but life’s too short for me to dig into that.) The second is at the more micro level, because it’s just about what to do under certain circumstances for an individual patient, whether in hospice or not.

These two patterns, Hospice and DNR, are formal recognition that near death, things are different, and we have to act differently. But now to my direct experience: despite an ominous prognosis, Ellen’s not at either of those two points yet, and so, institutionally, there’s practically no DST. It’s like a binary switch: either we act like you won’t die, and plan our doctoring on that, or we finally give up and off you go to Hospice. Here’s how this plays out. Hospitals are places full of protocols: vitals every 2 or 4 hours, neurological checks every hour, gotta pee before you get discharged, NPO (nil per os – no food or drink) before surgery, start a bag of fluids for practically anything, keep for observation for two days after X surgery, don’t go off the floor (or out of the ward doors), and on and on. Lots of protocols, mostly in place for good reasons.

But here’s the question: if you might have only 4-6 weeks left of life (if the current spread of cancer doesn’t respond to therapy) do those protocols apply? Should you really spend those two days under observation, living a substantial percentage of your remaining life in the hospital instead of at home? Should you really have that conversation you’re having with your family or friends interrupted so the nurse can write down your blood pressure numbers? Should you really have to spend the more than an hour a day (once you add it up) explaining your complex medical history over and over to each new nurse, resident, attending, etc., who comes to check up on you? Should you really get filled with IV fluids before a surgery to offset the dehydration risk that comes from the NPO protocol, which is there to mitigate the risk of throwing up under anesthesia, when those same fluids have a high risk – shown in the previous hospitalization – of causing swelling in your legs and feet which might make it painful to impossible to walk in your last weeks of life?

In our experience the protocols just don’t take into account DST. Here’s how I know: during our last hospital visit, I explicitly told nurses and doctors a story that approximately went like this: “Please treat us as if Ellen’s chart had a big DST sticker in it. It’s kind of like DNR but stands for Death Straight Talk , which, like a DNR, is treatment instructions for you from Ellen, but what it means is: first of all, we can, and do, talk about death straight, but second and more importantly, in providing your care, think about whether your actions are appropriate for someone who will likely die soon.”

The results of telling this story were clear: after some initial shocked looks, we got different care. The doctors let us go home “early” after Ellen’s Ommaya reservoir implant; we got “off-floor-privileges” while awaiting surgery; they didn’t make Ellen start on fluids at midnight before the surgery, etc. The humans involved responded deeply and with compassion to the truth that was embodied in a simple acronym: DST.

2) DST with family, friends, and community: If you want to create drama, lie. Lie explicitly, unconsciously, or by omission. In our case, we might call that Death Curvy Talk, or Death Denial Talk (DDT). The other night Ellen and I watched a dumb movie called “Meet My Valentine,” which is about a guy diagnosed with terminal brain cancer who decides not to tell his family but instead find a replacement husband/father for them instead. As a movie it was really dumb because that DDT was so obviously poisonous. But as a metaphor it’s revealing. If I look at where things feel twisty and drama-filled and out of whack, I see that I haven’t lived up to DST. As I said at the beginning of this post, we’ve tried to face things directly from the start. But something interesting has happened since the introduction of the DST acronym. As a token that we can refer to, it’s given us permission, or an opening, or something to actually get to to the straight talk more quickly. Now that it’s there, we invoke it. “Hey, I have a DST thing…”

Here’s a quote from an e-mail from a friend: “I wanted to offer to help, if need be, to begin/continue/whatever, discussion of burial, funeral directors etc. I have, unfortunately, intimate experience with this recently, as you know, and might be able to bring some perspective to this part of DST.” What a relief and and efficiency that this provides. It feels to me that the more I live into DST, the more this experience goes from what I call “dramatic” to what feels “powerful” or “moving.”

3) DST metaphysics and probability: Here’s the problem with DST. It assumes we know the specific future. Of course in one sense we do. All of us will die, we know that, but that’s hardly a specific knowing. So, using DST, how do we also talk straight about that one other hand of cards out of the 100–the one in which it turns out that Ellen recovers and later quietly dies in her sleep at the ripe old age of 103 well after I’m gone? This is the hard part for me. I used the metaphor that Ellen’s disease prognosis is like drawing a hand of cards. But that’s, at the very best, only a partially valid metaphor. Probability provides a great tool set for assessing aggregate outcomes, but it also can have the effect of deep dis-empowerment at the individual level. Just because your chances of getting breast cancer go up by X% if you have the BRCA1 mutation doesn’t mean that you don’t have any agency in whether it actually happens in your own body. From all our reading, it’s pretty clear to us that cancer as a bodily process is connected to the immune system, which is deeply connected to the central nervous system, and also connected to physiological terrain. So what power does that mean we actually have? I believe that diet, and stress, and my thoughts have an effect on “my chances” of getting cancer, and these are things I have control over. Bookstores, however, are filled with conclusions from this that to me are just magical thinking: that you can just think yourself back to health. But I also read and hear people jump to “don’t blame the victim” as soon as you mention the ways in which we do have agency. It’s kind of a double bind: if you believe in agency, then if you got sick or don’t heal yourself it’s your fault. But if you just take it as luck of the draw (i.e., not your fault) then how can you activate where you do have agency?

So to me this is where I don’t know how to have real DST. What is the “straight talk” that both acknowledges and deepens the agency we do have, and yet doesn’t fall prey to either magical thinking or blame-the-victim? Just because the odds are 99 to 1, does that mean we have to match the relative percentages of our talking time to those odds?

I don’t know the answers to these questions. But the core move in DST gives me guidance: open myself to what exists, or at least turn towards it rather than away.

Modern disease prognoses provide odds based on existing historical records: scientific studies. Open myself to them. But also the evidence of agency affecting cancer outcomes exists. Open myself to it. My pain and my joy in these days exists. Open myself to both of them. Paradoxically, denial and hiding and self-veiling also exist. So that’s OK, too; turning-toward will also periodically involve turning-away. This isn’t about some moral claim. It’s just a wish, a longing, perhaps a stance, to turn towards what I see in front of me. DST. Last words: just because I don’t wish to turn away from that which I do see, that doesn’t preclude me from turning toward that which I don’t see: all the potential branches of the future. Because what else is creation?

–Eric Harris-Braun