Margaret had been at the hospice house a couple days when I first met her. At 81 she had some periods of confusion, but for the most part her mind was pretty sharp. She had originally come in for symptom management, but the doctor was now thinking that she may be entering the active phase of dying. As I entered her room that day, she lay staring up at the ceiling. She didn’t react as I said hello, and dutifully took her meds at my prompting. Margaret was unable to get out of bed at this point so I carefully rearranged her position using pillows to help support her fragile bones. Something about her demeanor seemed so sad. She declined my offers to turn on some music, or the television, or to have a volunteer or the chaplain come in for a visit.
“What are you thinking about, Margaret?” I asked, and without missing a beat she responded, “Is this all I am ever going to look at until I die? This ceiling, that ugly wall?” Her world consisted of a hospice room, a very nice room, painted pale blue with framed pictures of her late husband, but still, just a small room with a small window, and the sad reality was, that yes, this pretty much was going to be all that she looked at until she died. The best I could do in the moment was to push her bed to a better angle within the room so that she could see the occasional person that walked by her doorway. Her words stayed with me that morning, and after making sure all my other patients got their meds and were comfortable, I rounded up a hospice volunteer and with the aide went back into Margaret’s room and offered to take her outside into the sunshine, bed and all. The look in Margaret’s eyes, a mixture of wariness, surprise and tears, told us that we were on the right track. The beauty of hospice beds, besides comfort, is the ease with which we could push her bed down the hall and out the side door, enlarged for just this purpose. We followed the paved path that led out into a garden area, spotted a bench located in a shady area under a tree, and rolled Margaret into place. Our volunteer was only too happy to spend some time outside keeping Margaret company. Margaret was more than happy to see the sky, feel the sun, and smell the flowers. It became her daily routine for the next four days. She died on the seventh day.
Among the 5 stages of grief, depression is probably the one stage we think of as expected and accepted. Who wouldn’t be depressed if they were given only months to live, or if they recently lost a loved one to a terminal illness? In these situations depression is a normal and appropriate reaction. The dying must let go of what would be, and the living must learn to live with the finality of losing someone they love. If the anger stage is loud and ugly, then the depression stage is sad, and quiet and lonely. Those struggling through this stage may have trouble sleeping, have little appetite, and less energy to fight the emotions brought on with dying. Depression may arise from their situation, their disease, or even from the medication or treatment taken to fight the disease.
There was a gentleman who was admitted into the hospice house late one evening. He lived alone and had been refusing the home visits from the hospice aide arranged to assist him with bathing and personal care. He was inconsistent in taking his medications and eating, and his son, who lived out of state, was worried. The next morning the hospice doctor examined him, reviewed his medications, and decided that he would be a good candidate for an antidepressant medication. In addition, the hospice social worker was working with the patient and his son in finding placement in an assisted living facility.
Although depression is a normal reaction to grief, a person is at greater risk if they lack support or turn away from the support of family and friends. It is important to evaluate each case individually to assess potential causes and factors. Within hospice, depression is addressed and treated, with medication and/or, by non pharmacological means such as volunteer visits, pet therapy, massage therapy, etc. As with all the stages of grief; denial, anger, bargaining, depression and acceptance, the journey through each is defined by the individual. One can pass back and forth between them, or skip as needed. As Dr Elisabeth Kubler Ross noted when she first described them, knowing where a person is in their grieving process helps us to better appreciate, understand, and reach out from our collective offerings in order to help.
The picture above comes from a very interesting read on the designing of end of life hospice care centers by Matt Bowskill.