Sally was 73 years old. She was in the hospital for her third time in four months. Her cancer was spreading in spite of the treatments offered by her cancer specialist. Her doctors sat down and reviewed the different options and the possible benefits and burdens of each of those options. When asked what she wanted to do, Sally said, "I want to go home, and I want chocolate ice cream."
When one cares for people at end of life, and one hears "environment," the first thing one thinks about is home. When you ask people what they want at end of life, almost everyone indicates they would like to be at home. Home can mean different things to different people. It can be a private residence, a nursing facility, an assisted living facility, and so on, but it's the place where the person now feels they belong.
Home, ideally, means a familiar environment and, if at all possible, an environment characterized by the presence of loved ones. The more years I spend working in hospice and palliative care, the more convinced I am that the single most important environmental health factor for those with advanced illness is "home" and the loved ones that come with it. One of the reasons I am such a big advocate of hospice care is that it often enables people to remain in their homes at end of life. Hospice can provide the medical equipment (e.g. hospital bed, oxygen, wheelchair, etc), the delivery of medications, the professional services, and the emotional/spiritual support to ensure high quality care wherever the patient considers home.
Even loving homes, however, can pose dangers to someone who is quite ill. Hospice personnel can do a home safety survey. Are there throw rugs that could accidentally cause a trip and fall? Is the bathroom close enough so there won't be dashes and stumbles at night? Is there oxygen in the house and, if so, can we make sure there is no smoking or open flames nearby? Does the patient need some sort of wearable alert device so they can call for help if they fall and can't get up? Is the lighting good enough where the patient keeps medications so he/she does not accidentally take the wrong tablet? Hospice helps people stay home and helps make sure that home is safe.
Sometimes, as hard as we try, care at home may not be possible. Symptoms may be severe and require special kinds of treatment or the caregiver burden is too great for a spouse who might be in ill health him or herself. When a patient can't be at home, a good environmental health plan is to make the new environment as home-like as possible. If we can't bring the patient home, let's do our best to bring home to the patient. Having familiar clothes, bedspreads, pictures, bedside items, and people available can help in this regard. And, of course, we need to make sure this environment is safe too, as someone who is elderly and ill can become disoriented in an unfamiliar environment making falls or accidents even more likely.
Our bodies interact with our environment through our five senses - sound, sight, touch, smell, and taste. Compassionate care of those at end of life requires a thorough understanding of each patient's sensory abilities - knowing which senses work well and which might be impaired - and then developing a "sensory" plan of care. Our "environmental" approach might include "aroma therapy," or softly playing the patient's favorite music, or offering gentle massage. For some, taste might be the best way to interact with the environment at end of life. Choosing foods that delight becomes more important than choosing foods according to their nutritional benefit.
With our cancer patient, Sally, there was ample time before this to push brussels sprouts over chocolate ice cream. Encouraging hospitalizations, diagnostic tests, and procedures may have made sense before, but those interventions will no longer serve to achieve her goals. Sally knows what she wants. If Sally wants to go home and Sally wants chocolate ice cream for breakfast, that's exactly what this doctor will order. That will be my environmental health plan.
Provided by Halifax Health - Hospice
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