Who must do the hard things?

July 13, 2009 -- Tonight's episode of Showtime's Nurse Jackie focuses on the care Jackie and the other ED nurses provide to a dying nurse who used to practice with them. The plotline offers an unusual portrayal of how the nurses manage their patient's end-of-life care, and equally rare, a serious and revealing look at the clinical interactions among very different types of nurses. The dying nurse--who makes Jackie look easygoing--asks Jackie to help her end her life, because she does not want to lie in hospice for her last couple weeks. As in past episodes, Jackie works around the system. She and the other nurses provide their old friend with the ending she wants, even though it is apparently a crime to do so in New York State. The nurses' actions raise complex and difficult issues related to our flawed end-of-life care policies, and Jackie's own consistent willingness to break rules in order to further her vision of what is right for patients. Although the plotline is more about psychosocial care and advocacy, there is also a scene in which Jackie, after minimal assessment, accurately estimates that a patient will die in 10 minutes, underlining her expertise in physical care. The episode, "Tiny Bubbles," was written by Rick Cleveland.

Arriving at All Saints Hospital for her shift, Jackie finds her old nurse colleague Paula, smoking, coughing, and generally not looking so good. Jackie sits next to her.

Jackie:   You know, with the lung cancer? Maybe you shouldn't be smoking.

Paula:   I know. It'll kill me! In 10 days, 2 weeks, maybe 3. If my sh---- luck holds up.

Jackie says she's sorry. Paula can't believe how civil Jackie still is after all these years; Paula says that in contrast, "I've always been a bitch on wheels, and we both know it." Paula notes that her "prick" oncologist has advised her that it's time for hospice and palliative care, but Paula has other ideas.

Paula:   I want to go out a little sooner rather than later. With a shred of dignity intact? If I check into hospice, I'll just lie there till I'm dead. I'm up to my tits in tragedy. I know how the story ends. So I want to go out with a little help from my friends.

Jackie's reaction is non-committal. She wheels Paula back toward the nurses station, where Paula and nurse Mo-Mo immediately start insulting each other.

Paula:   Oh my God, they still let you work here?

Mo-Mo:   You look like warmed over sh-- on toast.

Paula:   Well, at least I have a half-way decent excuse.

Mo-Mo:   Don't mess with me. (Showing her his ID badge.) I'm an RN now.

Paula:   Well, you'll always be an LPN as far as I'm concerned.

Mo-Mo:   I have both certifications, what do you have?

Paula:   I have cancer, you big queen.

Mo-Mo (to nursing student Zoey):   Some people are just too mean to live.

Paula asks after Bed 5, which Mo-Mo informs Zoey is famous for people dying in it. Paula says that sounds good to her. The nasty nurse manager Gloria Akalitus arrives and addresses Paula.

Akalitus:   Hello, Nurse Korsenowski.

Paula:   Akalitus! Sounds like a disease. Well, you know that, right? I got...(faking spasms)... Akalitus !

Jackie tells Akalitus they are waiting for a bed for Paula up in hospice. Akalitus says she's sorry to hear that. Paula assures Akalitus that she forgives her for her years of "sh---- treatment." Akalitus tells Jackie to let her know if she can do anything to expedite matters with hospice, "even if I have to pull somebody else's plug to make room." Akalitus leaves.

Paula:   What a ----.

Later, Jackie and her good friend, physician Eleanor O'Hara, look at the x-ray of Paula's trashed lungs. Jackie says she worked with Paula for 15 years, but Paula left about a year ago. Eleanor says this must be hard for Jackie.

Jackie:   You don't know the half of it.

Eleanor immediately gets what Paula has asked Jackie to do.

Eleanor:   Are you gonna do it?

Jackie:   She would do it for me.

Eleanor:   Do you want my help?

Jackie:   Nah.

Eleanor says she is there if Jackie needs her.

Later, Jackie is making Paula comfortable in a bed, and she asks if she can get Paula something to drink.

Paula:   Crushed ice with a hemlock chaser, please.

Zoey:   Shouldn't someone call up to hospice?

Paula:   I'm not goin' to hospice, Pippi Longstocking.

At another point, Paula injects herself into the treatment of a patient whose cat keeps injuring him, telling him about a patient from long ago who arrived at the ED with his testicle in a baggie. Jackie says nothing but draws the curtain between the two patients. Paula says he needs to kill that cat.

Jackie begins to gather morphine. Zoey senses something is going on. She consults Eleanor, who encourages hugs for Jackie at this difficult time, as Jackie herself looks on, amused.

In a surprise scene, we see Mo-Mo massaging Paula's feet, which she says she really appreciates, though they still bicker. She tells Mo-Mo about her weak ex-husband. Her lungs feel like they're "filled with razor blades." Paula roots through her purse, and gives Mo-Mo subway tokens, though as he notes, they are no longer used. Mo-Mo accepts them, but Paula wants to be thanked.

Mo-Mo:   Isn't a foot massage thank you enough?

He and Paula do bond about their mutual cigarette craving, and they also share a moment when Akalitus arrives. Paula says she has something in her purse for Akalitus, looks for a second, then brings out her middle finger.

The other nurses and Eddie all covertly drop off doses of morphine for Jackie to give to Paula. Finally, Paula says it's time for "a toast...it's time." Steeling herself, Jackie goes to the rest room and snorts some of her own drugs.

Zoey goes to Eddie to express concern about whether she will fail this "rite of passage," because she's not sure she is comfortable with what Jackie and the others are doing. Eddie is cagey and defensive. He does say he's never heard of anything like this happening before, and he assures Zoey no one will judge her whether she participates or not.

Jackie puts all the morphine in a champagne toast. Nurses and Zoey gather around Paula's bed, with glasses of their own (sans morphine). Paula toasts them.

Paula:   Here's to you, and here's to me, and if we ever disagree, f--- you. And here's to me. (She drinks her champagne.) What are you all looking at me for? That's all I got. (She pauses, then whispers urgently to Jackie, starting to panic.) Jackie! I need a priest!

Jackie runs to find the priest, who is giving the last rites to another patient. She feels the patient's pulse and assesses: "OK, you got 10 minutes, honey, I need him for five." She pulls the priest away (conveniently, there is no family). We see the priest giving Paula the rites, and she passes away. The priest leaves. The nurses remain.

Jackie:   F--- you and here's to me (echoing Paula's words).

Mo-Mo:   Hilarious.

They all start to laugh. Akalitus throws back the curtain, looks around the circle of nurses, then at Paula's IV bag.

Akalitus:   If there's anything funny with that bag, I'll have your asses. Every single one of 'em.

Of course, there won't be anything funny with the bag, since Jackie put the morphine in the champagne.

This plotline points to some problems with U.S. attitudes toward dying, and suggests how some nurses might want to respond to those problems, however plausible Jackie's morphine harvest might really be. Here, a well-informed, competent person--and the show makes very clear that is Paula's status--has clearly decided to avoid an imminent dying process that she sees as a pointless, undignified prolonging of her pain. And Paula is suffering, as the comment about lungs "full of razor blades" indicates. Jackie provides Paula with the means to do what she wants, though the final act (drinking the champagne) is completely that of the patient. The show also makes clear that this assisted suicide is a special case; Eddie notes that he has never seen it at the hospital before.

In general, U.S. society does not seem able to provide a person like Paula with an above-board way to achieve this ending. In many cases nurses are confronted with terminal patients who are suffering and who do not wish to prolong their lives, but who face difficult legal and social hurdles to taking that course. What should Jackie have done for her old friend? Stress the merits of hospice? Refer Paula for counseling? Just say no? It is hard to imagine a different scenario in which Paula, given her preferences, could have come closer to the way she wanted to die than the death Jackie gave her. And it is hard to see why Paula should not have the right to that ending.

Of course, a distinction is often made between simply refraining from life-prolonging measures, which is lawful when certain requirements are met, and affirmatively acting to end life before it would otherwise end. It appears that in New York, as in most U.S. states and many other nations, assisted suicide is a crime even in the context of a competent terminal patient who has strongly expressed her preference for that result. On the other hand, it appears that such laws are rarely enforced in some jurisdictions, and Oregon has had a "physician-assisted suicide" law in place since 1998. Critics of assisted suicide argue that even if it might seem acceptable in certain cases, allowing its use to become more widespread could lead to abuses of vulnerable persons and communities. (See Final Exit Network.) What, they might argue, would protect a patient from such abuses? Perhaps such patients should have psychological examinations to ensure that they are really competent. Maybe counseling would change their minds. In some cases, perhaps the terminal prognosis is incorrect. Should there be a waiting period, to make sure the patients feels the same tomorrow? Next week? What if Jackie had just decided Paula's life was not worth living, used her power to end that life, and assured others that was what Paula wanted?

The U.S. health system is largely oriented toward interventions to preserve life at all costs. Nurses have had to fight even to provide the option of allowing a natural death when patients want that. Some nurses confronted with terminal patients who want to die, with the moral distress of suffering they cannot fully relieve, have taken unauthorized measures to ease such patients' suffering, and these measures have at times probably hastened death. But that is not something Hollywood has spent much time on, certainly not with a focus on the nurses who are most likely to be facing the situation directly. In a January 2009 episode of ABC's Private Practice, two physician characters did struggle with the request of a dying patient--another physician--for drugs to hasten his death. One physician wanted to give him the drugs; the other objected strongly. The two ended up staying at the dying man's bedside at his home for many hours until he died, which physicians are much less likely to do than nurses are.

This episode of Nurse Jackie does not send a very positive message about hospice, and hospice does not seem to be the right choice for a person like Paula. But in many cases the palliative care of hospice is a vast improvement--and far more "dignified"--than the interventions-till-the-end medical model that many still pursue for terminal patients. (See our biography on Florence Wald, a nursing pioneer who worked to promote dignity in dying.)

Indeed, nurses play a leading role in hospice settings, and many patients who are not after what Paula was value that option greatly. The episode might have included some suggestion that hospice is far from the worst result for terminal patients.

The episode is also notable for its serious depiction of the views and actions of the very different nurses who interact with Paula near the end. Paula herself appears to be a hard-core veteran, someone who resembles Jackie in her toughness, but who lacks Jackie's psychosocial virtuosity, to say the least. Paula's interactions with Mo-Mo briefly suggest the heirarchy among nurses. It's not clear how much of the audience will get what "LPN" means, that licensed practical nurses generally receive about one year of college-level training, as compared to the minimum of roughly three years for registered nurses. Of course, the show cannot easily explain all that without sacrificing realism. At the same time, Mo-Mo--like Jackie--is tough and dedicated enough to provide effective care (the foot massage, the banter) even to a patient who abuses him and whom he seems to loathe. This plotline is another learning experience for Zoey, who struggles with what the veteran nurses are doing, and whose presence they manage to tolerate. Akalitus, as usual, is the nasty bureaucrat with little regard for the patients, even a former colleague, continuing the show's relentlessly negative depiction of the nurse manager. At the center is Jackie, the clinical leader with the strength and expertise to give this patient what she really wants and deserves--by committing another crime.

 
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