In Far West Texas, One Hospice Nurse Brings Consolation to the Dying

For those who’ve loved views of the Davis Mountains for many of your life, it appears solely proper that you need to get to spend your closing days amid these acquainted vistas. However many terminally unwell sufferers within the Massive Bend area discover themselves shuttled off to nursing amenities in El Paso or Midland or elsewhere—removed from every little thing and everybody they know and fortunate to have a window, not to mention scenic environment.

Complete hospice care, which prioritizes a affected person’s consolation on the finish of life, hadn’t been obtainable within the area because the nineties, when the service was discontinued due to monetary difficulties. Then final yr, Angels Care Hospice, a Midland-based supplier, observed the necessity in Brewster County, the place these age 65 or older make up 1 / 4 of the inhabitants, in contrast with simply 13 % statewide. The corporate employed Karen Ramirez, a 56-year-old registered nurse, to serve Texas’s largest county—a territory larger than Connecticut—which incorporates the cities of Alpine, Marathon, and Terlingua.

I first heard about Ramirez final spring, by my pal Sage Keith, whose 66-year-old father, Rick, was dying of pancreatic most cancers in Alpine, a group of about six thousand residents with the restricted entry to well being care that’s typical all through a lot of rural Texas. Like many in his place, Rick needed to search therapy elsewhere—in his case at MD Anderson Most cancers Heart in Houston, thought-about one of the best hospital of its variety on the planet however a nine-hour drive away. These journeys forwards and backwards turned extra arduous as Rick’s situation worsened. Ultimately he was given a alternative: pursue a last-ditch therapy choice that may prolong his life by solely a matter of days, or proceed to hospice care.

Nurse Karen Ramirez. {Photograph} by Hannah Gentiles

The household determined it was time to take him house, however that was simpler mentioned than finished. No ambulance would journey that distance, and Rick was too fragile to resist the drive sitting in a automotive seat, in order that they rigged up their very own medical transport. Sage’s fiancé had not too long ago acquired a Ford Tour SUV for his or her enterprise as Massive Bend river guides, and he fitted the again of the car with sleeping pads and bedding they’d usually present to their purchasers.

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Moments after they arrived with Rick at his home in Alpine, Nurse Ramirez confirmed up. She had seen to it {that a} pharmacy crammed his prescriptions for ache medicines, and she or he supplied the household with provides, together with pads for incontinence and bedsheets with handles that might make it simpler to maneuver him. She defined to the Keiths how she would help them by every of a number of phases of hospice care, which made Sage really feel “relieved,” she recalled later.

Noticing Rick battle to take a seat up, Ramirez supplied the household an previous hospital mattress that she had in her private storage unit. (Angels Care hadn’t but secured a supply of sturdy medical tools—resembling beds, walkers, and wheelchairs—for its Brewster County sufferers.) She gave the Keiths her private cellphone quantity and later proved prepared to reply calls and texts at odd hours.

Ramirez is an almost thirty-year resident of Brewster County, and that introduced reassuring familiarity. Rick was a retired highschool historical past instructor and cross-country coach, and considered one of Ramirez’s two daughters and her son knew him by the athletic program. Ramirez addressed him as so many others on the town lengthy had—not as “Rick” or “Mr. Keith” however merely as “Coach.”

Months later, after his loss of life, Sage spoke in regards to the significance of bringing her father again to Alpine—“the dignity of having the ability to die in your personal mattress and the house you created, surrounded by the household that you simply constructed.” That wouldn’t have been potential with out the work of Ramirez.

There’s usually a stigma or concern hooked up to any point out of hospice care, seemingly rooted in an aversion amongst many Individuals to discussing the ends of our lives. “We now have a youth and well being tradition, and so we’re not likely buddies with the concept of loss of life,” mentioned Megan Hebdon, an assistant professor on the College of Texas at Austin Faculty of Nursing whose analysis topics embody hospice work. “We don’t actually see it as one thing that’s a part of the continuum of life.”

Hospice care falls underneath the umbrella of palliative therapy, which goals to cut back the struggling of sufferers with severe sicknesses by managing their signs. When a illness reaches a sophisticated, seemingly irreversible stage, some sufferers—usually on the recommendation of their households and health-care suppliers—resolve to transition to hospice.

“In terminal most cancers therapy, typically the therapy is inflicting so many negative effects that the affected person isn’t actually dwelling,” Hebdon defined. “Once they’re on the level the place they don’t seem to be dwelling properly or dwelling the way in which they’d wish to spend their time, that’s when shifting to hospice care could also be a better option to assist them get snug and assist them have experiences they worth earlier than the top of life.” Most medical health insurance plans cowl this care, supplied the affected person meets sure standards. For these with Medicare or Medicaid, a health care provider should certify {that a} affected person is terminally unwell, with a life expectancy of six months or much less. The variety of Individuals enrolled in hospice by Medicare has risen in recent times, growing by 20 % from 2016 to 2020.

Rural Alpine, close to the Reesing household’s house. {Photograph} by Hannah Gentiles

In hospice care, all remedies meant to gradual or treatment terminal illnesses stop, however many individuals mistakenly imagine meaning the loss of life of the affected person is imminent. “They usually see it as giving up fairly than as one thing that may actually enhance the standard of life for everybody,” Hebdon mentioned. In lots of instances, she added, sufferers who transfer to hospice care find yourself doing properly for months and even years. She’s even seen some “graduate,” which means that their signs and functioning enhance dramatically, they usually go away hospice. The common affected person is in hospice look after ninety days.

Hospice groups, together with the one on which Ramirez serves, usually embody social staff and chaplains who assist the affected person and household with the ramifications of loss of life. Ramirez is hardly immune to those results. Once I met her in August at Penny’s Diner, close to the sting of Alpine, she choked up as she instructed me that considered one of her sufferers had simply handed away. “Yesterday damage,” she mentioned. “He was a superb man.”

Ramirez has coronary heart illness and in addition has hassle consuming due to problems associated to a gastric-sleeve surgical procedure. At Penny’s she ordered an iced tea and nothing else. A few years in the past she broke her hip, and she or he now typically walks with a limp. She mentioned it was due to her personal well being points that she shifted the way in which she thinks about caring for her sufferers. “I used to be in denial for a very long time with my well being issues,” she mentioned. “By means of accepting my very own issues, I’ve needed to study that different folks have to simply accept theirs.”

Initially from Nova Scotia, on the Atlantic coast of Canada, Ramirez determined to maneuver to Texas after graduating from nursing faculty. On the time many Canadian nurses have been being recruited to Florida, however she’d already seen that state and wished to expertise one thing new. She was 26, and it was November. “I selected Texas solely as a result of I used to be within the snow,” she mentioned. She landed in Alpine with each intention of finally returning north. As an alternative she met her husband, an Alpine native, and raised their three kids. At occasions her drawl sounds totally Texan. Different occasions, the elongation of her vowels on phrases resembling “about” reveal her way more northern roots.

Ramirez spent the majority of her thirty-year profession on what some would possibly contemplate the other finish of the nursing spectrum. She labored within the maternity ward at Alpine’s Massive Bend Regional Medical Heart, serving to to usher new life into the world. Ramirez finds end-of-life care simply as rewarding, if no more so. “Delivering all these infants, it’s a cheerful time,” she mentioned. “However I truly see extra love in hospice than I did with the infants.”

In 2018 her mom was recognized with lung most cancers and lymphoma, so Ramirez returned to Canada to stay along with her for 2 years. There she witnessed the worth of her mom’s palliative-care nurse, which impressed her to alter her specialty. “The connection is just a bit bit nearer,” Ramirez mentioned of hospice care. “You could have the intimacy of being invited into somebody’s house.”

Nurse Karen Ramirez within the kitchen on the Reesing home. {Photograph} by Hannah Gentiles

Earlier than beginning her job in Brewster County, Ramirez obtained every week of coaching at Angels Care’s Midland workplace, the place she shadowed different hospice staff. Like a whole lot of nursing, it’s a bodily demanding job. Sufferers usually should be lifted and assisted with bathing and toilet visits. Ramirez’s well being points don’t make it any simpler, particularly contemplating that she’s the only full-time supplier in a 6,200-square-mile county. On a typical day, she’ll drive wherever from 25 to 150 miles to go to 4 to 6 sufferers. She sees every one a minimum of twice every week, for visits that vary from thirty minutes to 2 hours. Till not too long ago she was on name 24/7, however she now shares the accountability with one other member of her workers. She depends on the assistance of a nurse’s aide in addition to a licensed vocational nurse, who alternate seeing sufferers between Ramirez’s visits.

Other than driving lengthy distances, one of many largest challenges she has confronted—and one distinctive to a rural space resembling Brewster County—is buying provides. In some instances, Angels Care can ship the issues she wants. In additional pressing conditions, she’s needed to solicit the assistance of her two daughters, who stay in Odessa, to shuttle provides from the Midland workplace. She meets them on the midway level, in Coyanosa, eighty miles from Alpine. One latest enchancment got here in August, when Angels Care secured a contract with an Alpine firm to offer sturdy medical tools in order that Ramirez doesn’t should fisha hospital mattress out of storage for some other purchasers.

We left the diner to satisfy her subsequent sufferers. Her SUV doubles as an

workplace and carries paraphernalia for each her job as nurse and her function as grandmother. Within the again seat was a booster seat and, on the ground, an oxygen tank. We drove alongside a winding highway outdoors city that supplied gorgeous views, a reminder of why some folks select to stay on this remoted portion of Texas. Ramirez instructed me that the sufferers we have been going to see, a pair, had been in her care since she began as a hospice nurse, in December 2022. “This isn’t a narrative of dying,” she mentioned, pulling as much as their ranch-style house. “It’s a love story.”

Outdoors the Reesing household’s home. {Photograph} by Hannah Gentiles

Ernest Reesing, who goes by “Doc,” met his spouse, Jo, at a dance in Navasota, seventy miles northwest of Houston, on the night time after John F. Kennedy was assassinated, in 1963. The band was taking part in a rustic and western tune. “I requested her to bop,” he mentioned. “She by no means would let me go after that.”

The 88-year-old sat in a leather-based armchair in the lounge of the Alpine home that he and his spouse have occupied for 47 years. Light household portraits cluttered the partitions. He wore a polo shirt with the Texas A&M brand emblazoned beneath the collar and “Doc” embroidered on the pocket. He lengthy labored as a professor of veterinary expertise at Sul Ross State College, in Alpine, and served as chief of town’s volunteer hearth division.

In an adjoining bed room, close by of his chair, his spouse, Jo, 83 years previous with late-stage Alzheimer’s, reclined in a hospital mattress, solely her head of cropped white hair seen above her bedsheets. Their daughter, Susan Carroll, who’s 58, had moved in additional than a yr earlier to assist her dad and mom. She instructed me that Ramirez has been a blessing.

Doc had been Jo’s main caretaker till final yr, when he was recognized with congestive coronary heart failure. His organ operates at solely 20 % of its capability. He strikes with issue, utilizing a walker that Ramirez refers to as his “velocity buggy.” Doc, too, is now a hospice affected person underneath her care. She took his blood strain, checked his oxygen stage with a pulse oximeter, and examined his ankles for indicators of swelling.

Ramirez often makes use of a measuring tape to find out weight achieve or loss, which is simpler than getting sufferers with restricted or no mobility to step onto a scale. A rise in physique mass would possibly point out fluid retention and necessitate a change in medicine, whereas a affected person getting thinner may immediate her to advocate extra day by day meals. She additionally helps sufferers handle their medicines, usually distributing capsules into organizers for simple entry. She adjusts the positions of her motionless sufferers often to forestall bedsores.

Ernest “Doc” Reesing and his spouse, Jo, in her hospital mattress, at their house. {Photograph} by Hannah Gentiles

Ramirez went into the bed room to examine on Jo, who appeared diminutive, virtually swallowed by her mattress. Jo’s legs have been tucked up near her stomach, the best one wrapped in a wound dressing to stave off an infection. Her femur had damaged. Fractures are frequent amongst older adults, particularly ladies, whose bones have turned brittle. Jo’s break had penetrated her pores and skin, however given her situation, there was no technique to reset it.

Often, Jo would open her eyes, together with when Doc kissed her brow. “You’re nonetheless mein schatzi,” he mentioned, utilizing phrases he’d realized as a GI in Germany in the course of the fifties: You’re nonetheless my sweetheart. “She’s ready for him,” Carroll whispered to Ramirez, who nodded.

Together with his velocity buggy, Doc walked us out. He struggled to remain upright, steadying himself in opposition to the automotive within the driveway to observe till we’d left. In her line of labor, Ramirez will get requested the query quite a bit: How a lot time do I’ve left? “I’ve realized to say, ‘I’m right here for you so long as we’d like,’ ” she mentioned. “ ‘We don’t have a timeline.’ ”

This text initially appeared within the November 2023 challenge of Texas Month-to-month with the headline “To Dwell and Die in Far West Texas.” Subscribe in the present day.

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