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She received far more
Martha Keochareon

Nurse Martha Keochareon invites nursing students´┐Żto study her own dying process

January 11, 2013 -- Today the New York Times ran a front-page story by Abby Goodnough about Martha Keochareon, a retired Massachusetts nurse who, while dying at home of pancreatic cancer, invited students from her nursing alma mater to come study her. The piece focuses more on the drama surrounding Keochareon's death and the real-world experience Keochareon offered the students than it does on the importance of nursing skills. Commendably, the report does quote two nurses with expertise in end-of-life care, one from Holyoke Community College (the alma matter) and another from the American Association of Colleges of Nursing (AACN). But the report fails to specifically identify either one as a nurse. The piece does offer readers a basic sense of what nurses do and how they are educated, with references to college courses and clinical training. In particular, the article briefly highlights how nurses are educated in palliative care, describing an AACN program designed to do that. And the piece refers to the challenges nurses may face in providing adequate pain relief to those who are dying. In fact, even conveying that nurses are educated in colleges at all can seem like an achievement for the elite media, particularly in view of the handmaiden vision that still prevails in many Hollywood products. We thank Abby Goodnough and the New York Times for this prominent and generally helpful story.

Martha KeochareonThe piece is headlined "As Nurse Lay Dying, Offering Herself as Instruction in Caring." It says that in early November Keochareon contacted the nursing school at Holyoke Community College, from which she had graduated in 1993. Keochareon explained that she had cancer and wondered if students wanted to do a case study, "feel what a tumor feels like," or learn more about hospice care. The piece describes the college's positive reaction from the perspective of "Kelly Keane, a counselor at the college." In fact, Keane appears to be a nurse educator with a BSN and an MEd. In any case, Keane was "intrigued" because, in the piece's words,

Holyoke's nursing students, like most, learn about cancer from textbooks. They get some experience with acutely ill patients during a rotation on the medical-surgical floor of a hospital. They practice their skills in the college's simulation lab on sophisticated mannequins that can "die" of cancer, heart attacks and other ailments.

But Keochareon was offering a chance to examine and question an actual dying person, something that students would not normally get, Keane notes. A few weeks later, nursing students Cindy Santiago and Michelle Elliot began visiting Keochareon's house, where she was
"bedbound, cared for by a loyal band of relatives, hospice nurses and aides." Keochareon invited them to sit on the bed and talk. The students hesitated, because they had been taught to avoid that to prevent germ transmission. And their impression of hospital nursing was, according to Santiago, more like "I'm here to take your vitals, give you your medicine, O.K., bye"--which may be a fair description of what nursing can be reduced to in a terribly under-staffed or under-educated setting, but does not begin to capture what the profession actually is. Anyway, the nurses asked questions, like about how Keochareon had survived so long with pancreatic cancer.

Martha KeochareonThe piece explains that the invitation gave Keochareon "a chance to teach something about the profession she had found late and embraced -- she became a nurse at 40, after raising her daughter and working for years on a factory floor." Keochareon says it seemed like most other nurses did not relish the chance to teach nursing students, but she "loved it." The piece notes that Keochareon's teaching project was "not just for students, but also for her -- a way to squeeze one more chapter out of life." This is a point that Keochareon's sister Ruth Woodward also made in her eulogy at the funeral. Keochareon wanted nurses to understand her illness, Woodward said, but there was more:  "I notice that every time that Martha gave of herself she received far more. In fact, she received a few moments of less pain and I suspect that she received life itself -- a few more hours, even days, with purpose." This idea rarely surfaces in the rush to call nurses selfless angels. Improving patients' lives offers real psychic benefits to nurses themselves. 

Martha KeochareonThe piece spends time on Keochareon's life and emotional state, but it also provides valuable context about the palliative care training nurses get. It says such training is not an important part of nurse training "partly because there are not enough clinical settings to provide the experience." However, the piece notes,  

The End-of-Life Nursing Education Consortium, a project of the American Association of Colleges of Nursing, has provided training in palliative care to some 15,000 nurses and nursing instructors around the nation since 2000, focusing not just on pain management but also on how to help terminally ill patients and their families prepare for death. In addition, some students do rotations with hospice nurses, said Pam Malloy, the project's director. But Ms. Malloy said that nursing schools still do not focus on end-of-life care nearly as much as they should. "We live in a death-denying society, and that includes nursing," she said. "People have begun to understand it's important, but we're nowhere [near] where we need to be at this point."

Martha KeochareonThis is a good passage about nursing education, underlining that nursing colleges have a professional association that undertakes initiatives to improve education nationally and that nurses undertake clinical rotations. The quotes from Malloy are helpful, though it would have been a lot better if the piece had noted that she is in fact an oncology nurse specialist with a masters degree in nursing. Ironically, the AACN presumably would not speak for a community college like Holyoke, since the AACN represents four-year nursing colleges that grant bachelor's degrees--a sign of the disparities that often lurk behind the scenes in nursing.

The piece also gets further into Keochareon's condition, revealing that it took several years for "doctors" to diagnose her cancer. Evidently she had suffered from wrenching abdominal pain, diabetes, and other symptoms before "a doctor finally ordered a CT scan" and the cancer was diagnosed in 2006, with a prognosis of death within a couple years. The nursing students were "outraged" to hear all of this, but Keochareon apparently felt relief to at least know what the problem was. She advised the students to "just dig a little deeper -- you know?"

Pain relief was a big issue for Keochareon and the students. When the pain became "unbearable" due to the cancer's spread, Keochareon was hospitalized for a week "while doctors assessed how to control it." Of course, "doctors" were not the only ones assessing how to control her pain, since in an inpatient setting, nurses take a leading role assessing and managing pain 24/7 while physicians typically stop by only once a day. The piece later says that "the new drugs that doctors had prescribed" did not control the pain, and Keochareon was "trying another combination" that also did not help much, when nursing student Santiago visited again. At this point we do get a quote from Santiago: "In school they always teach us that pain management is the biggest thing -- like, you know, we have to treat the pain. With her it's like, how do you treat it? Like, you've tried everything. What else is there to try?" That at least suggests that nurses play some role in addressing pain beyond simply giving medications.

Martha KeochareonThe piece also suggests that the nursing students had some ongoing role in Keochareon's care. Seeing her exhausted direct care givers, the students understood that, as Keane puts it, the patient "isn't Martha per se" but "the entire family." The piece says Keane urged the students to stop asking questions and instead practice "therapeutic communication," saying "'I'm glad to be with you; you must be frustrated; you look uncomfortable,'" and letting Keochareon "just talk and talk and talk." This all suggests Keane has nursing expertise; pretty good for a "counselor"!

At one point, Keochareon tells Santiago that she is "ready to go," which distresses the student, but Keochareon tells her not to feel bad. Santiago "shak[es] her look of concern into a smile," but she weeps after leaving the room; apparently she is thinking about her father, who also has advanced cancer. The piece suggests that the other student, Elliot, is less troubled by death, "having seen it in her job at a local hospital" where she is "a licensed practical nurse." The piece explains that Elliott is "pursuing a registered nurse degree to advance her career." Technically, at a community college, that would be an associates degree; the piece might have clarified that nurses also get bachelor of science degrees at four-year institutions. Martha KeochareonKeochareon also dispensed some final advice, telling Santiago that "learning from books was good," but "learning from patients was better." Keochareon adds that she is sorry she "went downhill so fast" and thought she could teach more. Later, after it becomes clear that Keochareon will soon die, Elliott regrets not having "asked more about how she felt about death." Keochareon died not long after Christmas. The piece notes that Santiago and Elliot will soon resume classes:

When the new semester starts this month, Ms. Santiago and Ms. Elliot will return to more conventional coursework: a pharmacology class, for example, and rotations in maternity and acute care. But they will also present to their classmates what they learned in the little house in South Hadley. Ms. Santiago said she would remember Ms. Keochareon "until the day that I die" -- especially her resolve. "Who in her situation, to be like that, would call up and say, 'Hey, I want to teach a student about my cancer?'" she said.

Martha KeochareonThe last passage is a good summary of an article that conveys some information about nursing education--with references to degrees, academic calendars, textbooks, pharmacology classes, simulation labs, and clinical rotations--but probably focuses more on more pragmatic and emotional aspects of nursing. Of course, those are important elements of the profession, but the emphasis on them limits how much really new information the piece can convey about the work. Many readers already know that nurses spend time with dying patients and that it's important for nurses to be able to relate well to them. And the idea that "learning from patients" is better than "learning from books" makes us a little uneasy. Would the media ever say that about physicians, for whom advanced technical knowledge is widely understood to be critical? On the other hand, at least there do seem to be nursing "books"! And with Hollywood continuing to turn out products like Grey's Anatomy, in which physician characters provide the end-of-life care that nurses do in real life, an article reminding readers that in real life nurses play a leading role in the care of the dying is not a bad thing. The piece also manages to give readers a number of reminders that nurses are educated at colleges and that they have real health care skills.

We thank Abby Goodnough and the New York Times for this report.

See Abby Goodnough's article "As Nurse Lay Dying, Offering Herself as Instruction in Caring," which appeared in print on January 11, 2013, on page A1 of the New York edition of the New York Times.


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