Critical care, critical comfort

May 1, 2002
A dental professional's touch can be calm and reassuring during a loved one's final days.

by Anne Nugent Guignon, RDH, MPH

A dental professional's touch can be calm and reassuring during a loved one's final days.

We can't escape it. It is a fact of life. Each one of us will face the loss of a loved one sooner or later. Some people never want to think about this inevitable event, while others try to prepare as well as they can. Despite the most meticulous planning, it is doubtful that we can ever really prepare for the sheer magnitude of these events.

The shock of losing someone quickly is enormous. Grief, anger, loneliness, and sadness can descend upon our spirit immediately. What happens if a sudden stroke, heart attack, or accident leaves someone we love lying in a hospital critical care unit day-in and day-out, or maybe some type of long-term care facility?

Medical personnel focus on keeping the patient alive, not losing the body. Dental professionals might have a slightly different spin on this type of health care. First of all, much of our focus is on prevention. Secondly, our thinking is finely tuned to a patient's comfort. Finally, for the most part, our care allows patients to walk out the door of our dental practices and function better on a daily basis.

Can we, or should we, play a role in our loved one's care? Do we know enough about patient care to step out of the boundaries of the dental treatment room and provide comfort to these patients? Dental professionals have extraordinary skills, well-honed through the years. We can give our loved ones care that is very different from that offered by the traditional medical community. I know this is true.

I faced this challenge with my father 18 years ago and went through a déjà vu experience with my mother-in-law last fall.

My husband, Derek, tried to reach his 79 year-old mother by phone on the last Sunday in September. There was no response. He knew she had not planned to go out, so he decided to go to her town house and make certain that all was OK. He found her upstairs in bed. Charlotte struggled to move. Her speech was slurred. Derek called 911. He assumed a heart attack, but she had actually suffered a massive stroke in the middle of the night.

Derek was distraught by the time I got to the emergency room. He couldn't understand a word his mother was saying. Trying to remain calm, I carefully listened to every sound she uttered. It didn't take long to begin to decipher her garbled speech. Three decades of listening to patients talk to me in reclined positions with all kinds of contraptions in their mouths was ample preparation. To make matters worse, Charlotte was very afraid and exhibited understandable confusion. I am certain that she, even in her wildest dreams, would never have imagined that her dental hygienist daughter-in-law would become her link to the world, her translator. It was reassuring to see some sense of calm come to a woman who never liked being in a situation that she could not control.

The emergency room nurses were anxious to know what medications Charlotte was taking. Derek and the paramedics had only grabbed a couple of pill bottles. Her regular physician was not available until Monday morning, so I began to ask this very private woman about her medications. She rarely divulged information about her health, but, during the past few months, she had indicated that her doctors were concerned about a "leaky valve," kidney dysfunction, and hypertension.

The doctors needed to know her medications, so I began to do the hardest health history of my career. The health history review in a dental office seemed tame by comparison. First, I asked Charlotte what she was taking, trying to decipher the slurred names. When I couldn't understand the drug name, I started reciting all of the popular drug names I could remember. It was a little miracle each time Charlotte and I landed upon the right name. The following morning, her internist verified the list.

Charlotte became even more disoriented later that night. She was seeing the "boogey man" and large bugs, behavior reminiscent of an Alzheimer's patient. With a calm and steady voice, I assured her that her room would be off limits to these terrors. As the days passed, she told me that she found my calmness comforting. Many times I felt helpless. I didn't understand all of the monitors or all of the procedures, but I knew how to stay calm. Dental professionals do stay calm. But when someone you love is in a crisis, staying calm becomes a supreme test. The gift of calm is immeasurable.

Dentists and hygienists are experts in helping patients. We are tuned to subtle body language. We know how to detect fear, anxiety, and discomfort long before it becomes apparent to others. Nurses and physicians move from patient to patient in the hospital setting, but we are used to spending much longer periods of time with our patients, so it becomes second nature for us to detect the earliest signs of discomfort.

Day after day, I watched the hospital nurses and other health care professionals take care of Charlotte. Nurses are incredibly adaptable, taking care of groggy patients, patients in pain, patients with no energy, patients who have lost the will to live, and patients who are grasping at every last shred of life. I admired how much they could accomplish in such short periods of time with each patient. I did not envy how much responsibility they had for patient care, yet they still had to rely on doctor's orders to initiate treatment. It became abundantly clear that some patient comfort could fall through the cracks.

Charlotte began to complain of soreness in the groin area. Her bed linens needed to be changed one evening after an accident. The nursing staff was shorthanded, so I assisted the nurse with the necessary cleanup. The source of Charlotte's discomfort was obvious once I saw her inflamed skin. She had developed a candadiasis infection. Her skin was the same fire-engine red as a patient's palate under a partial denture. When the nurse began to apply a cream to the inflamed tissue, I inquired if the ointment was antifungal or just a soothing emollient. The nurse responded that she would ask for an antifungal cream. I was stunned. We see candadiasis infections every day. They can be aysmptomatic, or they can be very uncomfortable. I hope we appreciate our patient's discomfort and respond accordingly.

As the hospital days ticked away, I continued to watch the nurses' care for patients. Their number-one job is getting the patient stabilized, but Charlotte's overall comfort continued to deteriorate. The IVs, the catheter, the oxygen canula, and the breathing treatments were each necessary and out of my realm of expertise. But what about her dry mouth? Her ability to swallow had been compromised, and the doctors were worried about aspiration pneumonia. During the second week, she was not allowed to have anything by mouth. I mean nothing - no sips of water, no ice chips, no nothing. Her lips began to crack. Her whole mouth was dry. She was miserable, and I was miserable watching her suffer needlessly.

Charlotte was fortunate to have a very caring neurologist. I explained to her that there was a special oral lubricant available at the drugstore, which would protect the oral mucosa from further desiccation. She agreed that we should try this gel.

I showed my husband and all of the nurses how to coat her lips, but I was the only one brave enough to coat the inside of her mouth. She told me that it really helped her, so I kept applying the gel, even after she accidentally bit me. For the next four weeks, it became a challenging ritual to get Charlotte to open wide enough to slip an index finger full of soothing gel into her mouth. She was grateful for this little bit of relief, and we joked about the article I was going to write about how dental professionals can help critically ill patients. When I told her I was going to make her famous, she would just smile.

Many of our patients suffer from xerostomia. Whether it is from medications, radiation treatment, or Sjogren's syndrome, it is miserable. I was worried about Charlotte's xerostomia and felt that the gel was only a stopgap measure. The doctors were still worried about aspiration pneumonia. Who was right? I didn't care to debate that issue. I just wanted to moisten Charlotte's lips and mouth with life-giving water. Finally, the doctors gave their clearance. It was OK to let Charlotte suck on ice chips as long as she didn't choke or cough. I told my husband I knew I could help her.

Armed with a cup of ice chips and a pair of textured gloves, I slowly raised Charlotte's bed to an upright position and placed a towel under her chin to catch the inevitable drips. I searched for the longest sliver of ice and held it tightly in my fingertips while I supported her head with my other hand. The trick was to let her suck on the ice without swallowing a lot of water, or worse, aspirating some of the liquid into her lungs. I tilted her chin down, just like taking an X-ray on a gagging patient, knowing this would reduce the possibility that she would suck a lot of liquid into her mouth at one time. We proceeded slowly. I had to keep her from choking. All of my years of being a hygienist paid off. For the next three days, Charlotte and I were successful on this maneuver.

That next weekend, I was scheduled to speak in Wisconsin. On Thursday evening, I promised Charlotte that we would graduate to Popsicles when I returned on Monday. At a quarter past six on Saturday morning, my cell phone rang. I instinctively knew Derek had lost his mom and the Popsicle day would never come.

Hygienists and dentists are nurturers by nature. We are patient advocates by nature. We just can't sit still when we see treatable pain or discomfort. Every night when I left the hospital, I thanked my lucky stars that I had chosen to become a dental hygienist. I had been accepted into a nursing program three decades ago. At the last minute, I changed my major to dental hygiene. I had picked the right profession and was thankful that my dental hygiene skills allowed me to care for and give comfort to someone outside of my dental hygiene treatment room.

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