Trish’s Mental Health Resources Blog

1991 Advanced Level as a Professional Nurse Experiential Learning

DePaul School for New Learning

Foundations of New Learning

Teacher:  Catherine Marienau       

Advanced Level as a Professional Nurse – Experiential Learning

QUARTER:  Winter                   

YEAR:   1991

COMPETENCE STATEMENT: 

PW-10 Capstone  Can effectively administer health care at an advanced level as a professional nurse.

THE LEARNING EXPERIENCE: 

My learning experience began as a nurse’s aide in 1966. After 3 years as an aide I went to school to become a practical nurse; I practiced as a licensed practical nurse off and on over a 15-year period. My experience varied greatly from a psychiatric unit, a recovery room, a coronary intensive care unit, a long-term care facility, an oncology unit, to opening a health office for a small manufacturing company when OSHA laws went into effect. Finally, in 1984, I graduated from Indiana University, passed the registered nurse state board exam, and began practicing nursing in various types of intensive care units. 

REFLECTIONS:

I thought that I had learned a lot in nursing school until I went to work. Most of what I learned was, in reflection, dangerous. Some intensive care units have structured programs for teaching you what you need to know – some don’t. I recall my first day as a graduate nurse in an ICU. The head nurse said that I would work with another nurse by following her around all day. After 1 hour a man who was electrocuted came in and all I did was do chest compressions on him as his heart continually stopped all day. The second day I was told there are your 2 patients, you may not have time to eat lunch.

There were some formal classes, but by the time you had them, you could have hurt someone. So upon reflection, the learning was less than desirable, to say the least.       

A vital part of the learning is the politics involved. I thought we were there because we really wanted to care for sick people. Instead, I learned about “game-playing”, and competition, and that it was a system that was very hard to survive in if you had any sense of fair play or altruism. I am surviving now by the skin of my teeth by not working for a hospital; I work for a nursing agency and go to a different hospital sometimes every day. This way I can just go in and just care for the patient. The system thank God, did force me to be confident and self-reliant because I saw that it was necessary for survival. This is why I can go work anywhere.

GENERALIZATIONS:

To sum up, the last 7 years spent working in intensive care units I can certainly think of many stories to tell, but the overwhelming thought that disturbs me is that I do not think that all patients have their civil rights. The most basic of rights, the right to our personhood and our bodies is frequently stripped away by a patriarchal medical system. There are times that I think that I will not be able to bear one more day being a part of this system. As with any system, all those involved must keep up their role in the system in order to keep it going. I no longer “fit” in the system because I do not see my role in keeping any type of oppressive system in operation.

I now see that the value system I began forming is being betrayed as I work in nursing every day. When elderly patients complain about inadequate care they are said to have “lost it” in their head, you know, they’re old and confused. Pay them no mind.

I must, however, stay in the system to pay the rent and the advanced education that will allow me to hopefully begin to tilt the power structure in favor of the patients.

APPLICATIONS:

I hope to take the negative aspects of what I learned through nursing experience and with specialized education make things better within the system for the patients who need us very much.

HOW IT FULFILLS THE COMPETENCE:

I am functioning in nursing’s most complex areas: intensive care units, coronary care units, and open heart units.

EVIDENCE:

-Resume

-Evaluations from previous supervisors and employers

-Certificates of advanced training in nursing

EVIDENCE DESCRIPTION:

-Resume of past experience

-Evaluations from:

Michael Reese Hospital, Coronary Surveillance Unit, by Nurse Manager Linda St. Julien R.N., M.A.

Pediatric Unit, by Nedra Skale R.N., M.S.N.

Olympia Fields Osteopathic Medical Center, Coronary Intensive Care/Open Heart Unit, by Helen Hallman R.N., & Maria Layman R.N., Nursing Administration Supervisor

Myerscough Medical Staffing that they received from LaGrange Hospital after I worked there through the agency off and on for about 1 and 1/2 years.

-Certificates of advanced technical nursing education (on-the-job training):

-Advanced Cardiac Life Support – 1988 (What medical personnel do beyond Cardio-pulmonary resuscitation).

-Certification in the Intraaortic Balloon Pump (Used on patients after other measures are not enough to sustain the heart after a heart attack.

-Class in how to read an electrocardiogram. A requirement in intensive care units. 

1991 Triumph on the Bunny Hill

DePaul School for New Learning

Foundations of New Learning

Teacher:  Catherine Marienau                

Triumph on the Bunny Hill

Leisure activities are meant to allow us a temporary escape from our work, study and/or responsibilities. It is time when we can hopefully do whatever we choose. Hopefully, it’s a time when we don’t have to worry about time. To some leisure is what we do for fun – it’s an adult term for play. To others, it’s simply relaxation or getting away from routine.

To me, leisure is all of the above but also includes the concept of reflection upon the quality of one’s life. We are frequently so busy fulfilling the role that we think society has cut out for us that we fail to take the time and allow ourselves the personal space to examine just what we are doing with our lives. Leisure time can be a sabbatical for examining the quality of our lives. I used my leisure experience to correlate a new frightening experience, (snow skiing) to the fear of facing life in a single role after spending 14 years in the traditional role of wife, and mother. 

To a working mom, who is also a nursing student, leisure might be simply taking a long hot bath after the kid is in bed. Even a McDonald’s hamburger can seem like a magnificent feast if eaten at a leisurely pace without interruptions. Leisure is frequently foreign to superwomen. You sometimes are forced to sit up alone at 3:00 AM just so you can get your thoughts together.

So here you are losing your mind, trying to fulfill the many roles and duties designated to you by society (according to your genital anatomy) and at the same time trying somehow to fit in an identity quest. Just when your last neuron is about to experience a cataclysmic synaptic explosion your darling husband says that the two of you don’t do anything fun together! There you were foolish enough to have been thinking – survival.    

He wanted to find some common leisure pursuit that we would both like – this was sure to save the marriage! We agreed to try something neither of us had ever done before – so downhill snow skiing it was.

I was terrified to try skiing. It looked dangerous and I was 36 years old for God’s sake. I questioned trying something this risky at my advanced age. I also felt that a major part of my life was at stake – my 14-year marriage. Right from the start this was much more than leisure to me; it was more than getting away from my job, college, and motherhood responsibilities.         

So here I go. The ski school said that they grouped people according to ability level, but – I saw those “others” actually ski to the area where the lessons started! I walked there in sheer terror of putting those sticks and boots on my feet. I did not believe that you could have any control over your speed and direction going down a mountain full of slippery snow, let alone with those massive sticks tied to your feet. 

The first thing that you learn is to snow plow – boy is that important! You form a triangle with the curved points of the skis together facing down the hill. You use your knees to apply pressure onto the skis to dig into the snow. The amount of pressure applied controls the speed. Wha la – simple! I had no trouble understanding the physics principles involved in how to snow ski – I did have trouble with the fear that I would screw up the well-designed scientific principles and be sorry as hell.

I proceeded with the lessons until we were to start the intermediate hill. My God, that intermediate hill had curves, bumps, and steep inclines that looked more powerful and believable than any scientific logic. At least on the bunny hill, you could see the bottom and if desperate could roll down the hill on your butt if you chickened out.

So, I sat in the lodge paralyzed by fear, disgusted, and disappointed with myself. I was a wimpy woman – a failure. That damn fear and lack of confidence had me at its mercy.               

I began to realize that I didn’t like being in a situation where I felt I didn’t have reasonable control. I felt like the mountain had power over me – power over my mind. I slowly, during the 4 days in the lodge watching others ski, came to see that I had similar feelings about other parts of my life. Having the leisure of time to reflect made me realize I had no control over my husband’s “Archie Bunkerism” and the type of marriage that we had. His attitude had taken control over my life. It was just as scary for me to question his status quo opinions as it was to conquer that bunny hill. Both were things that you had to do alone, within your inner self. This time spent alone gave me space to search within for the courage that only I could muster.  

When I woke up on the final day of the trip, I decided that I could not leave without trying on my own to see if I could use my newly acquired knowledge about snow skiing. Somehow unconsciously, I sensed this was a “do or die” situation for me.

Most of the people at the resort were on the same package that we were, so that meant that they would all be well beyond the bunny hill by now. That meant that I might have the bunny hill to myself. Well, almost to myself, it was just me and the toddlers – I could deal with them. I stood at the top for quite a few moments talking to God, praying – I was now determined to do it. But I had to do it on my own terms, at my own speed, and without being critiqued as I fell flat on my face. I kept saying loudly in my mind, “I will do this”.     

I get goosebumps just remembering that precious moment. I was in the middle of the bunny hill, the tips of my skis were pointed inward, I had just enough pressure on them to make me go slow enough to make it fun without undue fear. I felt the wind blowing past my smiling face, I felt a delightful thrill in my heart and enormous pain in both of my knees. I felt free at that moment, free to dream, to dream of just being me, of finding the me that I somehow lost in the stereotypical role that even I thought I must fulfill.  This brief exhilarating feeling that I had not had in so long put me in touch with a spirit within myself that was desperate to express itself. 

I don’t know of words descriptive enough to describe the feeling of triumph I felt after getting to the bottom still standing on those sticks. I can tell you that I screamed, I hugged the poker face attendant at the lift (he actually smiled), and I could not wait to get back up the hill to do it again. You really can go 1 mile per hour, you can stop right in the middle of the mountain and you can get down standing on those skis. It is a real thrill. I went home feeling on top of the world – I had achieved a major accomplishment. Knowing this, I somehow also knew, I had other major life hurdles to ski through as well.

The feeling of conquering your own fear is very uplifting. It gives you confidence and enhances your self-esteem. It gives you the courage to think – gee what else could I do that I never thought that I could? This experience made me realize I did have the courage to face who I really was and who I was determined to be regardless of any damn fear.  This was much bigger than leisurely learning to ski – this was a major life event for me. It changed how I saw myself. This leisure pursuit ended up being the catalyst for an enormous growth spurt in my life. I realized that my growth was being enormously oppressed living with this type of man. If I could take control of a mountain, surely, I could do whatever I needed to do to find “me” again.

You find determination inside yourself; no one else can give it to you. You hold the power over your own potential. You have the power to get rid of obstacles in the way of your growth – whether it’s an Archie Bunker husband or overcoming the fear of snow skiing. 

I still snow ski. Each time I’m on top of a mountain, in control, I experience not only the fun of skiing, but I reflect upon how much I’ve grown since then. I now share skiing with my daughter. (To her it’s simple leisure for there wasn’t any fear involved for her – she just plowed on down that mountain right away). I ski with friends now. I even went on a skiing vacation ALONE after getting divorced. (This was done by a woman who previously felt too self-conscious to walk into a restaurant or bar alone). Leisure can help you to put life in a different perspective, it allows you to step back and look at your life while not actually involved in living it. It has provided me with a thoroughly life-enhancing experience that has been a part of my taking the lead in defining my quality of life. I now know you cannot have quality of life without an individual personal identity, even if doing so demands facing fear.

1991 Practical Use of Algebra

DePaul School for New Learning

Foundations of New Learning

Teacher:  Catherine Marienau                

Practical Use of Algebra

Non-SNL Coursework

QUARTER:  Winter          

YEAR:  1991 

COMPETENCE STATEMENT: 

PW-1 Can use mathematics to describe and solve problems.

THE LEARNING EXPERIENCE:

Algebraic math was a part of my nursing education; it was incorporated into the appropriate areas and thus not labeled separately as a math course. However, this did really prepare me for the kind of math I would be using when I went to work in intensive care. This is where I really learned to use math and to see its vital importance to my patients’ care.

REFLECTIONS: 

At many local community hospitals, the doctors figure out the dosages of the super-potent drugs. I had worked in two local type hospitals before going to work at Michael Reese. Here you are working with interns and residents, they come from many different medical schools and are still considered students. The nurses are NOT students. They apparently are left to learn the math required on the job, because they always asked us how to do it.

I had grown up thinking that I was terrible in math so the fact that this was going to be such a vital responsibility in my new job I was terrified.

I also soon learned that the other nurses had little patience with the fact that I felt unsure of myself using these new formulas and trying to them at the bedside of a critically ill patient. So, it made me determined to KNOW it! I went to our clinical nurse specialist and asked her to teach me. She did teach me most of what I needed, but even she did not know how some of the figures were figured out. I HAD to know that too.

GENERALIZATIONS: 

An example of the math that I need to use I can best explain with a situational problem. A man comes to the coronary intensive care unit and is having a heart attack. As a result of heart damage and the inability of his heart to pump well, he loses his blood pressure. We then use drugs that will constrict his blood vessels to send blood to his vital organs, like his brain, heart, and lungs. This drug is called dopamine; the dosage of this drug determines the effect on the body, for example, if you give too high a dose you can damage the kidneys and give him more problems than he already has. This is why you must know how to calculate the dose properly.

The first thing to be considered is the concentration of the drug in the intravenous fluid. Let’s say you mix 400 mg of dopamine in 250cc(ounces) of fluid. You need to know how many micrograms of the drug are in each cc of fluid. SO……

250cc : 400mg : :  1cc : X mg

____   = _______

(400 mg divided by 250 cc = 1.6 mg/cc)

Now we know that each cc of fluid contains 1.6 mg of the drug.

We have a problem because we need to know how many micrograms are in each cc of fluid.

1.6mg          1600mcg    (Because 1000 micrograms = 1 mg) 

_____ X 1000 = _______  

 1cc             1cc

So … 1600 mcg/1cc

These drugs are so potent that they must be given on machines that will pump it into the patient at a specific rate in cc’s per hour. What we need to figure out is how many micrograms per kilogram per minute (mcg/kg/min) to give it at; this must then be put in terms of cc’s/per/hour that the pumps deliver.

The formula then looks like this………..

mcg x kg x 60 minutes (in 1 hour, which is what the pump delivers)

_____________________ =   

  1600 mcg per 1 cc

Let’s say we want to give 5 mcg/kg/min to this patient.

5mcg x 68kg x 60      20,400

________________ =  _________ = 12.75 or 13 cc’s per hour  

1600mcg/1cc            1600

We set the pump at 13cc per hour and the patient will be receiving the right dose.

If you take over a patient who is already receiving dopamine it is your responsibility to figure out if the right dose is being given. There is a shortcut that I have discovered that works well. If 1600mcg is in 1cc, if there are 60 minutes in an hour (the pump works on cc/hr) you can just divide the mcg by 60 and you get a constant factor.

So …

1600mcg

_______ =  26.6 mcg each hour

 60min

So when you walk in and find the rate at 13cc/hour you can quickly figure out if it is right. The formula would look like this:

13 cc per hour x 26.6     345.8

_____________________ =   _____ = 5 mcg/kg/min

       68kg                68

If any of these variables change, then you must do the whole thing over. For instance, the patient’s weight, the concentration in the bag, or the amount you want to give. This is only the formula for one type of drug.

Some are given in just mcg/min and then the weight becomes irrelevant. For instance, nitroglycerine. If you have a

50mg       0.2 mg                         200mcg

_____  =  _______  x 1000 to find mcg =  ________  divide by 60 = 250cc      1cc                             1cc

A constant factor of 3.33. Then you just multiply 3.33 by the number of cc/hour to find how many mcg/min.

You then proceed to fill in the amount in mcg that you want to give, you take the patient’s weight in kilograms, let’s say 150 pounds which you would divide by 2.2 to get the weight in kilograms (2.2 kg = 1 pound), or 68 kg.

Let’s say we want to give 50mcg/min. We then divide 50 by 3.33 and set the pump accordingly – at 15cc/hour. To check your figures you can take the cc,s per hour and divide by 3.33, or 15cc multiplied by 3.33 = 49.5 mcg/min (close enough).   

Sometimes we do what we call titration of these drugs according to the patient’s symptoms. If we are using dopamine for low blood pressure we increase it if the pressure is low and decrease it if it goes up to an acceptable level. With a medication like nitroglycerine, used to relieve chest pain by dilating the coronary arteries, you increase it or decrease it according to the patient’s pain. Sometimes if a person is unstable you may be changing the amounts you are giving every minute or so. You must keep checking what amount you are giving so that you prevent other side effects of the drugs.

There are many other things that critical care nurses calculate on a daily basis. If you require more I will try to explain. Some of it requires knowledge of anatomy and physiology like figuring some one’s cardiac output (how many cc’s of blood the heart pumps out per minute). There’s cardiac index which is found by taking the cardiac output and multiplying it by the person’s body surface area (we use a chart to figure this by the height and weight). We figure systemic vascular resistance (the resistance offered by the body to the blood on its way out of the left ventricle on its way to the body, which would be high with high blood pressure). These involve many formulas and many patient parameters that would require tons of explanation. 

APPLICATIONS:

As a nurse who goes to a different hospital every day, I desperately need these skills to survive, to say nothing about my patient’s survival, and my not being sued. Each hospital mixes drugs in different concentrations, so you have to start from scratch each time. Some hospitals have charts to calculate the drugs, but what if they don’t? I find that I end up teaching other nurses about the constant factors at least once a month because they can’t believe there is a faster way to figure.

Doing this is making me reflect upon the past 7 years of critical care nursing – I see what I could not see while just doing what I had to do. This now illustrates to me why they are now advertising, “If caring were enough, anyone could be a nurse.”

HOW IT FULFILLS THE COMPETENCE:

I can and do use math to describe and solve problems as a part of my work every day.

Spring, 1991

DePaul School for New Learning

Foundations of New Learning

Teacher:  Catherine Marienau                

Male Literary Inspirations: Henry David Thoreau, Russell, Bertrand, & Martin Luther King Jr

Thoreau

FORM – The first English class exposed me to Henry David Thoreau, born in 1817. Thoreau used essay and book form; his ideas were seen as radical in his time, but succeeding generations viewed them with admiration. He is most famous for his living experiment where he lived for a couple of years alongside a pond in New England; he wrote occasionally in journal form. He also wrote poetry. He also expressed his civil disobedience (in addition to his work by the same name) by not paying his poll tax because it supported slavery. He thought human rights were a precious thing.  Thoreau used eloquent language to express his views, for instance, “The mass of men lead lives of quiet desperation”, seems profoundly true to me.

CONTENT – The basis of Thoreau’s content was to tell others to “simplify” their lives. He advocated defining success in your own individual terms, ignoring public opinion, and thinking for yourself. He criticized the current economic and social systems.

STYLE – His style was rather philosophical in nature. I was amazed at his sentences that frequently had 4 or 5 semi-colons in them! I was impressed. I was also impressed by the way he made simple everyday events seem somehow profound. He formed his unique ideas about life while at Harvard University and through the influence of his older neighbor and friend, Ralph Waldo Emerson.

Thoreau’s Walden contains several types of writing: descriptive, argumentative, and expository. In the book, he discussed 4 basic topics: the desperation in which most men lead their lives, the economic myths that led to their desperation, the joys of living close to nature, and the higher laws that lead man from wildness to genteel.   

Bertrand Russell

I also came to love the work of Bertrand Russell; he was eloquent with his sarcasm and common-sense evidence to prove his points. His work called “Intellectual Rubbish” led to my examining my religious convictions and writing a paper about my idea of intellectual rubbish that earned me my first “A” in a written assignment in college. (My intellectual rubbish was the fact that in order to give the sacraments in the catholic church you had to have a penis – we all know of the absolute necessity of this piece of anatomical equipment in the catholic church).

FORM – Russell used book and essay form.  Anyone who was raised catholic knew that those nuns never took off their habits. Russell would take that “general knowledge” literally to the point that you had to realize how ridiculous it was. He says that even in the shower those ladies kept their habits on. He wrote essays that eventually went together into books on related issues and subjects.  

CONTENT – His contents in Intellectual Rubbish and Why I Am Not A Christian involved attempted to apply reason to subjects such as sexual ethics, morality, freedom, mortality, and education. He is brave enough to tackle subjects that leave him open to criticism by those who “believe” simply because of “faith”. He challenges the rationality of what we frequently don’t think to question – I love him!  

STYLE – He used sarcasm, wit, humor, and logic to get his message across about how ridiculous some of our common assumptions are about religion and politics. While his work was philosophical, it was at the same time easy to read even for me in one of my first college classes.

         Martin Luther King Jr.

My second English class exposed me to Martin Luther King Jr. His writing has the ability to grab at your conscious emotionally, intellectually, and at your innate sense of justice. I hope to someday write like him – I hope to write in a way that will move people and enable them to be tolerant of others whose morals and views differ from their own. (Examples being issues about abortion, the right to die, and racism).

FORM – The class assignment was to read his “Letter From Birmingham Jail”. He wrote it, of course, in letter form to fellow clergymen. He had been jailed for 8 days because of his campaign against segregation in Birmingham. He specifically directs the letter to WHITE clergymen who criticized his work and blamed him for breaking the law.  

King also used speeches as a form to express his passion. I always get goosebumps and tears in my eyes when I hear, “I have a dream……….”.

CONTENT – The contents were brilliantly directed at the conscious, guts, and intellect of his fellow ministers. He talked about equality and human rights that no clergy could dare argue with.

He defends his civil disobedience to the other clergy so well that I’m surprised the whole country didn’t join him. The contents of the letter addresses the criticisms he received from white clergy who did not understand what he was up to.

He addresses their criticisms and questions about what he is doing. He simply tells them that he is there because his organization is functioning there in Birmingham and simply that injustice is there – isn’t that reason enough?  He makes a correlation between what he did and what the apostles and Jesus did to spread their gospel; truly attacking the very principles that clergy stand for.

He explains why direct nonviolent action was necessary – to force negotiations that had previously been done but failed to remove racially degrading signs in the community. He said it was a historical fact that privileged groups seldom give up privileges voluntarily. The oppressed must demand that the oppressors stop. The clergy criticized his timing of the sit-ins and he said, “Justice too long delayed is justice denied”. When is the right time to demand your freedom? Negroes had waited 340 years for their constitutional and God-given rights. He said it’s easy to tell someone to wait for their freedom when you have not seen your mother and father lynched, your brothers and sisters drowned at will etc.   

STYLE – His style was to intelligently clutch at your heart. I know I was not prepared for the emotion that it would wrench from me; I was glad I had decided to read it before I went to sleep because I could not contain my tears.

The style and content were directed at the very core of morality. He chooses words that have the ability to reach right inside your core to humanness and vulnerability that is the same for us all – black or white.

He writes with intelligent passion and clearly makes an eloquent unshakable argument for civil rights that is now a classic among arguments.

While reading his work I was also able to apply his ideas to the issues of patients and women’s rights.

Bibliography

Krutch, Joseph Wood. (1982). Ed. Walden and Other Writings of Henry David Thoreau. Essay pp. 105-340. Walden. Bantam Books, New York.

Miller, Robert K. (1986).  The Informed Argument a Multidisciplinary Reader and Guide.  Part 2-section 9. Some Classic Arguments.  Letter From Birmingham Jail. New York: Harcourt Brace Jovanovich.

Russell, Bertrand. (1950). Unpopular Essays.  Chapter 7.  An Outline on Intellectual Rubbish. New York:  Simon and Schuster.

Russell, Bertrand. (1957).  Why I Am Not A Christian.  New York: Simon and Schuster.

Spring, 1991

DePaul School for New Learning

Foundations of New Learning

Teacher:  Catherine Marienau                

Jewish Culinary Culture

Food is more than just nutrition; it is very meaningful to humans. Our social life frequently revolves around food, singles find meeting each other easier when food is involved, and even business meetings revolve around food. We talk while cooking together, we share it with guests as a way to bid them welcome, we make gifts of food to one another, and we use food as a means of expressing our creativity.

Sharing food is a universal peace-promoting gesture. Even without speaking a person’s language, you can tell them that you mean them no harm by offering food – it’s a good peace offering.

Since eating is shared by us all it could easily be a good place to start learning about each other and thus reducing fear of the unknown. Because of current events in the Middle East, I decided to learn about Jewish values through their numerous dietary practices. 

We have very strong emotional attachments to the food that we grew up believing was good for us; these beliefs are difficult to change. I am going to share with you some basics cultural aspects of Jewish cooking. I hope to answer questions like: what does kosher mean? Why do Jews have so many dietary rules and what do they mean? Jewish dietary laws are very complicated and have their origins in the Garden of Eden, with the forbidden fruit. I will attempt to briefly summarize these rules and the accompanying cultural values they express.

Kosher means “fit to eat”; the system of determining such fitness is called kashrut; this system falls into 3 main parts: allowable and forbidden foods, the preparation of meat, and the separation of milk and meat.  Treyf is a food that is not kosher. Pareve foods are those considered neutral and OK to eat with either meat or milk.

All fruits, cereal, and vegetables may be eaten according to a biblical statement. They must be examined and cleaned to make sure they are free from insects, however.

They may eat animals that chew their cud and have cloven hooves; all others are forbidden. Kosher meat comes form the forequarter and organs of beef, veal, or lamb. Any meat or poultry must be killed by a shohet (ritual slaughterer). A limb torn or cut from a living animal is forbidden along with an animal that dies by itself and not from slaughter. Traditions of ritualistic slaughtering (called shehitah), date back over 3 thousand years to meat sacrificed at the Tabernacle in Jerusalem. The rules of slaughter come from ethical ideals which are designed to reject the sacrificial practices of paganism. The method of slaughter is prescribed by tradition and attempts doing so in the fastest, most humane way possible.  After proper slaughter, the shohet examines the animal to be sure that it was healthy and thus fit to eat. They are not allowed to eat an animal that has died of natural causes or that has a disease. 

The Bible has a list of allowable birds and fowl: chicken, duck, goose, and turkey are OK. All birds of prey are forbidden. Eggs are OK as long as there is no blood inside it.

Jews never eat foods with milk and foods with meat at the same meal; they even use a different set of dishes to serve milk and meat dishes; they use separate cleansing methods for the utensils also. They are even required to rinse their mouth and wait certain periods of time between milk and meat dishes. The historical basis of this prohibition prevented the ancient Hebrews from pagan customs of animal sacrifice; it is related in, “Thou shall not seeth a kid in its mother’s milk” (Deuteronomy 14:20). It was also a way of aiding digestion.

Jews were also taught, not to sacrifice a kid and its mother together (Leviticus 22:28) and not to boil a kid in its mother’s milk (Exodus 23:19). Although dead goats are not affected by these rules, they do affect people in that they attempt to promote humans to be concerned about the suffering of other creatures; they do NOT reinforce brutality.

Fish has always been a mainstay of the Jewish diet. Only fish with scales and fins may be eaten. Caviar, eel, shark, and shellfish are forbidden. Reptiles including “crawling things” are forbidden. They eat lox (which is smoked salmon), smoked whitefish, and pickled herring as a protein with their daily meals, frequently served on bagels. Whitefish, pike, and carp are combined to create gefilte fish (stuffed fish) which is served as an appetizer. Friday evening meals frequently include Shabbot which includes chicken soup and a main dish made with chicken. Chicken is considered a staple in their diets. 

To the Jews eating fish symbolizes the hope of redemption for Israel and reminds them of the mercies of God. In Genesis, God blessed man and fish several times, creating a mystical triad; he urged them to “be fruitful and multiply”, and from this, fish came to represent fertility and immortality.

In folk tradition, a woman who ate a fish that was inside another fish would become pregnant. For some, the 7th day of the wedding feast is a “fish day”, when the groom sends the bride a plate of fish, she steps over a fishnet and symbolically becomes pregnant. To this day North American Jewish women wear fish amulets around their necks with the hope of becoming pregnant.

The Jewish bible absolutely forbids the ingestion of blood; this stems from the Israelites wanting to go against the pagan practice of drinking blood. To Jews, blood is a sacred gift from God and a means of atonement. To extract blood from the meat they use salting or broiling.

To Jews a meal is not a meal without bread; the Sabbath is an occasion for their favorite hallah, which is a sweet egg bread. Their bible calls for the first of the dough to be given to the Lord and a portion for a gift throughout the generations. Even modern Jewish families, who don’t practice a lot of the dietary rules, still cling to the Sabbath for rest and family togetherness. (Not a bad idea).

The Bible is fairly clear in explaining why the Jews have been ordered to live with these strict dietary rules. “You shall be holy unto Me, therefore, you shall not eat……” and “I have set you apart from peoples that you shall be Mine.”  These special rules are to set the Jews apart from others and enable them to serve as “a light unto the nations.” And to transmit the message to all mankind.  The Rabbis of the Talmudic era were without doubt about the purpose of the kashrut; it was to refine man by disciplining his basic appetites. In other words, God doesn’t really care, for instance, how you kill an animal, but the laws are for the refinement of the man himself.   

In the later ages, more practical reasons for the laws were presented, hygienic reasons: pigs were too dirty to eat, because of their scavenger-like eating habits, and shellfish were considered contaminated because they breed best in polluted water.  There are some discrepancies in the laws: although horses are seen as clean animals, they are forbidden. These dietary laws are still valid today, mostly because of the old biblical reasons: to set the people apart, to allow them to better fulfill their role as interpreters and teachers of God’s law. The rules were developed for man to discipline his appetites above the level of the animal world and as constant reminders of his higher plane of existence.

The history of Jewish dietary rules dates back to ancient Palestine and has served as a means to differentiate Jews from others. Back then, mere planting or harvesting of the first grain, or finding an animal large enough to feed the group was the reason for celebrating. Fear, giving thanks or regret past sins caused them to offer sacrifices to God. There were strict laws regarding these sacrifices too. To the Jews, the ceremonial rites surrounding their foods had great meaning to them; these rites served to express the relationship between God and nature, in addition to the relationship between the Levi (priests) and the Jewish people. It is clear that foods have deep symbolic meanings to the Jews.

It’s not unusual to hear of a religion having special days when they have either feasts or fasts, but the Jews use an entire written code of dietary laws that address everything on their dinner table. Many theories have been proposed in an attempt to explain the rules in the Torah. The faithful, however, think that commandments from God do not need a reason.  

Anthropologists have long discussed the Jewish dietary laws, especially the exclusion the shellfish and pork. Mary Douglas, an anthropologist from Britain, thinks that some animals were simply arbitrarily forbidden, to reinforce the exclusivity of Jews. Moses forbade the most delicious meats. The laws forbade all animals of land, sea, or air whose flesh was the tastiest; the goal was to prevent gluttony.

Columbia University anthropologist, Marvin Harris, says that the Jews excluded pigs for economic reasons. He claims that rabbis forbade pigs because in the ancient Middle East the Jews could not maintain the pigs in the hot desert, no matter how good their taste was. 

Jews view their home tables as God’s alters since in history their Temple was destroyed. Salt has meaning at their tables: the purity of God and the Temple, it wards off evil spirits, serves as a symbol of permanence, a good omen, and was even sprinkled on newborn babies for good luck. Salt is required on the table before each meal; salt is evenly spread on bread after the blessing.  Much of Jewish life centers around food; these specific rules for the dinner table serve to remind the Jew of his separateness and his oneness with God.

The Sabbath is their day of rest and falls on Saturday; rest includes not cooking. As a result, an entire cuisine was created so that could be cooked in advance. No fire could be kindled on the Sabbath, so they would make dishes that could be started on Friday evening, finishing as the embers die out.

I have a friend who is Jewish. He has made dinner for me numerous times. Most of his dishes are boiled and used chicken as a protein source. For bread, he serves Matzo made from boiled dough shaped like a donut or bagel. He says that his mother boiled meat, not because of any dietary rules, but because she hated to clean the pans after frying. He says the rabbis made all the fancy rules just to have power over the people and to occupy their minds so they would keep out of trouble. Please keep in mind, however, that this is a Jewish man who eats bacon!

I loved the essay done by Max Apple in Esquire magazine (Feb 1984). He made me realize how difficult it would be to be a Jew today and try to follow kashrut. Imagine having to ask a waiter, “Do you have a kosher table? Do you separate your milk and meat products? Do you stay away from shellfish? Are your animals ritually slaughtered? “

Max says the most prevalent type of Jew today is what he calls the, “at-home kosher.” This is a kashrut they design themselves to fit in today’s society; they just follow the rules at home. It is an attempt to cling to ancient culture, but at the same time not interfere with modern life. To them kosher is a cultural symbol, not a taboo, and a choice rather than an obligation.

Max says that he realizes that he could eat a cold pork sandwich, in a synagogue, on Yom Kippur, and live happily ever after. He knows these rules don’t make sense in our modern world. He knows that it is a pain in the neck trying to find the right food and especially a pain to explain to others what he will and won’t eat.

However, when even your breast milk was kosher and the dietary prohibitions are deeply rooted in your identity, you accept fully that your culture’s aesthetics and ethics are wrapped up in these rules. He says he can put up with it all because, after all, there are no “kosher thoughts” – he is still free to think.               

Jews who follow these strict dietary rules are showing strong religious faith. Symbolically, if any group of people followed other biblical teachings like, “Love your neighbor as yourself…..” (Leviticus 19:18) then the world would certainly be all the better.

Bibliography

Nathan, Joan.  The Jewish Holiday Kitchen. 

Gubbay, Lucien & Levy, Abraham.  The Jewish Book of Why And What.

Sokolov, Raymond.  The Jewish-American Kitchen.

Newtol Press.  (1985, Feb).  Commentary Section.  “Kosher Ecology.”

Apple, Max.  Esquire. (1984, Feb).  “The Stranger At The Table.”

Fall 1991

De Paul University

World of Work

Steve with Aids: A Case Study 

Steve was a 34-year-old male. He was brought to the intensive care unit around 8:00 PM. I was at the beginning of a 12-hour night shift (7:00 PM to 7:30 AM). He had been admitted to the regular floor, but when his respiratory problem became acute, he was transferred to ICU. The nurse from the floor who brought him was dressed in full isolation attire – like what you might need for bubonic plaque, just a bit exaggerated. She said that Steve might have Aids but she wasn’t sure – and no, she had not asked him if he did or did not.

I could see immediately that Steve was going to need artificial ventilation before the night was over. He was receiving the maximum amount of oxygen that you could receive without being on a respirator. He was breathing 60 times per minute (12-20 is normal), his heart rate was 160 (normal is 60-100), his color was bluish, and his eyes were bulging with terror. I thought to myself that he looked like an Aids patient and by the sound of his chest I thought he probably had pneumocystis (the pneumonia that Aids patients get). I realized that there was not much time for me to teach Steve what he needed to know about being on a respirator; he should know enough so that he could make an informed decision.

The first thing I said to Steve after telling him my name was, “Steve, do you have Aids”?

He responded, “Pat, I have reason to believe that I do, but I have been denying it for a couple of years”.

I said, “Are you gay Steve?” (If I had this to do over, I’m not sure I would have asked this.)

He said, “Yes, I have always been gay, I’ve never had a sexual relationship with a woman”.

I said, “Steve, the reason I’m being so blunt and to the point with you is that you are very critically ill; we don’t have time to beat around the bush. I have no prejudice about your having Aids or being gay, my concern is your serious health status right now”.

“Am I that sick, Pat”? He said trying with great difficulty to breathe and talk at the same time.

“Yes. You are breathing so fast that you will soon need to be intubated and put on a respirator; it will blow air into your lungs for you. Otherwise, at the rate you are breathing now, you will simply tire out and not be able to breathe at all.” I said this while holding his hand and using what I hoped was a really concerned voice and manner. I was careful to maintain longer than normal periods of eye contact in the hopes of communicating sincerity and concern. I was trying to use my eyes to communicate a horrible truth yet do so with caring. I hoped that my eyes could say more than simple words.

“Do you mean that I will die without it”? he said.

“Yes, that’s exactly what I mean.” I said.

I gave Steve some time to think about all this mind-blowing stuff. I left the room to check on my other patient and get myself together.

I brought back an instrument that would monitor Steve’s oxygen saturation with a little probe placed on his finger. The saturation should be at least 90, Steve’s was 60. I was actually amazed that he was still sharp enough mentally to communicate with me with a saturation that low. I told Steve about the numbers (his heart rate, saturation and respiratory rate); I explained what they meant and left the conversation open so he could feel free to ask questions.

Finally, he said, “Pat, what is it like to be on a respirator”?

“Oh, God, Steve, you really ask hard stuff. I’ll explain what usually happens. They give you a drug in your IV (intravenous line), like valium, to help you relax and tolerate the tube being put down your throat into your trachea. The tube is large, and it can be a terrifying experience that makes you choke and buck the tube being in there. It makes you feel like you can’t breathe even though it helps you to breathe. You will feel a strong urge to pull it out. A balloon is inflated at the end of the tube to hold it in place, then the tube is taped to your mouth to secure it even further. Many patients need to be kept sedated the whole time the tube is in, but there are some that can just lay there and let the machine ventilate them – this happens less frequently.”

“After they get the tube in they hook up the machine to give you air”? Said Steve panting.

“Yes, that’s right. Another thing is that when you are under the influence of drugs like valium, you can no longer consent to your own treatment because your thinking is altered.” I stopped allowing questions before I went on. I could see his mind going around and around. So I changed the focus for a while and asked,

“Steve, you said you have reason to believe that you have Aids. Were you ever tested”?

“Yes, it was about 2 years ago, and they said that I was a carrier. They said that I didn’t have Aids yet. I went on with my life and tried to forget all about it because I couldn’t deal with it”. He said looking down at the bed.

I left the room again because I was finding it hard to deal with it emotionally myself – I needed to break away. I told him I’d be right back.

As I left the room, I was greeted by 3 young women (around Steve’s age). They asked if I was his nurse, I said yes and could sense that they were very concerned. I took them down the hall to a vacant room so we could talk. After assessing their relationship with Steve I knew that they were quite sincere. They said that they had gone to grammar school with him. They always knew he was gay; they loved him and were close friends.

They were not surprised that he thought that he had Aids. I explained that he was seriously ill right now but hesitated to go further without talking to Steve about what information was OK to share with them.

I went in and asked Steve, “There are 3 ladies here to see you who seem very concerned about you. They are asking me questions and I want to know how much or what you want me to say to them”.

“Pat, they are as close to me as family, they brought me here. You can tell them the truth just as I sense you are doing with me”. 

“OK Steve, I needed to know that. How are you feeling”?

“Well, he said, I am starting to feel really tired like you said.”

“Steve, we are going to be doing a blood gas in about 10 minutes to see how your breathing is. It will give us more detailed information than this oximetry.

“Pat, I don’t know what to do, I don’t know if I want to go on that respirator and be drugged up. Will it make me better”?

“We don’t have the HIV test back yet so at this point we can only go on what you have told us and how your condition appears. If you have Aids, it will not cure the Aids, it will certainly temporarily make you better by giving you the oxygen you need right now. It will prolong your life by forcing air into your lungs since you are too sick to do it for yourself”, I explained. “I want to try the respirator, I’m tired now and I want to try it overnight because I am so tired and it will let me get some rest, especially with the drugs, then in the morning, I will feel better. In the morning I will take off the respirator and see how I feel. It will be better to make such an important decision when I am rested”. (Steve said between taking little puffs.)

“Oh my God, Steve, we have so much to talk about and so little time to do the subject justice,” I said, wondering where to begin in telling him that you can’t just “try” the respirator. Cases about taking people off respirators are very involved and our society has not dealt with the realities that this technology is posing every day.

Just then I saw an older black man outside the isolation door peeking in. I went to the door and asked the man who he was and he said he was Steve’s father. I asked him to wait a few minutes.

“Steve, your father is here. What do you want me to tell him?” I asked.

“Oh God, Pat, I haven’t spoken with my dad in 3 years. He doesn’t understand my lifestyle and he just couldn’t understand – so we haven’t seen each other in 3 years.”  Steve said with true sadness in his eyes along with tears.

“Do you want me to explain what’s going on”? I asked.

“Yes, I guess so, but how about saying that I just have Aids Related Complex not actual Aids”? He asked already sensing what my response might be, and with a smile shook his head “no”, meaning to tell him the truth.

“Steve, the problem here is one of time, if you go on the respirator, you won’t be able to talk because it pushes against your vocal cords on the way to your trachea. So, we have to gear our actions to fit the time you have to communicate verbally. You can write while on the respirator, but we have to untie your hands first. Before he had a chance to ask me about that I realized that I left that out and said. “Oh God that’s another thing about being on the respirator, most hospital policies dictate that the patients’ hands must be tied to prevent them from pulling the tube out – its uncomfortable and anyone would want it out”.

“Ok Pat, I realize this is a lot of work and stuff for you too. Let’s deal with my dad as you said time is important. I can ask him to make the decision for me. Oh God, I forgot my dad is terrified of hospitals, he lost a couple of relatives in them and hasn’t been able to go back into a hospital in 20 some years. It must be really hard for him to be here”, Steve said with understanding in his eyes.

“Would you like me to talk to him first to help him to deal with it? Maybe with help and support he will be able to cope. Do you want me to be honest with him?” I said wondering how I was going to care for my other patient, who was now on autopilot because of my being with Steve so much.

“Yes, Pat, be honest, you’re right, time is important and I really love my dad. I’m so glad that he’s here. You know all sons want desperately to be accepted by their fathers.” (He said, moving me to tears.)

I went out of the room, told the father that I had to check on my other patient, but that I would be back and speak with him at length in a few moments.

I went to the charge nurse and explained what was going on. I told her that the patient didn’t know yet whether he wanted to go on a respirator and thought he could maybe just go on it for the night – she realized I had a lot of explaining to do. The other nurses could hear me and were all supportive – to my surprise. One of them said she would watch Eleanor for me (my other patient who was already on a respirator with no chance for survival). So I went to speak to Steve’s father with my heart a little relieved.

I brought Steve’s father to a room down the hall that was vacant. We sat down and he immediately told me that he did not think that he could go in the room. He explained his horror of hospitals. Then he asked, “What’s wrong with Steve, nurse?”

“I understand from Steve that you and he haven’t spoken in 3 years. Is that right? I asked.

He nodded, “Yes”.

I proceeded. “Steve said that you don’t approve of his lifestyle, so you know that he is gay?,” I asked.

“He never really told me. We didn’t talk much about it but, I suspected that it was some crazy things like that. I don’t approve of them funny guys – you know that stuff is sick and its just not right.” (He said getting obviously angry just at the thought of gays.)

I could see I was not going to change his values at this time and that wasn’t my goal anyway. My goal was to get Steve the support he needed to make the decision that faced him. My goal was to help Steve to have a peaceful death whether on a respirator or not. So I proceeded with great caution.

“Mr. Smith, (not his real name) Steve is pretty sure that he has Aids; the reason he is in intensive care now is because he has a pneumonia that seems to be of the type that Aids patients get. Right now, his breathing is very bad. He will probably need to be put on a respirator because he won’t be able to maintain his life breathing like he is now,” (I said holding my breath to see how he coped with it.)

“Miss nurse, its so sick to think that my own son has that disease. I don’t think I can go in the room,” he said.

“Mr. Smith, Steve got tears in his eyes when I told him you were here. He told me how he has missed you since you two stopped speaking. He said that he loved you very much and that he knew how hard it must be for you to be here since he knows how hospitals affect you. Steve really needs you right now. I will try to help you to go in the room. I will be with you and answer any questions that you have. Sometimes understanding things can help you to cope with them, even things this bad,” I said, hoping to reach him.

“Can I get that Aids thing if I go in there? I’m scared of that, too. And what do I say to him. No, I can’t do it, I just can’t go in there. He will have to handle this himself, he got himself into it. It’s not my fault he got this sickness,” he said, getting up and pacing. I sensed that I better grab him somehow now, or he would be out of here.

“Mr. Smith, this is hard for me to say but I feel that I must. Steve is dying. Even with the respirator, Steve is going to die in the very near future. I know he loves you very much. You two don’t have time to let anything get in your way. I think he would feel better dying if he thought that you two had mended things. Perhaps you could just go in once, just seeing you here would make him feel better,” I said, thinking that maybe I sounded like I was begging and feared it would turn him off.

“Miss Nurse, will you really go in with me? Will you tell me what to say? Will you let me cover myself up so I won’t get Aids,?” he asked, with an overwhelming nervousness in his voice.

“Mr. Smith, I will give you all you want to cover yourself. Come with me, and we’ll get you dressed,” I said, as I led him to the isolation cart.

We got him dressed with a gown, hat, mask and gloves. (I had nothing to cover and protect his heart, though). We went in the room together. Steve was sleeping so I had a few moments to explain the things in the room and what they were all about. I wanted him to feel safe at least with the physical environment.

I touched Steve’s hand and said, “Steve, your father is here.”

“He’s here in the room? He’s right here you mean,?” he said, so tired that he could barely see.

I took Mr. Smith’s hand and guided it toward Steve’s saying it’s OK to touch him. He did take Steve’s hand. Thank God.

“Dad, I’m so glad you came. I know this is really hard for you. It means a lot to me,” he said, clutching onto his dad’s hand.

“Its OK, son. I’m wondering how you are doing?”

I sensed that it was OK for me to go, to give them time together. Steve had done a great job of breaking the ice.

I said, “I am going to give you two a little time to talk while I go see about getting Steve’s blood gas done. I’ll be right back.”

I left the room and came across the 3 ladies who were Steve’s friends. Now they wanted to talk. I explained that Steve thinks that he has Aids, and it looks like he has the type of pneumonia that goes with it. They were not surprised. They totally accepted his being gay – it really didn’t matter to them – they said they loved him. I explained the seriousness of the situation and told them about Steve’s not knowing if he wanted the respirator or not. I explained that I still had to discuss it with him further, but that his dad was his priority now.

They were shocked that his dad came, they were aware of that situation. They were very glad that I was able to get him in the room. They said that they would do whatever was necessary to help Steve; they would stay at the hospital and really be there for him. They said that whatever Steve chose was OK with them. I was happy that Steve would have a support system. 

I had already told the respiratory therapist that Steve needed a blood gas done, but she was very busy down in the emergency room. I knew I had to remind her and I did. Actually, I hoped that she would be delayed a long time because I needed time to give Steve all the information he needed to make his decision. Steve’s dad had left the room and was sitting down the hall. The 3 ladies were in with him now. At least he got to talk to his loved ones before we got the bad blood gases.

As I was trying to get some charting done a heavy-set black lady approached me. She said, “Are you, Nurse Pat?

“Yes, I am, Pat Anderson. Can I help you?”

“Yes, I’m Steve’s aunt, his mother died when he was a baby and I raised him as my son. Can you tell me how he’s doing?,” she asked.

“Sure I can,” I said, as I led her down the hall to the empty room where we sat down.

“What’s your name?,” I asked.

“My name is Jones (not her real name), but call me Dorothy, dear.” She said.

“Did you see Steve’s father in his room? I asked.

“No, my God, he’s here? I’m so glad to hear that,” she said, with obvious surprise.

“Have you seen Steve lately? What has your relationship been like lately?,” I asked.

“I talk to him on the phone all the time and he visits me at least once a month. We are very close, so I know that he is gay and I accept that. What is he in intensive care for?” She asked.

“Steve told me that he has reason to believe that he has Aids, he was tested 2 years ago and told that he is a carrier. He told me that he has been denying the whole thing ever since, but he became so short of breath last night that he had to come to the hospital. It appears that Steve has the type of pneumonia, called pneumocystis, that Aids patients usually get. I explained.

“Is it real bad? Could he die? Oh my God, I have to see him. Said Dorothy, now terrified with tears streaming down her brown face.

“Before you go in I need to talk to Steve alone to discuss the blood gas that was done to check on his breathing,” I said.

The blood gas was horrible – so bad that I didn’t know how he was still alive. I went in to talk to him. I asked the ladies to leave and they did. I began by telling him that the time factor was getting down to the wire.

“Steve your Aunt Dorothy is here, I will let her in but I need to talk to you alone first. Your blood gas shows that you need the respirator or you will die very soon. Have you thought any more about what you want us to do for you? I asked.

“Pat what do you think, what would you do if you were me? Can it make me better? Can I just try it like I asked you about before? I don’t know what to do.” He pleaded.

“Steve I can’t tell you what to do, you must decide, your life belongs to you. I can tell you that you cannot just try the respirator. Once on it, it can take a court order to get you off of it. Have you heard about cases like the Karen Quinlan case where people end up in the courts to get people off respirators or to stop tube feedings? These are complex issues. Our society hasn’t really dealt with these issues yet but I know you can’t just go on it overnight. Remember, once intubated, if you are on drugs you will relinquish the control over your decisions. Remember that your hands will be tied, you will not be able to eat or speak, and if you do have Aids, which you think that you do, you will possibly never get off the respirator. I say possibly because no one can know for sure how a patient will do.” I said.

“Pat, what would you do? I could die on that machine. Since I have Aids I’m going to die anyway. He said.

“I feel obligated to tell you what being on the respirator is like. There are some patients who can get better, get off the respirator and breathe on their own again. I want you to know all the possibilities. It is possible that you could go on it, not need drugs, and get better in an unknown time span. I can tell you what I know about other hospitals and how they deal with Aids patients. St. Joseph Hospital in Chicago is the Aids center for our area. They do not intubate their Aids patients; they do not send them to intensive care. Those are their policies. They think that since they cannot yet offer a cure they should not painfully prolong their lives. On the other hand, Cook County Hospital does intubate and ventilate their Aids patients. Steve, there are no “right” answers. You must go on with what your guts tell you. I just don’t want you to think that you can easily get off once you go on. I want you to know what a big decision this is.” I explained.

“Pat, you seem like a real strong, caring nurse. I somehow know that you are sticking your neck out for me because you care. I feel that – thanks.” (He grabs to hold onto my left hand in addition to the right one).

“Steve I think I am just doing my job being honest with you. I believe in your right to choose with all my heart. If you really must know what I would do, I will tell you that I would not choose to be on a respirator IF I had a terminal illness. We don’t know for sure whether your illness is terminal or whether it is at a terminal stage. After all these years of caring for people on respirators, I know I would not want it for myself or for anyone I loved who was terminally ill. You cannot do what I would do though, you must make your decision to fit your values. I should not be telling you what I would do. What I would do doesn’t pertain to you. My conscience will probably make me pay for telling you what I would do. I will be supportive of whatever decision you make. I’m afraid that you need to make it soon though because things are bad with your breathing, and I need to discuss all this with the doctor right away.” I said.

“I want to talk to my aunt and my dad before I make my decision – OK?” He pleaded.

“Sure, Steve I will go and get them.” I left to get them.

While they were in with Steve I told the other nurses who were in the nurse’s station about his asking me what I would do and I told them that I did share my own personal feelings with him. A male nurse, whose opinion I do NOT respect, from working with him before, said I was horrible for telling him what I felt. He said I was a disgrace to nursing and went on and on yelling at me. I held my tongue for a while, listened, and decided that he was not putting on this show of morals with my patient’s concern at heart; he had not recently spent 2 1/2 hours with this man. I looked him straight in the eye and told him to shut up -it was none of his business. I was not in a popularity contest, I had no idea beforehand that I would judge that a patient needed this type of honesty. I was terrified that I could be wrong, I was so emotionally affected by the situation I could make an error in judgment, but my guts told me that things were going right.

I called the doctor who was assigned to Steve (he didn’t have one when he came to the hospital – so he was assigned a doctor). I told her that Steve was debating whether or not to go on the respirator. I told her about the blood gases and the rest of his assessment too. She was very short with me on the phone, and I could tell she was not pleased to be involved in this situation.

She said, “Well, he’ll die soon and if he’s not a “Do not resuscitate” by the time he stops breathing we’ll have to code him,” she said.

In other words, I better hurry up. If a patient codes (his heart stops beating or he stops breathing) without a DNR (do not resuscitate) order we are legally obligated to do everything to try to save his life, including intubation and placement on a respirator. Then Steve would not have a choice.

I went in to talk to Steve with his father and his aunt in the room. We talked for what seemed like 6 hours, but it was probably only 15 minutes. Steve vacillated between going on the respirator because his dad initially said he should try all that he could to live, to doing whatever his aunt and dad decided, to realizing that he must make the decision. Steve finally told me that he didn’t want to go on a respirator. He said that he had lost control of his bowels and urine – that was killing him. He was going to stay in control of his breathing. He couldn’t lift his fingers to write because he was that weak. I saw that if he took his oxygen mask off for 30 seconds to take a pill his heart rate went down to 40 and his eyes started to roll back in his head. He talked about all these things and decided not to be intubated.  

He said he had a lot he wanted to say to his father, his aunt, and especially to his lady friends. He said that he decided to take the time he had left to say things that were important to the people who meant life itself to him. His father and aunt soon came to agree with Steve’s decision.

I called the doctor to let her know about Steve’s decision so she could give me a DNR order to make his choice legal. She was very angry with me and said, “What did you tell him? Why did he decide such a thing? I want to speak to him and his family right now”.

I went in to tell Steve and his family that the doctor wanted to speak to them about Steve’s decision. I brought the portable phone in the room.

Steve was not very interested in speaking to the doctor, nor were his family. They said that she only saw him for about 5 minutes during his stay at the hospital. 

The doctor called the isolation room directly and spoke to Steve himself. I, of course, could only hear his responses to her. He told her that he did not want to be on a respirator. He said he would only try it overnight so he could get some rest. He told her that I told him he couldn’t do that because sometimes people have to get court orders to take someone off a respirator. He said he didn’t want to change any type of involvement like that over what should be his decision. He said that Pat, his nurse, had spent a lot of time with him explaining what it’s like to be on a respirator and that he has decided against it.

The doctor must have asked to speak to the aunt because Steve handed the phone to her. The aunt said, “Pat has explained a great deal to us and we agree that Steve should be the one to decide in matters involving his body. The doctor said something and the aunt responded, “Yes I would agree to an order not to do emergency stuff to him.” She said to the doctor, then handed the phone to me.

“What’s your name?” the doctor asked.

“Pat Anderson,” I replied.

“Just who the hell do you think you are telling him that you need a court order to get someone off a respirator? You should never tell a patient anything like that,” she barked.

“I explained to Steve that going on a respirator is a big decision. I think patients have the right to know what they may be facing. How could I, given that I had the opportunity to explain things to him, not do so?,” I replied.

“You are not an attorney, so you cannot advise patients about the legalities of medical care. I will be reporting you to the hospital administration in the morning,” she said.

“I am qualified to tell patients the truth about being on respirators because I have spent 20 years working in hospitals. I do know that you don’t just put someone on a respirator for the night and they don’t just take them off because they change their mind – it’s not that simple. I don’t need to be an attorney to know that. I was telling Steve about possibilities. I explained to Steve that the issues posed here are very controversial. I shared my experience in these matters with him,” I asserted.

 Steve’s aunt grabbed the phone before the doctor could respond, “You listen here doctor, this nurse, Pat, is HERE with us. She is not giving us any bullshit. She is HERE with us and we FEEL her concern for Steve. We will listen to her – not you. So you give her that order to let his heart stop and leave us alone,” she said with passion in her voice.

She handed me the phone and the doctor said, “Write the DNR order. I will be reporting you in the morning,” she said with fury in her voice and hung up on me.

I called the doctor back to have another nurse witness the DNR order as this doctor did not exactly inspire trust in me.

I went back to the room and the family apologized for the doctor talking mean to me. Steve said, “Pat I knew you were a strong nurse and I knew you were not doing things by the book. Thank you,” said Steve.

The aunt and father went to get coffee. I helped Steve change his wet diaper, helped him to take a pill, changed his position in bed, and asked him what his understanding was about the DNR status.

“I’m not totally clear but I’m sure it is OK,” said Steve.

“It means that if your heart stops or you stop breathing we will not pound on your chest, we will not intubate and put you on a respirator, we will not use electricity to shock your heart, nor will we use emergency heart stimulants to force your heart to pump. We, however, will take care of you, we just don’t do heroics. We take care of your needs to the point of not forcing you to stay alive after your body has given in to disease,” I explained.

“Pat that sounds beautiful to me,” he said, as he held both my hands to his heart.

“Well, I’m getting out of here now. I will let you do that talking you said you wanted to do. Your lady friends have been waiting to get in here to be with you.” I said as I left the room smiling at him. He smiled back weakly. I can’t describe the eye contact between us – it pierced me to the core with its meaning.

I told the ladies to go ahead in. I explained that he had told me that he had things he wanted to tell them – things he always meant to say – he would say now.

I saw his aunt and father down the hall and told them Steve wanted to talk to them in a little while when the ladies left.

I peeked into the room about 20 minutes later and was touched to see Steve talking 100 miles an hour and trying to breathe 60 times a minute all at the same time. Tears still come to my eyes when I picture the scene. The ladies were all physically close to him, one touching his foot while standing at the foot of the bed, one holding his left hand sitting next to the bed on the left, and the other one wiping his head with a cool cloth. They were laughing one minute and I saw tears well in their eyes the next minute. I sensed a profound joy and sorrow in the room.

Later the ladies asked me what would happen to Steve. They wanted to know what to expect as far as his death. They planned to be with him. I explained that as he got less oxygen to his vital organs his heart rate would probably slow down eventually to zero, then he would probably just not be breathing anymore. I could not say for sure that that’s exactly what would happen but I told them that that’s what happened when he took the mask off to take a pill, so I imagined that’s how he would die. They went to take a break – it’s very hard to stay with the dying patient; it is so emotionally draining that you MUST take breaks. I told them I would call them if I thought the time was near so they could be there with him.

His father and aunt had their time with Steve. I saw his father hug him so I think things were “cool” between them. Aunt Dorothy gave him T. L. C. (tender loving care) as I imagine she had done all of his life.

I went in to take Steve’s vital signs and give him some medications in his intravenous line. He said, “Pat I feel real good about things now. My father and I have fixed things, I told my aunt how much I loved her and those ladies and I rehashed old times from way back in grade school. I told them I loved them too.”

“Steve it’s against the rules to make the nurse cry – I think it’s written somewhere,” I said, feeling overwhelmed and trying to use humor to deal with it.

Steve smiled, I’m sure with understanding. “I can’t tell you how much your honesty has meant to me. I hope you don’t get in trouble. I know I have been denying my Aids, but somehow you have helped me to stop denying. I accept it now.” Steve could no longer hold his eyes open, I knew those were his last words.

Steve’s heart rate dropped at about 6:25 am. I called the ladies and the aunt to be with him. It happened as I thought it would, his heart rate simply slowed down gradually to zero and she had a last gasping breath. He died with peace, dignity, and his loved ones were near. Steve never knew that his father left because he couldn’t take it anymore.

I overheard one nurse tell another nurse, “Pat might be starting a new trend in nursing – being honest with your patients. Another nurse told me that she would not have thought to tell him that he had a choice; she would have seen intubating him as an emergency because of his bad blood gases. Some other nurses who heard her said that they would have just intubated him too. They told me I was brave to do such a thing. I realized that we were all taught that patients have the right to refuse treatment, we are not taught how to buck the system to help them to do so.

As I was leaving the hospital that morning about 8:00 am I ran into his aunt who hugged me for what seemed like 1 hour (I was so tired). She said thank you.

I left that morning feeling like someone had just vacuumed out my brain and my heart. I knew that this is what I feel and think that I do best in nursing – giving patients honest information, in the language they understand, showing them that I care and thus giving them real power over their health care.

Grade: A

Bibliography

Minogue, Jack.  (1991, Fall).  School For New Learning Class, DePaul University “Ethical Decision Making”

Weber, Leonard J.  (1976).  “Who Shall Live? The Dilemma of Severely Handicapped Children and Its Meaning For Other Moral Questions” New York, Paulist Press.

1988

English 105

Purdue University

Dr. Bolduc

Got an A!

                                                    Jet Lag      

The entire universe operates via cyclic or rhythmic processes; from the galaxies rotating around their centers to the microscopic world of the atom. The cycle of day and night which lasts for 24 hours is caused by the earth’s rotation around its axis; the specific distance from the sun affects the amount of light and the amount of warmth present. The nucleus of an atom has electrons revolving around it which control it’s cyclic processes.

Man is also cyclic, his body clock or his physiological clock functions to tell him when to eat, sleep, be active or when to play. Man’s rhythm is circadian. Circadian comes from the Latin word, circum which means “about”, and dies which means “day.” This biorhythm involves a period of 24 hours; also called the circadian cycle; this cycle controls our levels of wakefulness and sleep. “The cells of our bodies contain timers or “individual clocks” which in association with RNA (ribonucleic acid) process proteins in a cyclic 24-hour period.” 1 

So our actual chemical makeup contains our clock. The clock receives cues from several sources called Zeitgebers (a German word which means “time giver”). Some of these cues are external and some are internal. Light is an important zeitgeber in controlling our circadian rhythm; lighting cycles regulate endocrine function in our bodies. Our endocrine glands control the production of hormones such as adrenaline, cortisone, and thyroxin which all play a role in regulating our circadian rhythm; cortisol levels are high early in the am and low in late evening; cortisol levels rise to their highest an hour before the person awakes in the morning.                                                         

Neuroanatomists are now aware of a pathway from the eye to a spot in the hypothalamus called the suprachiasmatic nuclei which allows light to have an internal effect on the synchronization of our rhythm. This nuclei seems to be in control of our rhythms. Research has shown that if the connection between the retina and the suprachiasmic nuclei is damaged, light can no longer reset the biological clock, in spite of the fact that the person can still see.

The pineal gland is also known to function in controlling our clock; in humans, it secretes large amounts of melatonin in young children; the greatest amounts are secreted at night during sleep. The level of melatonin declines towards puberty; melatonin also makes people sleepy; children with large amounts thus sleep more than adults. Studies with sparrows have shown that you can exchange a jet-lagged sparrow’s pineal gland with one from the new time zone and cure his jet lag. Removing the pineal gland in rodents allows the suprachiasmatic nuclei to rapidly adjust to a time zone change. The pineal gland is suppressed by some drugs used to treat mental illness; a widely used antidepressant has been found to reset biological rhythms in rodents.

An internal zeitgeber is a temperature; ordinarily, our body temperature (inside or core temperature, not on the skin) rises at midday to 37 degrees centigrade and falls at night to 36 degrees centigrade.  The temperature curve is an easily measurable indicator of our biological clock. The electrical activity of the brain shows distinct stages in the sleep-wakefulness cycles that can be measured via an electroencephalograph or EEG. 

The urinary system does most of its work during the day, the purpose being to allow undisturbed sleep; studies have shown that the byproducts of the hormones that control circadian rhythms can be found at corresponding appropriate times in the urine. Studies have shown that midday corresponds with the time that people are found to have the best ability to perform complex tasks; this correlates with the fact that most people like to be awake during the day.

Light and temperature act as cues to control our circadian rhythm, yet studies have shown that there are existent circadian rhythms even under experimental conditions with constant light and temperature; these are called free-running rhythms. Without light-dark cues the circadian cycle is said to be running in a free-running manner; it is following the natural internal timing of the body. “Sleep experiments have proved, however, that humans are capable of adapting to a slightly shorter or a slightly longer day.” 2 

We rarely exceed twenty to twenty-eight hours and are usually within an hour or two of twenty-four hours. Experiments attempting to change the circadian rhythm were unsuccessful. Young people placed in a cave-like environment with only artificial light agreed to go to bed when the clock said 11:45 PM and to get up when it said 7:45 AM. Though they did not know it the clock began normally, then gradually went faster till the day reached twenty-two hours. At the time the clock was at the twenty-three-hour part none of the participants had any trouble, but when it reached twenty-two hours only one person was able to keep up with the clock.          

After babies are born from a lightless uterus they exhibit many alterations in their sleep/wake cycle during the first two to three months; the cue that tells them when to wake up is their hunger; the contractions of the stomach wake them up. It takes about three months for babies to develop enough to become curious about seeing the world and thus gradually become more light active. By nine months their body clocks are like that of adults.     

Jet lag is a disruption in this rhythm caused by traveling across a number of time zones; the traveler’s entire body functions are out of sync with those of the people at his destination. When we cross more than four-time zones we exceed our clock’s ability to reset itself. The symptoms of jet lag are many: sleepiness, headaches, alertness, and being hungry at times that are inappropriate. Intellectual functioning is affected; it is hard to learn new things, hard to concentrate, and hard to understand things when experiencing jet lag. Other symptoms are anxiety, nervousness, irritability, anger, depression, and inappropriate euphoria or depression. Usually, the return of intellectual and emotional functioning occurs in three to four days. It may take a week for sleep, appetite, and energy levels to return to normal; levels of serum electrolytes (sodium, potassium, and chloride) may take a few days longer; it may take two months for hormone functioning to return to pre-trip normal.

Examples of geographic time zones crossed are: coast to coast in the United States is four time zones, California to Scandinavia covers twelve, and from New York to New Delhi leads to a complete inversion of the sleep/wake cycle. This desynchronization causes a phase shift between the physiologic and the geographic cycle. Flying east causes things to advance and going west causes a delay in the day/night cycle. ” Most travelers adjust to a new circadian cycle at the rate of one hour per day.”  3 

The older we get the more sensitive we are to jet lag. There are very few people who are not affected much by jet lag. Some find it easier to adjust to eastbound, some to westbound flights; some say that it is easier to adjust on home turf because of the familiar surroundings. ” It turns out that your body cannot adjust to changing time zones much faster than two hour a day, as though your skin can travel at arbitrary speed, but your insides are limited to about 100 miles an hour.” 4

An exhaustive study was done by Wegmann et al. in association with Stanford University School of Medicine and NASA (U.S. National Aeronautics and Space Administration) using B-747 aircrews operating regular passenger flights between Frankfort and the U.S. West Coast. The main purpose was to study sleep in aircrews exposed to time zone changes. They knew that multiple time zone transitions caused disruption in the circadian rhythm; their goal was to define changes in the twenty-four-hour fluctuations of selected variables. They studied sleep EEG and daytime sleep latency in the laboratory; they continuously recorded body temperature, and EEG and took frequent urine specimens. Additional measurements were conducted during pre-duty, during flight, and during a layover. In order to also check readjustment at home, the study continued for two days at home.

The design of the experiment was initiated because of their hypothesis: due to considerable time zone changes in the routes of the aircrews they would experience disruption of their circadian rhythms; they would then show sleep difficulties. According to their sleep log analysis, the surveys do not support the above hypothesis. The study showed that the pilots sleep much more on a layover and did not suffer from sleep loss when compared to their sleep at home. Results showed that time-zone transition did desynchronize their circadian rhythm, but with naps and staying awake for periods, and then sleeping long periods they were able to cope with the disruption. From personal conversations with the pilots, they found that they were very much aware of the potential difficulties and take serious measures to obtain enough sleep; the studies show that they are indeed successful. The study did find a difference with age; older pilots had to stay in bed longer to get enough sleep.

Another study was done by NASA in conjunction with an international research team; British, German, Japanese, and U.S. research teams each associated with an international carrier along with support in their own country. The goal of this layover sleep study was the assessment of sleep changes encountered with multiple time zone changes; how sleep differ at home when compared to sleep during a trip; the subjects were long-haul flight crews. After baseline sleeps EEG recordings, the crews underwent testing during nocturnal sleep followed by multiple sleep latency tests every two hours whenever they were awake and not trying to sleep; this provided objective information about the quality, and quantity of daytime sleepiness for comparison with the subjects’ own estimates.

The sleep recordings included EEG, electromyographic or EMG, and electro-oculographic or EOG activity. (EEG involves brain waves, EMG involves muscle activity and EOG records eye movements). Before each sleep recording the pilots completed a Stanford Sleepiness Scale or SSS, a mood assessment scale, and a self-report to check for adherence to standardization procedures. After awakening a questionnaire was completed involving self-reports about the quality and amount of sleep along with an SSS. Body temperature, heart rate, and urine were tested to clarify data about circadian rhythmicity. (Constant rectal temperature probes were used and all urine was collected to examine hormone levels).

NASA investigators found most crew members were able to get enough sleep during layover either by sleeping well at selected times or by sleeping less efficiently but staying in bed longer; sleep quality declined slightly in most cases; more so after eastward flights. Older (over 50 years) crew members got less total sleep and had poorer quality sleep. The human circadian rhythm is not only more disrupted by eastward flights, but also causes a longer resynchronization period. Sleep duration varies with the circadian temperature, the longer sleeps occur when the temperature is lower.

The study also showed that there is definite variance between individuals due to circadian type; some are morning, and some are night people. Similarities were found in the baseline daytime sleep latency curves; all showed a gradual increase in sleepiness during the day with a maximum in the late afternoon followed by a gradual decrease in the evening; these sleepiness rhythms continued after the time zone shift when back to home base. It is possible that crews could predict the easiest times to fall asleep and thus develop good strategies for sleeping away from home. Data obtained after eastward flights showed that ” adhering to more structured sleep schedules and limiting initial post-flight sleep would appear to facilitate the acquisition of adequate sleep during the layover.” 5 

Jet lag is a psychological and physiological stress on the body; studies on stress have shown that the more stress in your life the higher your odds are of becoming ill. Studies on lab animals show that when their biological clocks are tampered with, they are subject to higher death rates when exposed to toxic chemicals, alcohol, medications, and toxins from certain bacteria. Norman Cousins wrote about a serious illness he experienced after returning from a trip to Russia; he describes his perception of the illness in “Anatomy of an Illness” in New England Journal of Medicine, vol 295, Dec 23, 1976, pp 1458-63; although Cousins did not say that jet lag was the cause, it is possible according to Dr. J. Greist and Dr. G. Greist. 6

The short- and long-term effects of a single or a repeated experience with jet lag on our health have not been proven as yet; the type of studies that would be needed to prove the health effects would be very hard to do. Several factors are likely to be determining factors in how much we are affected by jet lag: the number of time zones crossed, the number of recent exposure to jet lag, and sleep loss. An interesting difference between the United States and the Soviet Union is that the Soviets assume that a change in the circadian rhythm would lead to deleterious effects; their cosmonauts maintain their earthly day/night cycles even while in orbit. The United States uses a variety of schedules; apparently, we expect flexibility in ourselves.

According to Dr. Strughold, Dr. R.F. Fitch, Chief of Internal Medicine at Wilford Hall USAF Medical Center, San Antonio, Texas, “the administration of hormone-containing drugs should simulate the natural circadian production pattern of the hormones, to avoid disturbing their role in running the physiological clock.” 7 

It has been reported that transplanted kidneys take about a year to get it together with their new body. Internal cardiac pacemakers automatically beat ten beats per minute slower at night.

The effects of jet lag can have serious meanings to those whose mission involves international political conferences; businessmen traveling abroad hoping to complete transactions involving large sums of money; Olympic athletes must do all they can to resynchronize themselves. There are numerous methods that have been suggested to help minimize the effects of jet lag:

Preflight adaptation is one; try to slowly adapt yourself to the time zone of your destination; if traveling east, go to bed and arise two or more hours earlier and gradually shift mealtimes so they are more in line with your destination. If traveling west, stay up later and get up later than usual. If possible, plan to fly to your destination a couple of days ahead of time so you can become adjusted before your planned activity. President Eisenhower did this in 1955 before meeting Nikita Khrushchev in Geneva for a Summit meeting. 8  

Some companies have a rule that their executives are not to sign any contracts within the first two days after a transoceanic flight. If you are unable to take time ahead for adaptation, be aware that the morning hours in the first few days after eastbound and the late afternoon after westbound are times to avoid signing contracts, making major decisions, or conducting affairs of state.

After arriving at your destination spend as much time as possible out in the sunlight, letting the sunlight help reset your clock. Joan Hamilton in Business Week magazine says that Czeisler, associate professor of medicine at Harvard, foresees that in the future airplanes may adjust their interior light to help reset our biological clocks. 9 

Socialize to stay awake and avoid daytime dozing. According to Joan Hamilton in Business Week magazine, frequent flyers get over jet lag sooner when they force themselves to socialize; she quoted a pharmacologist at Florida A&M University as saying, “We know that extroverts seem to get over jet lag faster than introverts.” 10

Low humidity in airplanes can result in loss of water; this can lead to changes in electrolyte levels (sodium, potassium, and chloride); it is recommended that extra water is a good idea because dehydration can cause fatigue, sleep disturbances, and a reduced capacity to reset the biological clock.

Alcohol and caffeine should be taken only in extreme moderation; they have the ability to turn off the body’s antidiuretic hormone, which causes water loss which in turn will also dehydrate you. Also, the pressurized cabin at five to six thousand feet above sea level makes two drinks (of alcohol) have the same effect as three.         

The gastrointestinal system operates with rhythmic periods of high and low, so if you eat a big meal at a time when your stomach thinks it should be asleep you are just adding to the burden of time zone adjustment for your stomach. Gradually shift mealtime to that of your destination. For this reason, eat lightly and at the correct time according to your destination. Increased altitude causes gas in your gastrointestinal tract to expand; carbonated beverages will thus have a worse effect than on the ground. 

It will help to make your transition easier if you rest at home before you leave; sleep or at least resting on a long flight will help, a short-acting sleeping pill may help also; Halcion and Restoril are two short-acting prescription products recommended. 11

“Intellectual function is often more noticeably affected than other biological functions”. 12 

For this reason, diplomats, business people, and flight crews need to really take care. 

According to the editors of Discover and B. Bower in Science News magazines, researchers N. Mrosovsky and P. Salmon at the University of Toronto after experiments with hamsters think that exercise may help to speed up the resetting of our jet-lagged clocks. Their study showed that active hamsters needed 1.5 days to adjust while lazy hamsters took up to 11 days. 13-14

People who work nights or periodically change shifts encounter symptoms very much like jet lag; in addition, police officers were shown to have high rates of alcoholism, sleeping pill use, accidents, and family disruptions. Lisa Bain says in Psychology Today, that neuroscientist, Charles Czeisler, of Harvard Medical School claims that “the problem is in the schedule, not the job.” 15 

Czeisler redesigned their schedule to better accommodate their circadian rhythm. There were three basic changes: one, instead of changing shifts every eight days, they changed every eighteen days; second, they changed shifts going from days to evenings and then to nights; third, Czeisler had the officers work only four days in a row so they could catch up on their sleep.                                                                       

The results after about a year were positive: The officers had fewer sleep problems and were generally more alert; car accidents were down by forty percent; alcohol and sleeping pill use were down fifty percent; the families felt five times better after the new schedule. Czeisler says that workers who have their circadian rhythms desynchronized frequently are functioning in an impaired state; public safety is thus a concern.

End Notes  

1       T. Alexander, “Biological Rhythms,” Encyclopedia of Psychology, (New York: Wiley, 1984), vol 1 pp 151.

2       Hubertus, Strughold, M.D., Your Body Clock (New York: Scribner, 1971), pp. 41.

3       Strughold, pp. 57. Dr. Strughold says that Dr. William Douglas, flight surgeon to the Project Mercury astronauts suggests this rule. 

4       Arthur, Winfree, The Timing Of Biological Clocks, (New York: Scientific American, 1987), pp. 4-5.

5       Graeber et al, “International Aircrew Sleep and Wakefulness After Multiple Time Zone Flights: A Cooperative Study,” Aviation, Space and Environmental Medicine, (Dec 1986, vol 57 (12, Sect II)), pp. 9.

6       John Greist, M.D., and Georgia Greist, Ph.D., Fearless Flying,  (Chicago: Nelson-Hall, 1981), pp. 71.

7       Strughold, pp. 32.

8       Strughold, pp. 61.

9       Joan Hamilton, “You Don’t Have to Give in to Jet Lag,”  Business Week, (Oct, 26, 1987) pp. 126.

10     Hamilton, pp. 126.

11     Editors of Changing Times, “Unsag From Jet Lag,” (May, 1988) pp. 104.

12     Greist, pp. 75.

13     Editors of Discover, “Overcoming Jet Lag: The Rodent Way,” (May 1988,) pp. 18.

14     B. Bower, “Hamster Jet Lag: Running it Off, Science News, (Dec 5, 1987 vol 132: no 23) pp. 358.       

15     Lisa Bain, “Night Beat”, Psychology Today, June 1988 vol 22, pp. 14-15.

Bibliography

Alexander, T.  “Biological Rhythms.”  Encyclopedia of Psychology.  New York: Wiley, 1984.  vol 1.       

Carlson, Bruce. “Pineal Gland.”  Encyclopedia Americana. ed.  Danbury: Grolier, 1986. 

“Circadian Rhythms in Metabolic Activity.”  Encyclopedia Britannica.  New York: U of Chicago P. 1988.  vol 25:487:2a.

Bain, Lisa.  “Night Beat.”  Psychology Today.  June 1988: vol 22.

Bower, B.  “Hamster Jet Lag: Running it Off.”  Science News.  Dec 5, 1987.  vol 132: no 23.

DuHamel, Meredith.  “Traveling Through Time.”  Woman’s Sport and Fitness.  Dec, 1987. vol 9: no 12

“Effects of Light on Biological Rhythms.”  Encyclopedia Britannica.  New York: U of Chicago P, 1988.  vol: 26: 519:2b.

Graeber, et al.  “International Aircrew Sleep and Wakefulness After Multiple Time Zone Flights: A Cooperative Study.”  Aviation, Space and Environmental Medicine. Dec, 1986: vol 57 (12, Sect II).

Greist, John, M.D. and Greist, Georgia, Ph.D.  Fearless Flying. Chicago: Nelson-Hall, 1981.           

Guyton, Arthur, M.D.,  “Circadian Rhythm of Glucocorticoid Secretion.”  The Textbook of Medical Physiology.  7th ed.  Philadelphia: Saunders, 1986.

Hamilton, Joan.  “You Don’t Have to Give in to Jet Lag.”  Business Week.  Oct 26, 1987. 

Kalland, Gene.  “How to Reduce Jet Lag.”  USA Today.  June 1988.  vol 116: no 2517.

Kalat, James.  “Endogenous Circadian and Circannual Rhythms.”  Biological Psychology.  3rd ed.  Belmont: Wadsworth, 1988. 

Luce, Gay.  Body Time.  New York: Pantheon Books, 1971.

Morin, Lawrence.  “Biological Clock.”  Academic American.  Danbury: Grolier, 1987.  vol 3:264-265.

“Overcoming Jet Lag, the Rodent Way.”  Discover.  May 1988.

Sakmar, M.D., Gardner, M.D., and Peterson, M.D., Ph.D.  Health Guide For International Travelers.  Passport Books, 1984.            

Strughold, Hubertus, M.D.  Your Body Clock.  New York: Scribner, 1971.

“Time Dislocation: The Jet Syndrome.”  Encyclopedia Britannica.  New York: U of Chicago P.  vol 14: 641: 2b.

“Unsag From Jet Lag.”  Changing Times.  May 1988.        

Wegmann et al.  “Sleep, Sleepiness, and Circadian Rhythmicity in Aircrew Operations on Transatlantic Routes.”  Aviation, Space and Environmental Medicine.  Dec 1986.  vol 57 (12, Sect II).       

Winfree, Arthur.  The Timing of Biological Clocks.  New York: Scientific American, 1987.

Pat Anderson

May 18, 1991

DePaul University

Law & Values-Spring 91                            

Midterm Exam                                            

Speech – Self Evaluation

WW-7 Competence

Introduction

Hi, I’m Pat Anderson, I’m going to talk to you about the right to die; I am very prejudiced about this issue. I am intimately involved in the issues of patient rights as a part of my daily work as an intensive care nurse.

Archie …

Now, try to picture Archie Bunker sitting in his favorite chair watching the ball game on TV; it’s Sunday afternoon, and there is a beer sitting next to him and a pizza in his lap. Edith comes in the door after volunteering at the local nursing home. She brings a dining room chair next to Archie and tries to discuss whether or not he wants to be on a respirator or have a feeding tube if he gets really sick. Can you feel him cringe inside? Can’t you imagine what Archie would say? “Je …sus, … Edith …

Well, Archie isn’t the only one who doesn’t want to face these issues. The legal and medical professions are full of Archie Bunkers on this subject. We act as if death were optional. Ours is a death-denying society.

The Laws …

Our right to die is protected by the First Amendment freedom of religion, the Fourth Amendment through the right to privacy, and the Fourteenth Amendment through the equal protection clause.

However, the legal system, and its lawyers, cannot escape the fact that before they are lawyers, they are human. They too deny death and would like to avoid thinking about it. The conflicting precedence that has been established within the judicial system illustrates this very humanness. I will use some cases to show what I mean:

In Lane vs. Candura, a confused 77-year-old widow was allowed to refuse amputation, despite having a distorted sense of time, a thought pattern that wandered and was at times, even combative. The appeals court found that she understood the consequence of refusing. She did not choose to live as an invalid or in a nursing home and did not fear death, but actually welcomed it since the death of her husband. The court did not find it had a compelling interest in dictating her quality or length of life. Courts in Arizona, CA, Florida, Maine, Massachusetts, and Rhode Island have come to the same decisions in similar cases.

This case illustrates that even a patient that is not totally medically competent CAN be seen as LEGALLY competent as long as she understands that without treatment she will die.

On the other hand, a woman who was a Jehovah’s Witness was forced to receive a blood transfusion after suffering a bleeding ulcer. Because she had children the court said the state had an interest in keeping her alive. She was a competent adult and knew there was a possibility that she would die without the blood. What kind of logic allows one person to refuse amputation (who is confused) but not allow a competent person to refuse a blood transfusion?

Suspect Classifications …

Aren’t we, by the conflicting nature of these cases, setting up suspect classifications.  What would have happened if Mrs. Candura were 21, would the courts have found differently, would her age have changed state’s interest in preserving her life – thus setting up an age class? Will we someday mandate that people under, oh say 65, must use whatever technology is around at the time? Is the right to die doled out according to age?

Can the courts reasonably say that all parents must use all available technology simply because they are parents? Will the courts eventually mandate that all parents must take all chemotherapy, radiation etc that could be prescribed – till oh say their children are out of college? Who sets up the limits of this doling out of rights? 

Another question is whether I, not being a Jehovah’s Witness, could refuse a blood transfusion because I feared Aids or Hepatitis? And would the courts have allowed Mrs. Candura to refuse a blood or the amputation (you may need blood during an amputation) if she were a Jehovah’s Witness?

As a nurse, I am aware that there are options and several different ways to treat a specific illness; I have refused treatments knowing that there are alternative methods to deal with the problem. But many patients don’t know about options – doctors don’t always give patients options, so will the courts give doctors “God reinforcement” by mandating that certain types of people must follow their doctor’s advise – even though 3 different doctors might prescribe 3 different treatments for the same problem?  The actual laws do not mandate any classifications.

Another set of cases that illustrate nonconsistency within the judiciary are the Quinlan and the Cruzan cases. The New Jersey Supreme Court allowed Karen Quinlan to be removed from the respirator; this was the first time the right-to-privacy law was used in withdrawing life support. And the first case proposes that doctors and families make these decisions intimate decisions. The court ruled that its interest in the preservation of life weakened the individual’s right to privacy. They allowed “substituted judgment” to be used. They did not demand “clear and convincing evidence” that she would not want to live as a vegetable. And of course, they didn’t know she would go on living at the time.  

The U.S. Supreme Court would not allow Nancy Cruzan to have tube feedings removed without “clear and convincing evidence”, despite the “substituted judgment” of caring parents. We can assume that if Nancy had been competent or had had durable power of attorney, they would have upheld the request because the court did not deny her right to refuse. The court passed the decision, into the lap of the states. (These issues DO involve fundamental rights that should not be allowed to vary from state to state.) The court left open the possibility that someone in New Jersey with aids may be allowed to remove life support, but not to his previous significant other in New York. Is this not another classification? Think about it – New Jerseyans and New Yorkers. Should the state you live in have relevance to your right to die?

Why was one case required to use the “clear and convincing evidence” standard and the other was not? How can we say a respirator can be removed and not a feeding tube – when they are equally sustaining a vital life function – breathing or eating? These contradictory rulings serve as examples of how the emotionality of these issues can make for bad law.

The judicial system can also get around facing these issues with court continuances; the patient may not live long enough to get beyond the continuances. The ones who end up suffering the high cost emotionally and financially are the patients and families. 

We have a hard time dealing with death, until the judicial system can learn to accept death as a part of NORMAL life it will not be able to be truly objective in assuring us our rights.

There is no law mandating the use of all the technology available. The laws were meant to protect our rights, even if we make an “unwise” decision. Of what value are laws that give you rights – only if you go along with the medical system?

Ethics …

To lawyers, this issue involves abstract concepts, but to me as a critical care nurse, it is not abstract at all. I see the torture that results from technology; I feel their anguish, I hear them beg for relief from suffering and I must be intimately involved in inflicting technology upon them – my heart is not “in it” if theirs isn’t. There’s an advertisement for nursing that says, Nursing: the human side if high tech. Most of the time I don’t perceive my work as humane at all because I so often see patients’ rights violated – I hate being a part of it.

There is paranoia about the law in health care. Health professionals are making treatment choices to avoid litigation instead of being directed by the actual needs of the patient. What’s ethically appropriate, goes along with the patient’s wishes, and is humane – serves as the best defense – ethically or legally. Defensive medicine makes the law primary and puts ethics second.

Technology is so easy to turn on. As a health professional, it becomes almost reflexive to DO something. Well, today we have so much to do SOMETHING with. When you are faced with an emergency and your adrenaline is pumping, using the technology can become just something to do while you’re shitting in your pants over the emergency, no matter how experienced, emergencies can be challenging and make you doubt whether or not you can deal with it. We get so indoctrinated in saving a life due to our education – no one stops to think about what the consequences will be of the technology.

Most health professionals were not taught to ask, “Am I saving a life or am I abusing a patient”?  Even if there are some of us who do ask, it is not practiced. If you as a health professional, say you feel the situation is abusive you are seen as an outcast – I know that feeling! Surely our goal cannot be to prolong suffering, to experiment at the patient’s expense, to make money or to support the ego of doctors.

Since the Cruzan decision, nurses may now have to change the focus of counseling families and patients about whether or not to start treatment since it may require “clear and convincing evidence” to remove it if the patient becomes incompetent or has a change in condition making him terminal.

Maybe this is actually for the best. Maybe we should be forced to let our adrenaline ebb before we rush in and “save lives”. Perhaps we should do more thinking before we make patients hostages to our technology. Do we sentence people to die a tortuous death instead of a comfortable one because their decisions to refuse don’t go along with our moral code?

A critically ill patient is struggling with the critical illness, should he be forced to struggle within the legal and medical system for the fundamental rights that the constitution promised him?

Patients at the MOST vulnerable times in their lives should not have to be concerned that some state will come along and claim an interest in their continued suffering.

Proof, proof that you would not want to live in a vegetative state. Proof, that if you are going to die you would like control over it? It may be more practical to have people who WANT to be kept alive indefinitely, in persistent vegetative states for years, who should prepare legal documents – it would save so much paper.

Moral decisions should not be court-ordered.

An interesting aspect about patients refusing treatment is that your competence is frequently not questioned until you refuse treatment. If the elderly refuse, they are said to be senile because after all, everyone wants to live as long as they can – no matter what! Right? Parents who tell doctors to do all they can for their crippled babies are thought of as model parents, but parents who refuse are said to be negligent, uncaring, selfish, and cruel.

I see control as one of the most vital aspects of human dignity. I have seen patients’ rights demonstrated on a continuum: from those who have been given none at all, to those who were given the ultimate control. Believe me, patients with control do better. It’s better for your health to be in control psychologically and physically.  

Death can even be beautiful when a patient has been fully informed, and given support and pain control. We should be with the patient in whatever he decides. If we give them the right to their identity and control, they can die in peace with dignity. The terminally ill patient has no control over how much technology science will come up with; all he wants is control over his own body.

Doctors are obligated to tell the truth. All of nursing revolves around the fundamental idea that patients have, not only the right to be involved in their health planning have the right to refuse, but it is commonly known that patients who are compliant get better faster when in control of their care. The difference between ethics and law is ethics goes much further and is aimed at the patient’s benefit – the law is to protect the caregiver.

I’m sorry to say that I frequently see patients being denied their civil rights in our paternalistic medical system. I see patients being treated like children. It’s similar to how the government in seeking to protect women, actually deprived them of their rights. We cannot protect people from the inevitability of death, but we can help them to die with comfort.

There is paranoia about the law in health care. Health professionals are making treatment choices to avoid litigation instead of being directed by the actual needs of the patient. What’s ethically appropriate, goes along with the patient’s wishes, and is humane – serves as the best defense – ethically or legally. Defensive medicine makes the law primary and puts ethics second.

Most health professionals were not taught to ask, “Am I saving a life or am I abusing a patient”?  Even if there are some of us who do ask, it is not practiced. If you, as a health professional, say you feel the situation is abusive you are seen as an outcast – I know that feeling! Surely our goal cannot be to prolong suffering, to experiment at the patient’s expense, to make money, or to support the ego of doctors.

New Law …

Back to the law again and with the hopes of ending on a positive note, I’ll tell you about a seminar I attended in March, given by the Illinois Hospital Association. The purpose of the seminar was to educate hospitals and nursing homes of new legal precedence established via the Illinois Supreme Court. The new law called The

Patient Self Determination Act will go into effect on Dec 1, 1991.

         This new law will:

         -Mandate that all Illinois hospitals inform patients upon admission about their right to refuse treatment.

         -Ask them whether or not they have advance directives.

         -Obligates them to place them in the medical record if they do have an advance directive.

         -Will require that patients be given written information about advance directives.

         -Must not discriminate against a patient for refusing treatment.            

         -Must educate staff and the community about advance directives. 

         -If doctors can’t go along with a patient’s wishes, they must see to it that they get a doctor that will.

         -It is supposed to ensure compliance with patient’s wishes.

         This law will make Illinois the most liberal state in the union as far as patient rights are concerned. The supreme court left it to the states and I’m sure glad that our state is taking real initiative in trying to insure patient rights.

 Conclusion …

         1.      The right to refuse or accept medical or surgical treatment along with the right to have advanced directives.

         2.      The providers must have written policies respecting the implementation of these rights.

         3. They must ask a patient upon admission as an inpatient whether he has an advanced directive and must document it in the medical record of the patient.

         4.      No discrimination is allowed if patients refuse treatment.

         5.      Ensures compliance with patient wishes.

         6.      They must educate their staff and the community about advanced directives.

Implications for the Future …

The change in the definition of terminal illness makes the living will an even more useful tool. It loosens the act’s restriction as far as the removal of artificial nutrition and hydration. 

The Patient Self Determination Act was a direct result of the Longeway and Greenspan cases. This new act goes into effect on 12-1-91 and requires a provider who participates in Medicare or Medicaid to maintain written policies and procedures. They must provide written information to adult patients concerning:

A combination of factors has led to societies’ demanding support for their rights in these matters:

         -The paternalistic nature of medicine.

         -The abuse of power in medicine occurs due to the patient’s extreme vulnerability and lack of knowledge. (Knowledge IS power).

         -The rapidly increasing amount of technology without corresponding laws to deal with its profound consequences.

***

Because illness places us in a psychological state of vulnerability we NEED assistance, support, and encouragement to assert our rights. Patients, despite knowing on an intellectual level that they have the right to refuse treatment, do need education, legal backup, and a collective societal sense of the plight of the ill person.

I would hazard to guess that the increasingly elderly population, affected greatly by this technology, has had a powerful effect on the popularity of these issues today. Society is demanding that the legal system address these sensitive issues because, although painful to deal with, the costs in human psychological and physiological suffering, is even worse to face.  I think that the education of the public will place more power in the hands of the healthcare consumer. I know that many patients desperately fear being on life support; they, however, also lack the psychological strength needed to refuse and thus face negative sanctions from their families, health professionals, and society in general.

The financial costs are very real too. They are even worse if you consider that many do not want expensive technology. I wonder how long Medicare and Medicaid will pay for “vegetative” care when even good health insurance is depleted? Eventually, the cost of this “useless” care will take away from the care of patients who can benefit.

I have not seen the issue of the severe nursing shortage discussed in my readings on this subject. No one seems to realize that there aren’t enough nurses to take care of these patients in vegetative states. How would you feel if nurses, who might care for your injured child, were too busy occupied with patients who were vegetative? Most nurses go into the field because they want to help people, can you imagine the rewards in taking care of vegetables that you know so well, on an intellectual level, are not gaining from your care? Talk about burnout!  

The new case rulings and the Patient Self-Determination Act are starting in the right direction. They cannot cure the many cases in which the abuse of technology is out of sight of public awareness, but at least it offers some hope for the future.  At least we are beginning to inform people that they DO have the power to control their health care.

Conclusion …

In conclusion, life without the freedom to control the intrusion of your own body, without your unique identity, is not a life that any state should be allowed to compel us to.         

Bibliography

The United States Law Week  Listing of U.S. Supreme Court 1989. Decisions 11-28, 58 LW 2307

Golden, Yosh (Law Bulletin Staff Writer). (1988). Hand-out Law & Values Class, De Paul University.  “Life Support Case Considered”  November 15.

Grady, William (Legal Affairs Writer) Hand-out, Law & Values (1989). Hand-out DePaul University “Justices Set Right-To-Die Rules Food Can Be Withheld From The Terminally Ill”.  Chicago Tribune  Section 1  November 14.

Illinois Hospital Association Seminar  “Life Sustaining (1991). Treatment Issues and Answers.” Hand-out. March 21.

The United States Law Week Listing of U.S. Supreme Court  (1990). Decisions  7-24, 59 LW 2049.

1990

De Paul University

Writing from the Inside

Teacher: Zoe Keithley 

Thankfulness …

I hate some parts of having money. I hate having to wonder about whether someone really likes me. Having money is new to me; how do rich people find true love – whatever that is? I used to only worry about whether or not they (the men) just wanted me for sex. Now it’s money and sex. I am still my usual insecure self in these matters. I doubt that age will ever change these parts of me.

I am thankful for good, nonjudgmental friends who accept me as I am.

I am thankful for peace in my world, for joy that I can perceive all around me.

I am thankful for trees, plants, and all the growing things that enrich our environment.

I am thankful for the new man in my life who listens to my ranting and raving about feminism and still likes me. He thinks I am probably right! He can understand how women must feel. What he doesn’t understand he accepts!

I am thankful for my delightful 17-year-old daughter. I am glad she picked a caring, non-chauvinistic boyfriend. I’m glad she was responsible enough to go to Planned Parenthood and assure me that I do not become a grandma before my time.

I am thankful for picking a career in which there is a drastic shortage; it affords me enough money so I can go to DePaul and get out of the profession.

I am thankful for good health; thankful to be the caretaker rather than the receiver.

I am thankful that I discovered my brain before I died. (In high school and up until about 32 years old I thought I was dumb).

I am thankful for this beautiful computer. I learned that I could be creative and write off the top of my head while taking a computer class.

1990

De Paul University

Writing from the Inside

Teacher: Zoe Keithley 

Older Relationships

There is a richness to older relationships. It is not a question of IS the relationship going anywhere – it is how close, how deep, and how vicious the quality is?

You accept me. I love you. I am me and you love me. This is joy.

The beauty of intimacy, of psychological and physical closeness. Sharing joys and sorrows, disappointments somehow buffered through the loves filter.

I love your touch – it tells me that I am.

In the dark, you are dark – aren’t we all? Yet we see each other.

What does sex mean? How does it make us feel? What do my touches say to you?

I want you more. I grow with you. Is not love beyond color? Can we intelligently say that love can only be white/white? Can’t human love be variegated? Are not zebras part of nature? Don’t opposites attract?  Don’t vivid contrasts shout to us? Do we love only if the skin color is right? Do we love only if the hair color is right?

1990 Women’s Roles: A Historical Perspective

(Put on note cards)

Grade: A+ (58 points out of a possible 60)

Teacher comments:  Stunning statistics on deaths in Mass and battery every so many second. Good to look at 3 areas. Amazing that laws are different in each area and you have to learn what the laws are. Pretty depressing stuff, isn’t it?  Interviews are a very good idea. 

Introduction

I’m going to talk to you about the abuse of women by the men that love them, their husbands, boyfriends, and exes. I was appalled when I began researching the problem that the criminal justice system keeps women in abusive situations. I am focusing specifically on the police, the court system, and the self-defense law.

October is National Domestic Violence Awareness Month. To make you aware I will tell you about some shocking statistics. The National Coalition Against Domestic Violence says that:

2-6 million women are victims of abuse each year. Experts estimate that 50% of females will be battered at least once in their life. The State of Mass claims that if a woman is killed by her husband or lover every 22 days. The US government statistics say that 1 woman is abused every 15 seconds. Abuse is the #1 cause of injury to women.

I was appalled by what I learned in the research I did. The criminal justice system keeps women in abusive situations. A study showed that some male professions had much higher rates of abuse than others; There is a high incidence among police, doctors, lawyers, executives, professors, and elected officials.  Because of this, I am focusing on the police, the court system, and the self-defense law. I plan to show why I think the problem is actually worse today.

The abuse was not seen as a social problem until the 60s and 70’s when feminists brought it to public attention. These feminists had a hard time getting started because they couldn’t find anything in libraries about the problem; they found lots of complaints of abuse though in the files of social workers. The University of Michigan Law School found abuse information hidden under other categories in police and hospital records. They faced a conspiracy of silence – a tradition of domestic privacy. Wife beating HAS a history, but it was deliberately undocumented – kept behind closed doors. By keeping it behind closed doors the law and society trivialize it and continues widespread ignorance about its prevalence and brutality. The abuse was always an epidemic without fear of interference.

Things started to change in the mid ’70s. The National Organization for Women then started the first task force on wife assault which led to the development of the first shelter. In the mid 70’s conjugal privilege changed to marital rape. The conjugal assault was LEGAL in some states through the early 70s.

Historically the female role was to support and nurture her loved ones under any circumstances; unfortunately, some of us feel that obligation to “stand by our man” regardless of the cost to ourselves. The violence is tied to a sense of male privilege and power along with the fear of femininity. One male author who counsels abusive men calls if the “Failed Macho Complex” or an overreaction to the male sex role. These men are violent because they do not see themselves as living up to the male sex role.

Three reasons have been noted for the changes that took place in the 70s: work on child abuse and national sensitivity to violence due to the Vietnam War.

Isn’t this about the time we took the “Obey” out of wedding vows?

The late 70s witnessed the establishment of congressional committees, the civil rights commission, and other government agencies started to study the problem; they began to introduce laws to protect women.

Wife abuse was not seen as a social problem until the 60s and 70’s when feminists brought it to public attention. Feminists, in their initial research, had difficulty finding out about the problem because there was nothing to be found in libraries. There was a conspiracy of silence due to the tradition of domestic privacy; the history of abuse was kept behind closed doors and deliberately undocumented. They found, however, files stuffed with complaints of abuse in the offices of social workers. The University of Michigan Law School found abuse statistics hidden under other categories in police departments and hospital records. They knew that when history was uncovered it would be a culture shock. The abuse was always an epidemic – it went on without fear of interference.

The National Organization for Women started the first task force on wife assault in the mid ’70s. It wasn’t until the mid 70’s that conjugal privilege was seen as marital rape; the conjugal assault was legal in some states till the early 70s. The law trivializes abuse when it says that it’s a family matter and lets it stay behind closed doors. There had been widespread ignorance about its prevalence and brutality.

Historically our female role was to support and nurture our loved ones under any circumstances. Violence is tied to a sense of male privilege and power and a fear of femininity. Unfortunately, some of us feel that obligation to “stand by our man” regardless of the cost to ourselves.

A male author who counsels abusive men calls it the “Failed Macho Complex”; an overreaction to the male sex role. He thinks these men are violent because they don’t see themselves as living up to the male sex role.   

One author sees 3 reasons for the change in the ’70s:

         -work recently done on child abuse led them to learn about wife abuse

         -the nation as a whole was more sensitive to issues of violence as a result of the Vietnam War.

         -an increase in the feminist movement.

Another author sees it in terms of movements:

         -the Woman’s Movement of the ’60s and the Antirape

The movement of the early ’70s led to the shelter Movement in the late ’70s. They say that the feminist movement sensitized females to sexism.

The late 70s brought about some changes in the US. Congressional committees began to study abuse; the civil rights commission and other government agencies began to study the problem and laws to protect were being introduced.

When I learned of a study done on which professions among men had the highest incidence of abuse I knew what I wanted to focus on; were: police, lawyers, doctors, elected officials, professors, and executives. These are all jobs in which the men have power over others. How surprising should it be that they may be more inclined to want power over their wives?

The Police

A government study in 1984 called the “Final Report of the Attorney General’s Task Force on Family Violence” said that the police failure to arrest was one of the most serious aspects of domestic violence. Most of the police are men and have been socialized to varying degrees to believe that a man has the right to discipline his wife; there is a high incidence of wife abuse among the police. Police protection is ineffective; in the late 70s half the reports were never filed.

The police are known to fail to save evidence, fail to respond to calls, or respond late, and try to bully women out of pressing charges, i.e. “Who’s going to pay your bills when he’s in jail”? The police get frustrated because the women frequently decide not to file complaints after they have gone out to the house; they see this as her desire to be beaten; she decides not to file because she realizes that it means facing a punishment more violent than she has just gone through. The police do not offer protection to these women so how can we expect them to press charges? Experts estimate only 10% of women even call the police; police departments around the country report a very high incidence of calls.

Another problem is that police get frustrated because women so frequently don’t sign a complaint after they have the police come out; she decides not to because she fears violent punishment; they see it as her desire to be battered. However, since the police can’t offer protection, as they say they can’t do anything about “mere” threats how can she be expected to press charges?

The police have “stitch rules”, to judge the severity and visibility of injuries, and they use this as criteria to arrest. An advice book for abused women gives the following advice:

         check with your local police on what the laws are in your area; do they have a mandatory arrest law

         decide what you want them to do ahead of time

         be sure to get case # and copy of report

         practice the call saying, “I’m being beaten, give the address and then details – DO NOT TELL THEM IT IS YOUR HUSBAND DOING IT!

Police call patterns have the ability to predict and prevent murder. Studies show 50% of all fatalities had called 5 times and 80% had called at least once in the last 2 years.

Experts estimate that only 10% of women actually call the police; the police departments report that the number of calls they receive is very high. Police dispatchers screen the calls; the police get mad if they go out to a domestic violence call and don’t think that the injuries are serious enough.

A study done in the late 70s showed that half the police reports were never filed – police protection was very ineffective.

A handbook that offers advice to abused women who want to get out despite the system was given this advice:

-call the local police to find out what the laws are in your area to see what they will do. Does your county have mandatory arrest laws?

-decide ahead of time what you want to be done within the local laws.

-get the case number and a copy of the police report.

-Practice saying “I am being beaten, my address is……”, DO NOT tell them it is your husband or lover.

Police reports can predict and could even prevent murder; it has been found that 50% of fatalities had called at least 5 times in the last and 80% had called at least once.

I inquired about what the police would do in my area (DuPage County) if I were a battered woman. I learned that my county has a mandatory arrest law, which means IF the police determine that there IS evidence they must arrest him. I was told that this county is much better than most. The police are also required to notify the local shelter of all calls that they receive; they also have mandatory counseling the abuser must go through (20 weeks) if arrested. They have a victims advocate program which will help a woman find a shelter out of state if needed. (studies show that if men are jailed they are a little less likely to re-batter). This is a model pilot program – in 1990!

The Court System

The Civil Rights Commission says that the criminal justice system fails women at every step of the way when she tries to get away from abuse. Prosecutors, police, and society do NOT see wife abuse as a REAL crime. Judges see women as trying to manipulate the system to control their husbands and settle quarrels. The justice system sees wife abuse as a private matter; courts see their role as holding the family together despite the cost to the women.

Courts are still today uncomfortable with domestic violence, they still see it as a private family matter; prisons are overcrowded and so they are lenient on abusive husbands. Unless batterers are treated as other criminals the courts are not protecting women. The courts see their role as that of holding the family – even if it is at the woman’s expense. Woman abuse is treated as a civil matter;  if a stranger beat you up, stabbed you, or repeatedly bashed your head into the concrete wall it would be a felony and they would be treated as a criminal. If your husband does it is either not prosecuted at all or treated as a misdemeanor – a civil matter! Unless batterers are treated like other criminals the courts are not protecting women at all.

April is an example of a woman trying to help herself within our system. She filed for divorce, and got a restraining order to keep her husband away – just what she must do to try to protect herself from his “mere threats”. Her husband broke into their house and stabbed her from her throat to her pubic bone. He went to jail, got out on bail, and killed her and himself. Studies have shown us that to get out of the situation the woman MUST leave. It’s when she leaves that she is killed; men panic with the loss of control, it is rare for a woman to be killed while living with a man.  The courts do not take threats seriously yet studies show almost all women who were killed were given “mere” threats.

An example of Lisa whose husband was in jail for gross abuse; she asked that she be notified if they let him out for any reason because she knew that he would kill her; they let him out on a work furlough, and he went straight to her house, broke in, dragged her outside and beat her to death with a gun butt in front of the neighbors.

Of 90% of women who filed complaints less than 10% were ever prosecuted. The district attorney can decide whether or not to prosecute. One book advising women said you must know what you want to be done because if you don’t the prosecutor will do what he sees fit. You may even have to demand another prosecutor. The prosecutor can deny taking a case to trial for these reasons. Even if you want to go to court he can deny it if he thinks:

         -the injury is not serious enough

         -the man says that he didn’t mean to do it

         -not enough evidence (no witnesses, studies show almost all domestic  

         -violence takes place without witnesses).

         -the husband has no past criminal record (studies show that these men are usually only violent towards their wives and kids).

They recommend women demand another prosecutor if he denies taking it to court.

Your success at the trial, if you can get this far depends on:

         -convincing evidence (witnesses)

         -whether the judge sees abuse as a crime.

         -how hard the prosecutor works

         -whether there are programs in your area to counsel these men.

         -whether the man seems sorry.

         -whether the man is seen as a solid citizen.

When the legal system imposes its prejudices on women they commit crimes of “omission” and give the husband a license to abuse. This judicial insensitivity and tunnel vision send her right back to the batterer. There is a lot of research around today to inform judges about the facts in domestic violence:

         -men get worse as they get older

         -it is never an isolated incident

         -the woman is always in danger

         -the threat of violence is constant, it’s not a question of whether will he do it again, its when, how bad, and will he kill her this time? The courts ignore what studies show:

         these men get worse as they get older

         it is never an isolated incident

         the woman is always in danger

         The threat of violence is constant

         Being married to the batterer can work against the woman too.

Unless you have filed for divorce the courts will not issue a restraining order; judges are reluctant (in some states forbidden) to keep a man off his own property – she the victim must leave. In the last few years some states have been allowing the use of expert witnesses to educate judges and juries about the psychology of abuse. About how it is like what happens in concentration camps – learned helplessness. But the judge can decide if he thinks it is needed in each case; if he thinks it was an easy murder case he can disallow it.

Being married works against you. You must file for divorce to get an order of protection.  SHE the victim,  must leave.

The Self Defense Law

The law does not “fit” women. In 1977, the usual defense for a woman who killed her husband was temporary insanity; most went to jail and were found guilty of murder. Women have not had the right to use the self-defense law equal to men.

On the surface, the law does not discriminate, but in its application it does. The law was written to be genderless, but we don’t SEE the woman as defending herself when she kills her abusive husband.  The self-defense laws evolved over the centuries and were made to “fit” what men ran into: bar room brawls that went to far, robberies and incidents where someone threatened them with a lethal weapon.

The self-defense law requires:

         -threat with sufficient potential harm, how does a woman prove she knows there is sufficient potential harm?

         -the harm must be imminent – even if it is the court will ask why didn’t she leave if he did this before.

         -you must try to escape and prove it – goes with why didn’t you leave.

         -must threaten with lethal weapon – men frequently do NOT use lethal weapons they use fists, feet etc.

         The law assumes men of equal size and strength. If a wife is beaten without a lethal weapon, no matter how savagely, it is NOT seen as a felony, it is almost universally treated as a misdemeanor assault. Even in states where it is a felony, it may be of no avail to a woman who kills her husband. Men’s situations are different than an abused women. With men it frequently occurs in public, women don’t have witnesses, and studies show a woman is likely to be beaten to death in a bedroom). is with a stranger, is with another man of equal strength and size (if this is not equal the courts have considered this). They are usually isolated incidents.

Women can’t use the law equally as it is:

         -wife beaten without a lethal weapon, no matter how brutal NOT seen as a felony

         -almost universally seen as a misdemeanor; even if in a state that it is a felony it will not help a wife that kills him

         -men don’t usually use weapons – fists, feet, pushing

         -must only kill while being beaten – not before or after

         -women’s situations are different than men’s, but the law does not consider this. With men:

         -it usually happens in public (stats show women likely to be beaten to death in a bedroom)

         -is with a stranger

         -is equal in size and strength

         -can try to escape without society making him go back to a situation

         -are isolated incidents

In 1977 the usual defense for a woman who killed her husband in order to defend herself was temporary insanity – most went to jail after being found guilty. Studies show women rarely kill #1 and if they do it is after repeated beatings and threats of murder and know they are about to face another assault.

In the last few years, there have been a few women who were found innocent because the courts are now allowing expert witnesses to teach about the syndrome of battered women. However, the judge can decide if this is a waste of the taxpayer’s time.

Women then must only kill him during a beating, while he is threatening to kill her – not before or after. Studies show that women rarely kill and when they do it is after being repeatedly beaten and threatened with murder.

Caroline is a good example. In 1979 she shot her husband while he sat in a chair 4 feet away.  Guilty 20 years.

The Violence against women Act of 1990 says that gender-motivated crimes will be categorized as hate or biased crimes and will be seen as civil rights violations. It will double the federal penalty for rape and will require restitution for sex crimes. Will also add funds for shelters (there aren’t federal now), and add special units to the courts for spouse abuse. Will also:

         -add federal money for shelters (none now)

         -add money for enforcement

         -add special units in courts for spouse abuse.

As research grew in the area of wife abuse the courts began to allow the use of expert witnesses to testify about the syndrome involved; feminists were claiming that jurors were not educated in the syndrome so couldn’t make a fair decision. They started to allow an expert to tell them that the syndrome is similar to what happens with prisoners in concentration camps and how learned helplessness works. However, this only looks like progress because the judge does not have to allow it if he thinks that the jurors can see easily that this woman just picked up the gun and killed him. There have been some recent cases where a woman got off; it is feared that we will be giving women a license to kill if we let them off.

Violent crimes against women have escalated in recent decades; criminologists have seen a surge in serial murders which are almost always white men against females. See a backlash against feminism – not the fault of feminism – a patriarchal culture terrorizes us whether we fight back or not, but when male supremacy is threatened the terror intensifies. It is unspeakably painful for women to think about men’s violence against them. Disbelief and contempt that we face when we speak out are traumatic and can be life-threatening. So we deny and repress to cope.

Bibliography

Barb. (1990).  Counselor, Family Shelter, Glen Ellyn, IL

Cmar, Joan. (1982).  Counselor, Haven House Shelter, Hammond, Indiana

Gillespie, Cynthia, J.D.. (1989).  Justifiable Homicide

Gondola, Edward.  (1989).  Man Against Woman

Hazelhood-Shupe, Stacey. (1987).  Violent Men, Violent Couples.

NiCarthy, Ginny & Davidson, Sue. (1989).  You Can Be Free

Okun, Lewis. (1986).  Woman Abuse

Roy, Maria. (1977). (Ed).  Battered Woman: A Psycho-Sociological Study of Domestic Violence.

Walker, Lenore. (1979).  The Battered Woman

(1990, June).  Good Housekeeping        

(1990, Sept\Oct).  MS

(1987, September).  MS            

(1989, March 27).  Time                                  

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