SOUTH HADLEY, Mass. It was early November when Martha Keochareon called the nursing school at Holyoke Community College, her alma mater. She had a proposal, which she laid out in a voice mail message.
I have cancer, she said after introducing herself, and Im wondering if youll need somebody to do a case study on, a hospice patient.
Perhaps some nursing students just want to feel what a tumor feels like, she went on. Or they could learn something about hospice care, which aims to help terminally ill people die comfortably at home.
Maybe youll have some ambitious student that wants to do a project, Keochareon said after leaving her phone number. Thank you. Bye.
Kelly Keane, a counselor at the college who received the message, was instantly intrigued. Holyokes nursing students, like most, learn about cancer from textbooks. They get some experience with acutely ill patients during a rotation on the medical-surgical floor of a hospital. They practice their skills in the colleges simulation lab on sophisticated mannequins that can die of cancer, heart attacks and other ailments. But Keochareon, 59, a 1993 graduate of Holyokes nursing program, was offering students something unique: an opportunity not only to examine her, but to ask anything they wanted about her experience with cancer and dying.
She is allowing us into something we wouldnt ever be privy to, Keane said.
So it was that a few weeks later, two first-year nursing students, Cindy Santiago, 26, and Michelle Elliot, 52, arrived at Keochareons tiny house, a few miles from the college. She was bedbound, cared for by a loyal band of relatives, hospice nurses and aides. Both students were anxious.
Sit on my bed and talk to me, Keochareon said. The students hesitated, explaining that they had been taught not to do that, to prevent transmission of germs. What they knew of nursing in hospitals Im here to take your vitals, give you your medicine, OK, bye, as Santiago put it was different, after all.
They had come with a list of questions. Keochareon was suffering from pancreatic cancer, and they had researched the disease ahead of time. They were particularly curious about why she had survived for so long. She had lived with her illness for more than six years an extraordinary span for pancreatic cancer, which often kills within months after diagnosis.
Why, the students asked, had she managed to keep eating and keep on weight? What was she taking for the pain? How long had it taken for doctors to diagnose her?
For Keochareon, this was a chance to teach something about the profession she had found late and embraced she became a nurse at 40, after raising her daughter and working for years on a factory floor.
When I was a nurse, it seemed like most of the other nurses were never too happy having a student to teach, she said, lying in her bedroom lined with pictures of relatives, friends and herself in healthier times. I loved it.
A LAST PROJECT
Now, her disease left her passing the days watching Animal Planet, reading a book about heaven and calling friends so much that her cordless phone never left her side. She also was planning meticulously for her death, down to the green wool cardigan and embroidered shirt she would be buried in. But Keochareon wanted more as she prepared to die. The project she envisioned would be not just for students, but also for her a way to squeeze one more chapter out of life.
In their conversations with Keochareon, the students learned that her symptoms had included a burning sensation after eating, for which doctors prescribed an acid blocker. Then came wrenching abdominal pain, which she said doctors dismissed as psychosomatic. She also developed diabetes, another potential sign of pancreatic cancer, and itchiness, possibly from blocked bile ducts.
In 2006, after she had felt sick for several years, a doctor finally ordered a CT scan, and the cancer was diagnosed. Keochareon was 53 and working in Charleston, S.C. She was told she would probably die within a year or two.
Santiago and Elliot were outraged. But they were surprised, they said, to learn that instead of anger or shock, the first emotion Keochareon felt after her diagnosis was relief because she finally knew what was wrong with her.
The best advice she could give future nurses, Keochareon said in her reedy voice, was to just dig a little deeper you know?
LET THE PATIENT TALK
At her request, the students kept visiting. The sessions provided a brief respite for Keochareons caretakers, including Roy Christensen, a cousin who moved back from Texas last year to help, and Peggy Casey, her favorite aunt.
At Keanes urging, the students eventually stopped asking questions and practiced what she called therapeutic communication.
The way weve learned in school, and havent applied enough, is just saying, Im glad to be with you; you must be frustrated; you look uncomfortable, Keane said. And let the patient just talk and talk and talk, and see where theyre at.
On a bright day shortly before Christmas, Keochareon had less to say than usual as Santiago perched on her bed.
You look good, Santiago said softly after they had chatted for a bit. Keochareon was clearly in pain; she mustered a brief smile and closed her eyes.
Im ready to go, Keochareon told her, opening her eyes again.
Santiago paused. Aw, she said, patting Keochareons hand. Well
Dont feel bad, Keochareon added.
I know, Santiago said, shaking her look of concern into a smile. I know.
RUNNING OUT OF TIME
Later that afternoon, Christensen, her cousin, called with an update. Keochareon had asked for an intravenous sedative that would make her sleep, delivering her from the mounting pain. That mornings visit, it turned out, had been the last.
Elliot, who had planned to visit Keochareon after her shift that day, regretted not having asked more about how she felt about death.
She already seemed to be at that spot where she had that inner peace about it, Elliot said. You want to ask them the questions: So what does it feel like to be dying? Do you know something we dont know?
Keochareon died nine days later, in the evening on Dec. 29. Christensen had asked her to wait for snow; nearly 6 inches fell that night, the first of the season. Only her husband was there for her death a consequence of the weather, but perhaps also part of her plan, Christensen said.
At the funeral, Keochareons sister Ruth Woodard spoke in her eulogy about just what prompted Martha to offer her situation up as a teaching tool. Keochareon deeply wanted nurses to understand her illness from the patients perspective, she said. But that was not all.
I notice that every time that Martha gave of herself she received far more, Woodard said. In fact, she received a few moments of less pain and I suspect that she received life itself a few more hours, even days, with purpose.