The Mortuary Show
Hospice Nurse Penny 👩⚕️
Episode 119: As a funeral director, the post-loss side of things in deathcare can be tough... Penny gives us the real deal on how it is BEFORE the loss happens. Dealing with crazy families (✔️), weird noises and smells (✔️), financial situations (✔️), and the death RaTtTtLleeEe. ENJOY!
@HospiceNursePenny
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Show Notes:
(07:45) – Ethics in death care.
(15:32) – How does the dying process REALLY work?
(21:06) – How death anxiety works (Hint: We’ve got a solution)
(38:08) – A not so fun, funeral director.
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Takeaways
- Family dynamics can complicate hospice care significantly.
- Grief can lead to irrational behavior among family members.
- Education about the dying process can alleviate anxiety.
- The death rattle is a common and distressing sound for families.
- Medications like morphine are used to ensure comfort, not hasten death.
- Social media can be a powerful tool for educating the public about death.
- Acceptance of death can reduce anxiety surrounding it.
- Home hospice care presents unique challenges compared to hospice centers.
- Understanding the normal dying process can help families cope better.
- Penny's experiences highlight the importance of compassion in hospice care.
- Broadcast on:
- 08 Oct 2024
- Audio Format:
- other
(upbeat music) - Very special guest today, ladies and gentlemen, we have hospice nurse Penny. I mean, if you're in the realm of death, like we all are at the mortuary show, you gotta follow her, you know what she's doing. A little bit of a different aspect, for those of you who don't know her, a lot of times we're talking more on the post-death side of things. Today with Penny, we have the hospice side of things. She's got a plethora of knowledge, makes them really both entertaining content and knowledgeable, also mixes in some comedy and some funness and some social awareness type of things I would like to say. So Penny, thank you so much for taking the time. You're a big deal in our lives. How are you? - Thanks for having me. - Absolutely. So I'd like to first know, maybe with a little bit of a hardest, hidden question, what is the one thing about being a hospice nurse over your career that would be the most challenging? And you don't really have to hold back 'cause you got a lot of funeral directors listening. So I mean, any side of that stuff, you don't have to-- - Oh, so I can talk about the challenges from the funeral directors? - Let's, oh, I'm sure you have nothing but complaints. - No, I mean, I would say, as far as that goes, I have mostly had wonderful interactions with funeral directors. I can think of one, negative one. Other than that, everybody has always been professional and kind and wonderful. As far as the most challenging aspect of being a hospice nurse, I would say that has to do with family dynamics. Dealing with people who are in grief, who are in denial, we don't like to use that word, but it is what it is. Dealing with family drama. We go into situations where this discord has been around forever. And we recognize that there's nothing we can do about it. We can't change it, so we have to work with them and try to get through it altogether. And sometimes that is hard. It always seems to kind of bubble up in these times of sort of crisis or end of life when all the family is around. We know that all too well being just in that space. And it is so hard because you're trying to do our jobs of providing the best care or providing the best post-care or service, whatever that might be. And it makes it really challenging when you have people that will pretty much disagree for the sake of disagreeing with each other because they're at odds. So it's got to be such a challenge, especially at those moments when big decisions are being made, I'd imagine. - Absolutely, yes. Especially for hospice patients, they can still maintain a full code status if they want to. And so that is often where a challenging situation's come up. Another one is giving medication morphine, especially at the end of life. There's a lot of hate and discontent when, like you say, they wanna argue for the sake of arguing. That's a really good one for them to pick on. - You know, and we also recognize that part of what's driving that isn't just their history of those dynamics, but you're compounding that with the grief experience too. Anticipatory grief for us, for you probably post-death grief. We have the more upstream version, which is they know what's coming and that's causing them to have a whole lot of grief around that. And so people just act a fool when that's going on. - It's got to be that buildup in that tension and it makes it so hard. And when you have families that are at odds, it's just, there's nothing you could really do with it, but stay out of the way. Do you remember any specific stories that you had a family that was actually difficult and what were some of the crazy things that happened? What was the outcome? - Yeah, I've had lots, but one in particular, the son lived with his mom and he was very much not getting what was happening with her. He was trying to get her up all the time as she fell because she just couldn't walk. And he was pushing her to try to do things and he wouldn't medicate her. She was in so much pain. He wasn't turning her frequently. She got a bed sore. It was really awful, I had to get his siblings involved and they actually went to court and got guardian and line of ship over her and kicked him out of the house and then moved her into a nursing home. And then he continued to come to the nursing home and get in the way of the staff, not letting them manage her symptoms, not letting them give medication. He became unwelcome at the nursing home. They said he couldn't come see her anymore. She was actively dying and she was very much lingering, probably because she didn't have her son with her because no matter how he was with her, she was still his mom, he was still her son. And that dynamic and that relationship had been created through their interaction, their whole lives. I believe he was the youngest child in the family. So I ended up, you know, wanted to go see her. Staff said, no, they called security, kicked him out. And I went out to talk to him and he was in tears, you know? He said, I just want to be with my mom. And I said, listen, you're not going to be able to be with her if you can't get it together. You cannot get in the way of the staff. They need to medicate her. She's suffering without that medication. And he, you know, promised that he would behave. He agreed to allow the staff to do their job. And he came in and he was able to sit with her and until she died. So it turned out, you know, it was a good outcome. - Yeah. - But it was a very, very challenging situation. - Yeah. And it's got to be so hard too, because he just wanted to be there for her, you know? And he just didn't, wasn't comprehending that what he was doing was not only not helping, it was hurting her situation. - Right, right. He was trying to be helpful, but he was being hurtful instead. He just didn't, he didn't want to lose his mom. I mean, it's hard to fault people when you know that their intent is coming from a place of love. But then you also have situations where it's driven by greed, you know, and I've had that happen too. I had a patient who was, we thought dying and her daughter had a mental illness. And we found out that she was over medicating her with a benzodiazepine. And she, her mom ended up after we figured this out and her sister got her out of the house and she was banned from the building where her mom lived. She was not allowed to be in there anymore. Her mom actually really perked up and lived for another year on hospice. Yeah. We thought she was dying, you know? And I kept being like, something's not right. I was keeping track of the medications. And she's really getting a lot of the razepam. That's not right, something's not right here. And sure enough, her daughter was over medicating her. Man, it's crazy what you'll see people do, especially from that financial side of things. And, you know, I've seen it before myself where, you know, a family try is disgusting as this is. To say a family's trying to take advantage of losing a loved one. And I've, at first hand, where people are asking for autopsies in situations that have absolutely no need for an autopsy, like someone would be, like in your carapani work. They were in hospice for several months or six months and they passed away. You know, they were at the end for quite some time and still asking for a private autopsy. And I'm just like, this is not adding up. And you see things or people ask for, for example, you mentioned the bed sore and like a family asked in this situation to take pictures of the bed sore. And I'm like, this is just not a situation. You know what someone is trying to do. And it really makes you a bit sick in those situations when people are trying to take advantage of their poor loved one that's gone the other way. And you try to stay out of the middle of these things, but you see it and it does happen. So you just got to do what you think is best in my opinion because there's no really right or wrong way to do it because you're kind of stuck in the middle. - Yeah, well, you can shut them down on the autopsy thing pretty quickly by letting them know they're going to have to pay for it. They don't want to do that. But another thing I've seen, and I don't know if you had people that have requested that you change the date on a death certificate, but like when you have a failure to launch adult who's living with a person who's dying and the person who's dying is getting social security. And if they die at any time during the month, they don't get paid. And so they wait until after to report the death. So in some places they can't, well, actually, I guess they could do that where death is pronounced. In my state, we don't pronounce death. The family just tells us when the person died. But they can definitely hesitate on that phone call or they try to keep them alive longer. By doing things that are actually harmful and going to probably end their life quicker, by trying to feed them, by trying to give them water, requesting IV fluids, these types of things that they think are going to help that person live and through the end of the month. Really, actually they're doing more harm and could potentially cause them to die faster by doing those things. I believe it though, it's just wild stuff that you see. I guess on that subject of both these things, I suppose, when you're seeing someone, I guess like from our point of view when someone has a bed sore, what are some of the things that you are proactively doing to like prevent those? 'Cause that's gotta be so hard when someone's there for such an extended period of time because it's just a natural thing that's happened in a tough situation. And when we see it, obviously it's sad and it's a pretty tough, gruesome thing that I don't think people realize, like for me personally, that is in the top five of things that I don't like dealing with, that's one of them. So what are some of those things that you have to do because I'm sure it's not a pleasant for you all, either as hospice? - Yeah, so first of all, most people on hospice die in their own home, so their family are their caregivers, and we educate around repositioning them because that is kind of the primary way to prevent skin breakdown is to reposition. Then there comes a point where we know that repositioning is more challenging and this skin is gonna break down. The skin is an organ, it's the largest organ in our body and the organs are failing when a person is dying. So sometimes we have patients that get wounds that are called Kennedy ulcers, and they are so bad that they can just, it's like the skin is melting. You can see the bone, you can see the nerves, you can see the muscle, it's really, really horrible. They smell horrible. - That smell is horrific. - Right, and in those cases, all we are doing is medicating the person for comfort. Certainly when we see somebody developing a bed sore, we are going to try to prevent it from getting worse. We do not try to cure it. We can't, we don't use wound vax. We do whatever we can to try to prevent it from getting worse. We try to prevent it from being painful and we try to prevent it from smelling bad because it was very off-putting the smell, right? I'm sure you know, but we also really educate a lot about, you know, keep them off that part of their body if you can, but also understand that those wounds are not necessarily a sign of neglect in a hospice patient because they aren't getting nutrition that's going to help prevent that or heal that, you know, and again, their skin is, it's dying. Their body is dying, their skin is dying. And when people are in bed for any extended period of time, you know, even a healthy person in the hospital can start to show a little bit of pressure ulcers or pressure breakdown, you know, within a couple of hours, you know? - Yeah, that's good to know. That's helpful information for us to understand. I think more people should realize that too because it just makes me think about like a family or two that have said, you know, they're claiming neglect. I'm like, I'm sure that's not the case. And it's just those situations that rubbed me really the wrong way, I suppose. Have you ever been involved like or know anyone that was involved in a lawsuit of that regard where a family's trying to, I'd like to say, take their anger out on someone else by displacing it in that way? Have you ever been involved at all? - No, not any lawsuits, definitely seen complaints, especially in my current position in quality where people will complain. Sometimes people will complain and their complaint is valid. They didn't get the care that they were hoping to get. Many times it's a person that was in a nursing home and they're kind of blaming hospice for what happened with their person even though it wasn't us that had anything to do with it. It was the caregivers at the nursing home. And sometimes people will complain and what they're talking about is something that's really normal. And that's why I am on social media normalizing death and dying because I've seen people, for example, we got a letter from somebody like a three page letter from the daughter of a patient who died on our service and she was saying that her mom died a horrible death. You know, she looked, she was suffering and she said, just look at this picture and she sent a picture. And so myself and the leaders who are reviewing this letter looking at the picture and were like, that's a normal dying person. That's what they look like when they're dying. That's, there's nothing unusual about that. So a lot of times people think that there's something really wrong with their person because they don't know what to expect when a person's dying. They don't know that they're gonna look different. They don't know that there's gonna be sounds and sometimes smells and, you know, all these things, they don't know breathing changes and the death rattle and eyes are open and change color and, you know, all these things that they don't know are gonna happen. And so, you know, when we're able to say, oh, that's normal, especially the breathing, the breathing changes are something that really concern people. My mom was gasping at the end of life. She was suffocating to death. No, no, actually that breathing pattern at the end of life is almost like an autonomic thing. They're just doing it. They're not moving air. They're really on their way out. They're not suffering at all. It's normal. It's a normal dying process. - Yeah. - That's great that you're doing that, you know, just bringing some normalcy to it and more understanding. And I think it's a great thing that you're doing that because it's just helpful for people to understand it. And it just will make more sense when you're going through a hard enough time. At least some people will have more awareness of what to expect in those situations. That's a lot of why I do the podcast in social media as well is for people to understand the level of work and dedication that it takes behind the scenes that isn't really noticed. And I'm sure it's the exact same thing with you. There is so much that goes into what we do and everything that we do is to try to help these people and these families. And I love that social media has been a way that we've been able to do that and bring a lot of light to places that were very in the dark and people were not understanding and curious about what made you first start, I guess, making the content. And what was the point where I was like, "Well, this is actually a thing now." - I've always been, I've been a hospice nurse for almost 20 years. And I've always been just a passionate advocate for hospice and educating about death and dying and normalizing it. It's always been something that, since I became a hospice nurse, I've been really passionate about. During COVID, I found my way to TikTok. - Yeah. - That's exactly what happened with me. - Yeah. - Trying to learn how to shuffle dance, never did. Making a few of the little fun trend videos, I'm 62 at the time I was 59, so like not really in the generation of TikTokers, right? So my videos went nowhere. But one day I told a story about a hospice patient and it went viral. And I realized, oh, wow, I have a platform that I can educate people on. Like, this is, I can actually do this like at a grassroots level. I can help people. And that's, it just took off. I got like 10,000 followers overnight. I went, oh shit, better tell my employer about this, better tell my husband about this. I went to work, it was a weekend, this all happened. On Monday, I notified our risk department and I said, I'm on social media and I am following our policy. I'm not doing anything against our policy. I'm not telling any information about our patients. And they said, well, let's look at it. Let's take a look at it. So they checked it out and they were like, oh, this is great, we love it. You're fine, no problem. - Hi. And from there, I just kept going on. - I mean, it's so cool that like anyone could do it now. And everyone has the ability to learn from people that are actually involved on the day-to-day things, which is so beautiful in its own way. How do you come up with all the content that you still, 'cause you post like crazy still. And I know how much effort it takes because I myself have slowed down on the amount compared to what I was a couple of years ago. So how do you still keep that passion alive and where are you finding the content as well? - So I've slowed down too. Like when I started for the first probably two years, three years, probably three times a day, I was posting videos three times a day. And now I don't even post every day, but I do post reruns sometimes if things were really helpful. I look to my comment section a lot. I get questions in my comment section. There are certain topics that never get old. So I readdress things often because you know how the algorithm works on all the social media platforms. Not everybody sees all your videos. And so I'm able to reach more and more people with the same topic. And I get a lot of inspiration from my work still because I do participate in meetings where we're discussing complex patients. And I know a lot from the quality and regulatory standpoint of hospice. So I post about things like that. And then I do watch a lot of the trends. And I always think about how can I make that relatable to hospice care or death and dying? Those are pretty much what I think a lot of people come for. The majority of my content is trends and me answering questions that people leave me in the comment section. I do story times. I do just straight education. I call it straight education. But really I'm kind of more known for the funny dark humor, lightening it up, you know, 'cause I always say death is a dark topic. We need to lighten it up. I think sometimes it's easier for people to digest a little amount of information. And it can be helpful too. I mean, you can actually educate somebody in an eight second video. I've done that. You know, when I first started out, I made a video to a trending sound that was a song that said it's just water. It's just water, it's just water. And the captions on the video were, if your person isn't drinking anymore, that's normal, something along those lines, you know, they aren't gonna die of dehydration, they're gonna die from their disease. And it went viral and I had a person in my comment section tell me that I had relieved the guilt they had for 15 years over not doing IV fluids for her dying dad. And I was like, wow, that was an eight second video. And, you know, I was like, oh, I have something here. You know, I can actually, you know, make a short little clip about something and people get it. And sometimes they don't get it. And so one thing that I started doing a while back and I haven't really continued it and I should, but I'd make a clip, a short clip. And then I would add onto that the education piece where I'm actually talking, you know. So I might do something about that's kind of funny around the death rattle. And then at the end of the video, 'cause TikTok, I know if you've been on TikTok since 2020, you know it's really improved in a lot of ways. And you can do longer videos and you can combine music and that stuff. So then I'll do something like that. But most of the time, even though the videos can be really nuanced, a lot of people get it. They get it. And then if they don't, they ask me questions and then I answer their questions. - There you go. And then you're getting more traction in that way so that it works out. That's beautiful. - Yeah. - How do you like the difference between more boots on the ground, you know, hospices now being more on the quality side of things? What's the biggest difference between the two? And I guess how do you like, you know, kind of not being in the, in the thick of it as much as you used to be? - Well, I miss patient care. And I do actually, even though I'm retiring from my current position, do want to go back to working per diem, doing patient care. I live in a very rural area. There's like a population of 86 in the town where I live. And so I've always thought I'd love to be able to just drive around and see patients. So I'm thinking about doing that. You know, when I first came out of the field, I was really ready for it. Not because I was tired of the work. I loved working with patients, even though the family dynamics were probably the hardest thing to deal with. But I commuted, I lived in Seattle area and it was a lot of traffic. I'm sitting in traffic for hours a day and being a hospice nurse, you recognize that life is short. You don't want to waste any of it sitting in traffic. So this position came available and I thought, okay, I'll do this. And it was very rewarding for me for several years. I have always been the type of person that if I'm gonna do a job, I want to learn everything about it. So I knew everything from the patient care side. I worked in hospice care centers. I worked as a case manager doing home hospice. I wanted to learn more about the regulatory side. And so going into the quality position and learning the regulatory stuff, you know, so now I'm an expert in that type of thing. But then I started really feeling disconnected. And by the way, I used to have death anxiety when I was younger and when I went into hospice, I stopped having that death anxiety. And that started creeping back for me. I felt not so connected to death anymore. But when I found my way to social media and started actually connecting with people through social media and helping in that way and educating in that way, it really, it kind of sparked something in me, you know, like it helped me feel connected again. - Yeah. - And so it's been very rewarding to be on the social media aspect of educating. I feel really connected to the people who follow me. I feel like I have a community. And I really love being able to help people in that way. So I still kind of wish I was doing the work and I've had opportunities in my personal life to help people still. And I do see myself like eventually going back to doing some kind of patient care here and there per day. Not full time, but just once in a while. - The full circle thing. I think it's so true that when you're around death, it gives you a completely different perspective on just life in general and taking an advantage of the little moments and just embracing just every day. And I think it's very valuable to have that experience and people that don't because 99.9% of the world don't have that daily experience around it to either maybe follow someone like you or at least entertain the idea and think about it rather than just kind of burying it down. And, you know, I think that's one of the death things. I do like creeps up is when you try to avoid it so much. - Absolutely. - Let it just be. And I think you just have a way better appreciation of life in general. - Absolutely. I people asked me, how do you, I was doing a TikTok live yesterday and somebody was like, I have done things, I already, what do I do? And I said, you know, you really need to just accept the fact that you're gonna die because when you can get to a place of acceptance, you just take all the power out of it. You can be like, yeah, it's gonna happen. I can move on and focus on my life and living. And I really think that acceptance starts with being willing to get in the conversation and talk about it, acknowledge it, you know? Educate yourself about what to expect, prepare for it. You know, legacy work, I say legacy work is great because if you kind of in the back of your mind are thinking, you know, I'm gonna go through my pictures because someday I don't want people to see these pictures after I'm dead, you know? Or that type of thing. I feel like getting to that place of acceptance is the key to getting over death anxiety. It really is. - Yeah, it's not an easy thing to do, but once you do it, I think it frees you up a little bit, that's for sure. So when you were more, you know, of inpatient care, were you in hospice centers or were you more at home? It seems like more so or-- - I did both, actually I worked longer in hospice care centers than I did doing home hospice. It's how I started. - I guess, what are the biggest things for you? Which one did you prefer as well? - So hospice care center primarily is for hospice patients who have symptom management needs that cannot be managed in the home. So they need skilled nursing, they need medications around the clock, they cannot be managed at home. It has nothing to do with personal care or caregiving. That's completely different. This is skilled, so they need nurses. And so people who are close to the end of their life will often have an exacerbation of symptoms up from their disease. So they'll have more pain, they'll have more breathing issues, they'll have more nausea, vomiting, agitation, terminal agitation is common. And so when they come to the care center, the intent is for them to get their symptoms managed and go back home, but because they're close to the end of their life, oftentimes by the time we get their symptoms managed, they're actively dying and they die in the care center. So I say being in the hospice care center is like in your face at the bedside, death and dying. Very, very intense, lots of deaths. In a day, you could have three, four, or five deaths. In a day, you know, in one shift. Home hospice, I did case management. There are different nursing positions within home hospice. There are nurses that go float, we call them float nurses. They go out and see the patient when needed for after hours. Admit nurses who do the admission to hospice. Case management is the person who's like in charge of the team and the team is gonna be a hospice aid, a social worker, a chaplain. And you are going to the person's home and we still do skilled procedures. We put in catheters, we access ports, we program pumps, we give medication if we're there and they need it, but primarily we are educating the family on how to provide the care for the person. - Okay. - We don't do 24/7 care. We are just going there and teaching them how to take care of the person. And in the beginning, if the person is kind of further upstream, we may be going once a week, once every two weeks, as the person starts to decline and we're needed more because things are changing fast, we may start going a few times a week to every single day to make sure that we're supporting that person. So I actually prefer, well, when I worked in the hospice care center, I thought, I never wanna do anything else. This is what I wanna do forever. I just always wanna do this. And then I was recruited by an agency to be a case manager and the hospice agency that I was working for, which was the second hospice house I went to, was starting to have some problems, serious problems. In fact, they no longer exist. They were, it was not a good situation and I could see the handwriting on the wall and I thought, I better get out of here while the getting's good. And so this other agency, they recruited me and I went to work and I thought, I'm not gonna like case management as much as being in the care center, but I actually did like it. One thing I say about being a home hospice nurse is, it's like a box of chocolates, going into someone's house, you never know what you're gonna get. So you might be going in a beautiful mansion or you might be going in a van down by the river. You're just going wherever that person calls home. So it has its challenges. I think, I don't know, I can't really say which I like better. I liked it all. I guess I would have to lean towards the hospice care center because of the commute factor. I think the worst part of home hospice is the driving. - I'm in a round, I'm sure. - Lots of driving involved. - Yeah, I don't know, I feel like the same way, like back when I used to do more transfers running around, it was like, "I'm spending half my day in the car." But then you kind of get used to it. It's like, "Oh, I'm listening to a podcast "or audiobooks and this and that." But, and then it's like, or I'd rather be like in the home or in the hospice unit. So it's got one of those where, I don't really know which is better. - Right, and to be fair, I now say I would like to drive around and see patients because there's no traffic. I mean, if there's a traffic jam, it's a cow in the road. You know, like there's, it's really, there's just no traffic here. And so I think that's, you know, being in the Seattle area and some of the worst traffic in the US, that was just awful. But like you say, you can drive around, listen to a podcast, listen to an audiobook, see beautiful scenery if you're in an area like I'm at. You know, that would be fine. But to literally be sitting stuck in traffic to where it was actually impacting my health. I got piriformis syndrome from sitting in my car for so long. You know, it, that was not fun. - No, that does not sound too funny. - Yeah. - I'd like to ask you, so you've mentioned death rattle a couple of times which our funeral directors are aware has a family ever been around to hear that? And have you ever had an experience where they just were like, what is going on right now? - Yeah, they're always around. I mean, it happens very frequently. So first of all, the death rattle is caused because a person who's dying can no longer swallow and they're not swallowing their secretions and those secretions build up in the airway and then the air moves over it when they breathe and it makes a gurgling or a rattling noise. So first of all, it's called the death rattle, which is not a great name, but the other name is, other name for it is terminal secretions and that's not great either. - Pass them both. - But it's very, it's highly predictive of death. I wanna say somewhere around the 80% of people who develop a death rattle will die within 48 hours. - Wow. - Yeah, so it is one of the most troubling things that a family experiences. They have such a hard time with that noise. It's very loud. It can be like a washing machine. If the person's been hydrated in the hospital, it can be really bad. And we educate, educate, educate, and they still, it's just like, they can't get away from that noise. It haunts them, it's horrible. We have medications we can give to try to dry it out, but they don't work. None of them have ever, I've, we've changed from scopolamine patches, to glycoparolate, to atropine drops, to a hascamine. Like nothing ever really works very well and it dries the person's mouth out. So it's like, it doesn't work that great and it dries their mouth out. Repositioning helps. I think repositioning is probably the easiest way to control it. But yeah, it's really hard for families to hear that noise. I've had one person in my whole thousands of patients that I've taken care of who told me that it didn't bother her. I actually walked into the room at the care center and heard the patient was rattling and said, oh, she's got a little rattle going on. That's really normal. You know, people launch into my explanation. It's just a noise. And she goes, oh, it doesn't bother me at all. I feel like she's trying to communicate with me. And so I was like, well, that's a sweet way to reframe that. But people, people don't like that noise. It really bothers them a lot. They, they're afraid that the person is going to drown in those secretions. - Right. - That's their fear. And you know, we tell them, no, they're not. They are not going to drown in those secretions. At all, it's not going to cause them to drown. But still, it just bothers them so much. - Yeah, that's a tough noise. There's no doubt about that. So I know you're pretty vocal on, you know, I'm trying to help make, you know, your patients feel peaceful at the end, whether it's through medication or whatever else. I'd love to hear your perspective on that. And, you know, what percent of families are usually with you on that side or how often are you recommending, or is that something that comes from higher up? Or does it come directly from the family? Like, how does that, how does that work? You know, putting a love one more at peace when they're, when they're close to the end there. - Well, most people are able to be educated if they're not already about the fact that we don't give drugs to hasten death. That is not, that doesn't go with our philosophy. We don't prolong life nor do we hasten death. That's a hospice philosophy in a nutshell. Most people are able to be really educated on that. But there are a few who don't want us to medicate. And typically what I will do with those people is once I give them the spiel of this is a safe dose, you know, we start people at usually about five milligrams of morphine. Five milligrams of morphine is less powerful than a Percocet tablet. Because oxycodone is like 7.5 milligrams equivalent to five milligrams of morphine. So, so we are giving them less than they would get if they take a Percocet. And a lot of people can really wrap their head around that or it's about the same as a Vicodin. And then they'll be like, oh, okay. Like morphine has a very bad stigma for some reason. A lot of times it's because we use a lot of morphine in hospice. It's cheap, it's the gold standard. It works the best for shortness of breath. It works great for pain. And so we use it a lot. And people associate the death of their person with getting morphine. For sure. To the point where people will actually say, I know they gave the morphine to end her life and I'm okay with that. And even when they say I'm okay with that, it's like, no, that's not. Even there. It's not, that's not what ended their life. They died from their disease. They died from their cancer. They died from their heart disease, their lung disease, whatever. That's what ended their life. The amount of drug that we're giving is not enough to end somebody's life. Right. People don't realize that there are many, many humans out functioning in society that are on chronic opioids for chronic pain. My cousin was injured when he was doing, he was a crane operator. He was in a very, very bad crane accident. And he was on morphine, long acting morphine for decades. You know, we don't just start grandma off with a huge blast of morphine. We start really small and we adjust the dose as needed when they are becoming more tolerant to it. And addiction is another concern. People are concerned with addiction and we let them know that, you know, we are giving the medication for its intended purpose. We are treating symptoms. That's what it's for. This isn't party time and we're not trying to get them high. And they don't have time to get addicted to it. Yeah, it's just not important anymore because they're gonna die. Yeah. Yeah. Well, that's a good perspective to give and I'm glad that you're able to articulate it that to most families and they can understand, you know, what's actually going on. That's gotta be helpful. My last question for you, I'd love to know what happened with that funeral doctor that one time that you had an issue. I kind of knew you were gonna circle back to that one. I was waiting, I was gonna say that for my last four. I was working at a hospice care center and our patient was dying and the family knew it. And they were okay with it. They didn't feel like they needed to be with the person when she was dying. And sometimes patients will wait for people to leave. For sure, yeah. But they left a pair of folded up pajamas in the room and when we called, it was in the evening, probably around six o'clock, we called to let them know that she had died. Actually, it was earlier than that. I'm thinking it was in the afternoon 'cause I worked until seven p.m. But anyway, and that's relevant. I'll tell you, wait a minute. She died and we called the family and said she died and they said, oh, can you ask the funeral home to put her pajamas on her? Those were her favorite pajamas. And she had been in a hospital gown. We said, yeah, sure, we could do that. So we called the guy and he came pretty late, close to the end of our shift. So it was hours after she died. And we said, oh, there were some pajamas they left on the chair in there. The family asked that she'd be dressed. And he said, well, that's gonna cost him an extra hundred bucks. - Oh my God. - And so my nurse that I was working with who was kind of the senior nurse was like, you know what? We'll just do it ourselves. And so we went in there and she was already in rigor mortis. And so we had to put it, it was not easy. I feel for you. I got a taste of what it's like to be a funeral director. And so we dressed her. And that was really literally the only bad experience I've ever had, ever. And I had a lot of experiences because I, you know, when we do home hospice, we're not usually there when the funeral home comes. - Right. - We are not usually there. We are there at the care center when they come. So because I worked for so many years in the care center, I had lots of experience with, I used to collect funeral home pens. What a great, party conversation starter that is, is to have funeral home pens, had all kinds of them. But they would bring us treats, of course, and all that kind of stuff. So no, I've always had great interactions with everybody except that one, that one dude who was just like, - We're going to talk to 100 bucks. - Yeah. - And it wasn't even like, I mean, he could have said, you know, we can, but we're going to have to let the family know that, that we're in. I'll take the pajamas with me. I got to call him and let him know. Or he could have just said, okay. And then he could have taken them with them and then called the family and worked it out with them. But his attitude was just like, well, it's going to cost him a hundred bucks. I'm like, okay, whoa. - Yeah, and okay then. - We'll do it, heavy free. - That wasn't, you know, too, too much for your experience 'cause today would be, unfortunately. - No, no, I think the biggest complaint that we get about funeral homes is how long it takes for them to pick them up. And in a way, that's kind of on us for not setting an expectation with them that, and we try to let them know that sometimes-- - But if you usually say, I guess, for timing, because I'd be interested to know, 'cause I'd normally know what I would say to a family. So it'd be interesting. - I always would tell them that the funeral home will call and let you know when they're going to be here, but it is the weekend, it's the middle of the night, it's whenever traffic is bad this time of the day, it may take a little while. So just so you're prepared. And also really trying to, and I teach about this a lot of my social media, really trying to educate people about the fact that death is not an emergency. - Yeah. - Because they also get upset when our nurses don't make it out there right away. And like I said, we are not required to pronounce death in my state. So we offer a time of death visit. But if it's after hours, it's possible, it may be three hours, and I've seen complaints, 'cause that's part of my job, is to review complaints. And I've seen complaints from people that said, it took three hours for the nurse to get here after they died, and it's like, okay, so I want people to understand that it's not an emergency. Sometimes it takes a while because we're seeing people who are still alive. And this is your last opportunity to be with your person in your home. You will never be with them in this environment again. Even if you have them embalmed, it's not gonna be the same. You were just with them, you saw them through to the end. Take a breath, relax, enjoy this time, be with them. - That's kind of protective. Yeah, I like that a lot. Because families always feel that it's a rush, it's a rush. And I understand that too, at the same time, because if your loved one is passed away in their home, it would be like, okay, we have had their time. But if you could spin it and say, this is your last opportunity, I think that gives people a little bit more of a leeway. And when I love what you said, Penny, we're dealing with other patients and other families and things like that. Everything is not instantaneous. And even though people come to expect that level, it's hard for us because we're dealing with so many different things at all times, both hospice and funeral directors. So I do like that perspective a lot for a family member. - I think people worry too about the body decomposing. Like they're afraid they're gonna start decomposing right away. And I remember we had someone in the care center for 24 hours once and we just turned the air conditioner on and cooled the room down. You know, it was not a big deal at all. - Yeah, yeah, that's great. Well, Penny, this has been awesome. I'd love to tell you about or tell our audience what you have going on now. I know if you're about to release a book, so please give us the rundown on that. And then we'll plug your socials too. It's hospice nurse Penny. So if you don't follow her, follow her, absolutely. And let's hear about your book too. - Right, I'm on all the socials, Instagram, Facebook, TikTok and YouTube. I also have a podcast called Death Happens and Insiders Guide to Dying. - Right. - That's found on all the pods. And my book is called "Influencing Death, Reframing Dying for Better Living." It's actually a memoir, but it's educational also. It talks about my journey in life and how I became a hospice nurse, how dealing with death impacted my life. And there's lots of great stories in it and it will be available for pre-order sometime end of October or beginning of November. I have a website hospice nurse Penny.com and people can sign up on my mailing list on there. I don't send out newsletters, so I'm not going to spam anybody, but I will announce when my book is available for pre-sale. - I want you to go out and get it so you can get the full story and learn some more. But thank you so much, Penny. This has been a blast and very knowledgeable, I think, for anyone in the death care industry, we learn a lot from you. And just your experience is really beautiful and love your perspective on how you're trying to make a difference in helping families and just giving them more perspective every day. - Thank you. Thanks for having me on. (upbeat music) (upbeat music) (upbeat music)