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The End: Death and Bereavement

Our son was taken from the nursing home to Beaumont Hospital for the last time late at night on November 11, 2011.

During the early afternoon in the nursing home he started to vomit with other signs of intestinal obstruction, this was a problem which has been occurring increasingly frequently for the last year because of the rapid deterioration of his general condition and the increasing weakness of the intestinal musculature [paralytic ileus] which is made worse by his immobility and the medications he has been receiving for such a long time.

The crisis started  with a slowly snowballing distension of the abdomen with vomiting and coughing and discomfort, in the past  when that situation arose we immediately stopped his feeding and called  his doctor who usually orders some  medication to encourage him to have a bowel movement and to  keep watching him for few hours , in the beginning when he started to have these episodes things they usually settled down in a very short time and then we restart his feeding, his fluids and his medication, but during the afternoon of the 11th things were  getting worse  so at  10 PM our  doctor decided that he had to be sent to the hospital which we did.

In the hospital after he was admitted after a very short stay in the emergency center they started evacuating his stomach to aspirate what has been there. His doctor decided that the gastric aspiration should continue for the time being, but two days later the whole situation

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seemed to be getting a good deal better , so it was decided that he should be restarted with a small amount of nutrition, he was now three days in the hospital and all that was getting was a small amount of glucose water which was going through an IV line which was in a very precarious situation.

Now when they were trying to restart his feeding through his NG tube they discovered that it was clogged and nothing was going through it even water, it was very clear that during the last few days when his feeding was stopped the tube has clogged which made it useless. and next day he was taken down to a special radiology unit which would do the replacement, few hours later he came up without a new tube, the people who were doing it said it was difficult to insert a new one and they were going to try again next day. Next day they were more successful and he came up with a new one. But the new tube was clogged again in two days’ time so it was decided that they were going now to try another kind which was much narrower and easier to insert, it was called a Dubbhof tube something like. the first one which he was given in the American hospital in Baghdad eight years ago.

ADubbhoff tube is a small-bore, flexible silicone tube usually inserted into the nose with a weighted tip that should preferentially be past the pylorus. It can be left in place for 6 weeks or more it causes less irritation than more commonly used nasogastric tubes. But even this one failed. He was now about ten days without feeding and enough fluids so they decided to feed him through a PICC line.

PICCs or Peripherally Inserted Central Catheters are long IV catheters which are inserted through a peripheral vein in the arm and threaded

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up to the superior vena cava. A PICC line is recommended for any patient requiring IV therapy for 6 days or more. PICC lines are used for antibiotic therapy, chemotherapy, pain medications and hydrations. But they are liable to cause infection of the blood.

The PICC line worked for one week , and at the end of it he developed a very severe infection of the blood which was treated with intravenous antibiotics .

The IV line failed and it impossible to replace it  by that time all his peripheral veins has collapsed so they reverted to intra-muscular injections. When the course of the antibiotics was finished his intestinal problem seemed to have improved so he was given another NG tube which worked for two days and then he developed another very serious case of intestinal obstruction. It was now  four weeks since he was taken to the hospital and during that time his general condition has deteriorated terribly, he was  very distressed and in pain and nothing was working, his doctor  came to me and said that  I am going to ask the other doctors who were involved and see what they might suggest.

Next day she  came back and said that everyone she had talked to including the hospital palliative team leader had suggested that we should take him to the hospice , it was like what we were told eight years ago by the staff of the American hospital in Baghdad when he was sent home, this time I thought it would be unfair to prolong his  agony and suffering, and after a long meeting with the palliative care unit we accepted  with a very heavy heart their recommendation and the boy was moved to the Beaumont hospice which is situated on the sixth floor

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of the central tower of Beaumont’s Royal Oak hospital on the 9th of December 2011.And put under the care of the palliative and hospice teams there.

Palliative care is a consultative medical care by an interdisciplinary team that promotes quality of life and relieves suffering. Palliative care can occur simultaneously with treatments that have cure and recovery as their goal.

Palliative care is an area of healthcare that focuses on relieving and preventing the suffering of patients. Unlike hospice care, palliative medicine is appropriate for patients in all disease stages, including those undergoing treatment for curable illnesses and those living with chronic diseases, as well as patients who are nearing the end of life. Palliative medicine utilizes a multidisciplinary approach to patient care, relying on input from physicians, pharmacists, nurses, chaplains, social workers, psychologists, and other allied health professionals in formulating a plan of care to relieve suffering in all areas of a patient's life.

This multidisciplinary approach allows the palliative care team to address physical, emotional, spiritual, and social concerns that arise with advanced illness.

Palliative care  Provides relief from pain and other distressing symptoms;

Integrates the psychological and spiritual aspects of patient care;

Offers a support system to help patients live as actively as possible;



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Uses a team approach to address the needs of patients and their families;

Will enhance quality of life;

Palliative care is applicable early in the course of any illness , the idea originated by Dame Cicely Saunders, who is  widely regarded as the founder of the modern hospice movement.

Dame Cicely Mary Saunders,22 June 1918- 14 July 2005, was a British citizen, a prominent Anglican, a nurse, a social worker, a physician and writer, she is best known for her role in the birth of the hospice movement, emphasizing the importance of palliative care in modern medicine.

During her life she received very high honors; She was made Dame Commander of the British Empire and a member of the Order of Merit.

Dame Cicely died of cancer at the age of 87 in 2005, at St Christopher's Hospice, the hospice she herself had founded.

The Beaumont palliative care team is two doctors, two practitioner nurses  a social worker, a chaplain and a secretary, the unit is headed by  Dr.Angela Chimelewski.

Dr. Chimelewski is a truly amazing young woman, she is 32, a graduate from Wayne State University in Detroit in 2006, had a three year internship in Beaumont in internal medicine, which was followed by a one year fellowship in Rush University in Chicago  at the Midwest Care Center in Cook  County Hospital from which she returned to Beaumont two and a half years ago to lead the hospital’s palliative care team. When my son was under the care of this wonderful doctor and her team, I was greatly impressed by her dedication to her work, her

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efficiency and to her total commitment to her patients’ welfare and that they should always receive the best possible care available. We became very good friends immediately. She is a very good teacher; she is always at a meeting, a continuing education course or a conference. She enjoys a good book on history or a good story when she has the time during her very demanding schedule. She is a member of the hospital’s ethic committee, She is very happy working in Beaumont she says it has very good people who are working in a very complicated environment.

The social worker is another very highly regarded individual, she has been married for the last twenty years, has two young children, she is from Michigan, my friendship with her started two years ago when she first started working in Beaumont hospital, she kept a great interest in our son’s struggle and continued to visit him and enquire about his condition in our absence.  I used to see her now and then when we were again in the hospital when we used to talk about our mutual interests like books and the mental problems of old age about which she holds a master’s degree, from then she started taking care of the necessary arrangements when was sent back from  to the nursing home. Towards the end of the boy’s journey he was under the care of the hospital’s palliative care unit of which my friend was now its social worker, and during his last days she was amazingly kind and supportive to the boy and to me. She was in the church with us on the day he went away.

Hospice, Hospice is a natural peaceful end of life to anyone with a life limiting illness. Hospice care provides end-of-life medical and


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supportive care. Hospice is a type of care and a philosophy of care that focuses on the palliation of a terminally ill or seriously ill patient's symptoms. These symptoms can be physical, emotional, or psychosocial in nature.

The hospice team provides comfort care not curative care; the hospice team cannot cure the disease.  At the center of hospice care is the belief that each of us has the opportunity and the right to live with dignity, free of pain and other distressing symptoms, connect with those that we love in meaningful ways and know that our loved ones will be supported by the professional hospice care team. Hospice care focuses on bringing comfort, self-respect, and tranquility to people in the final year of life. Patients’ symptoms and pain are controlled, goals of care are discussed and emotional needs are supported.

Beaumont hospice team was made of a doctor, a nurse care manager, a chaplain and a social worker and was headed by Wendy Warshauer. This was the team, which was taking care of my son when he was in the hospice.

Wendy is a truly amazing woman, witty, friendly and very intelligent and she has been tremendously helpful with this work , she is 51 was married for a second time six years ago, she has two daughters ages 18 and 21, from her first marriage, the elder one is studying psychology in Michigan state university in her senior year, the young one is working for a degree in physical rehabilitation in her freshman year also in Michigan state university .  She has been a nurse for 27 years the last five of them as hospice nurse manager. She graduated from a nursing school in North Carolina from which she graduated after 4 years in 1985

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as a registered nurse [RN], she said that what brought her to nursing was her belief that she needed to take care of patients, she is a problem solver and would always like to find solutions to problems.

The decision to take a patient is usually made by the patient’s primary doctor and the hospice’s doctor and the patient’s family who can reject the Doctors recommendation and keep the patient where he is.

We took our son to the Beaumont hospital hospice after long and very detailed meeting with our doctor and the hospital’s palliative team.

My son’s stay in Beaumont hospice which lasted for twelve days was pretty average and uneventful, during his stay there he was calm and peaceful, the only thing he was given was 0.5 mg of a very mild sedative  four times a day. During his stay in the hospice I was with him every day for most of the daytime hours, on the seventh day he received the sacraments, but on the last day, the 21st I left at 4 PM.

At 6 his nurse for the day who has been involved in his care for most of the time he was there called me at home, she said I am very sorry your son’s journey had come to an end but I hope that he is now in a better world.

She was absolutely superb, her name was Jill.

Next day we took him to a nearby funeral home where he was kept for two days, then  we took him to an Iraqi Catholic Church for a mass and then to the Holy Sepulchral Catholic Cemetery in Southfield where he was buried.

It was one day before Christmas, December 24, 2011.