The Nurse

Eleven Rooms

Chapter 15: The Nurse

Thea Andersen had been a hospice nurse for ten years, which meant she had been present for approximately four hundred deaths, which meant she had entered approximately four hundred rooms and found the breathing changed or the breathing stopped, which meant she had performed the pulse check and the pupil check and the noting of the time approximately four hundred times, the time noted in her careful handwriting on the chart, the time the official fact, the medical fact, the fact that said: at this hour, on this date, in this room, the dying was completed, and the noting was the act, the professional act, the nurse's final service to the patient, the service of recording, of making official, of translating the biological event into the documentary event, and the translation was precise because Thea was precise, because precision was the quality she brought to everything -- the medication dosages, the IV flow rates, the pillow arrangements, the timing of the rounds, the reading of the patients.

She read patients. This was her term, her private term, the word she used inside her own mind to describe the thing she did when she entered a room and looked at the person in the bed, the looking that was not casual observation but professional assessment, the assessment that took in the whole person in the first three seconds -- the color of the skin, the rate of the breathing, the position of the hands, the angle of the head, the tension in the jaw, the openness or closedness of the eyes -- and that produced, in those three seconds, a reading, a comprehensive understanding of where the patient was in the process, the process being the dying, the dying being the thing that the reading tracked, and the tracking was not measurement but perception, not data but knowledge, the knowledge that came from ten years and four hundred patients and the accumulated experience of a body that had spent forty thousand hours in the presence of the dying and that had learned, through the repetition of presence, to read the dying the way a musician reads a score, not note by note but as a whole, the whole apprehended at once, the reading instantaneous, the knowledge complete.

She read hands. The hands were the most reliable indicator, more reliable than the monitors, more reliable than the vital signs, more reliable than the charts that recorded the numbers and the dosages and the inputs and outputs that the medical system used to track the dying, because the hands told the truth that the numbers approximated, the hands displaying the patient's relationship to the dying in a way that was visible and legible to the nurse who knew how to look. A patient whose hands gripped the blanket was a patient who was holding on, who was resisting, who was not yet ready to let the dying proceed, and the gripping was a form of agency, of assertion, the hands saying: I am still here, I am still holding, I am still the person who holds things, and the holding was the identity, the last identity, the identity of a person who grasps. A patient whose hands lay open on the sheet, the fingers relaxed, the palms up, was a patient who had released, who had accepted, who had arrived at the place in the dying where the holding was no longer necessary, and the open hands were the signal, the visible signal of the invisible transition, the transition from the holding to the releasing, and the transition was the thing Thea watched for, the thing the reading tracked.

She read blankets. The way a patient held the blanket -- pulled to the chin or pushed to the waist, smoothed flat or bunched in the fists, tucked under the arms or draped loosely across the chest -- told the nurse the patient's relationship to comfort, to warmth, to the enclosure that the blanket provided, the blanket being the room's smallest room, the fabric enclosure that surrounded the body the way the walls surrounded the bed, and the blanket's position was the patient's statement about enclosure, about how much holding the patient wanted, how tightly the patient wanted to be held, and the tightness changed as the dying progressed, the blanket pulled tighter in the early stages when the body was cold and the cold was frightening and the blanket was the defense against the cold and the cold was the metaphor for the dying, and then loosened in the later stages when the body was past cold, past the temperature regulation that the living body maintained, the body's thermostat failing, the body finding its own temperature, which was lower, which was the temperature of a body that was between the living temperature and the room temperature, the body's temperature declining toward the room's temperature, declining toward the seventy-two degrees that Miriam had specified, and the declining was the convergence, the body's temperature and the room's temperature approaching each other, moving toward the same number, and when the numbers were the same the dying was done.

She had worked in three of Miriam's buildings. Willow Springs first, then Evergreen House, then briefly at Summit before returning to Evergreen House, and the working in Miriam's buildings had taught her the thing that she had told Miriam during the post-occupancy visit at Willow Springs, the thing about the buildings changing the way she cared, the thing about the wide corridors making her slower and the quiet floors making her quieter and the windows making her look, and the looking making her see the patients as people in light rather than as diagnoses in beds.

The seeing was the thing. The buildings made her see. The buildings, through their design -- through the proportions and the materials and the light -- created the conditions for seeing, the conditions in which the nurse could look at the patient and see not the disease but the person, not the chart but the face, not the diagnosis but the hands and the blanket and the angle of the head and the quality of the breathing, and the seeing was better care, was care that responded to the person rather than to the diagnosis, and the responding to the person was the thing that Miriam's buildings made possible, the thing that the architecture facilitated, the thing that the cork floors and the wide corridors and the east-facing windows and the nine-foot-six ceilings and the warm gray walls and the solid-core doors produced, not directly, not causally, but conditionally, the architecture creating the conditions for the care the way soil creates the conditions for the seed, the soil not growing the plant but enabling the growing, and the enabling was the architecture's contribution to the nursing, and the nursing was the architecture's test.

Thea was the test case. Thea was the building's user, the person who occupied the architecture more fully than any patient or family member, the person who spent twelve hours a day inside the building, who walked the corridors forty times a shift, who opened the doors and checked the monitors and adjusted the pillows and administered the medications and read the patients and noted the times, the person who knew the building the way a body knows a house, through the daily repetition of movement and use, and the knowing was comprehensive, was total, was the knowledge of every surface and every dimension and every sound and every smell, the knowledge of the building at two in the afternoon and the knowledge of the building at two in the morning, the knowledge of the building in light and the knowledge of the building in dark, and the two knowledges were different, were the diurnal and the nocturnal, the building's two faces, the building's two modes, and Thea knew both.

She knew which design decisions worked. The thirty-six-inch doors worked. She had worked in buildings with thirty-two-inch doors and the difference was not four inches but the difference between dignity and compression, between the patient entering the room and the patient being squeezed into the room, and the difference mattered, mattered to the patient who saw the doorframe pass close to their face as the bed angled through, mattered to the family who watched, mattered to Thea who guided the bed and who felt, in the resistance of the angling, the building's failure to accommodate the passage, and the failure was architectural, was in the dimension, was in the four inches that the architect had not provided, and Miriam provided them, and the providing was the architecture.

The cork floors worked. The quiet of the cork was the quiet that the dying needed, the quiet that said: the world is still here but the world is being gentle, the world is walking softly, the world is respecting your rest and your pain and your dying by not making noise, by absorbing the footsteps, by muffling the wheels, by softening the sound of the building's nightly business -- the rounds, the medication deliveries, the shift changes -- so that the patient could sleep, could rest in the threshold state, could occupy the between-space of the dying without the interruptions that hard floors produced, the click and echo that tile and linoleum sent through the corridors like announcements, like the institutional equivalent of a ringing phone, and the cork silenced these announcements, absorbed them, held them in its cellular structure the way it held the footsteps, quietly, warmly, the floor doing what Miriam had designed it to do.

The ceiling height worked. Thea had seen the difference. She had worked under eight-foot ceilings at her first job, a hospice in Salem that was a converted nursing home, the ceilings low, the rooms compressed, the patients lying under ceilings that pressed, that imposed, that said: there is nothing above you but this, this flat surface, this lid, and the lid was the ceiling's message, and the message was wrong, was the wrong message for the dying, and Miriam's nine-foot-six ceilings sent a different message, sent the message of lift, of release, of the space above the body that was not a lid but a sky, and the sky was what the dying needed, the openness above the body that compensated for the closedness within the body, the disease closing down the systems and the ceiling opening up the space, and the compensating was the design, was the architecture's response to the biology, the room rising while the body fell.

She knew which design decisions did not work. The fountain at Evergreen House did not work. The fountain was too loud, was assertive, was the sound of falling water imposing itself on the garden the way afternoon light imposed itself on a west-facing room, and Thea had told Miriam this, had said: the fountain competes with conversation, the fountain makes the families raise their voices, and the raising of voices is wrong in a hospice, the raising of voices is the acoustical equivalent of the eight-foot ceiling, the imposition of volume on the quiet, and the quiet should win, the quiet should be the garden's dominant quality, the way it was the corridor's dominant quality, and Miriam had listened, had catalogued the feedback, had designed the rill at Orchard House in response, the six-inch channel that was audible from three feet and inaudible from ten, the correction that Thea's feedback had produced.

Now Thea was in Room 6 caring for Lin. She was caring for the architect's mother in the architect's building, and the caring was the convergence, the point at which the nurse's knowledge and the architect's knowledge met, the point at which the user's experience and the designer's intention intersected, and the intersection was Room 6, was the room that Miriam had designed and that Thea inhabited and that Lin occupied, the three women in the room connected by the architecture, connected by the building that one had designed and one used and one was dying in, and the connecting was the room's function, the room's purpose, the room bringing together the designer and the user and the occupant in the same two hundred and forty square feet, the same nine feet six inches, the same warm gray walls, the same cork floor, the same east-facing window through which the morning light entered and fell on the bed and fell on Lin and was the light that Miriam had designed and that Thea worked in and that Lin received.

Thea read Lin. She read Lin every time she entered Room 6, every two hours during the day shift, every three hours during the night shift, the reading taking three seconds, the three seconds sufficient to assess the color and the breathing and the hands and the blanket and the jaw and the eyes, and the assessment producing the knowledge, and the knowledge producing the care, the care calibrated to the reading, the care adjusted to the patient's current position in the process, the process being the dying, and Lin's dying was at the stage that Thea read as threshold -- the stage between the active and the passive, between the holding and the releasing, between the hands that still gripped and the hands that would open, and the threshold was the stage that required the most attentive nursing, the most careful reading, because the threshold was the stage where things changed, where the breathing changed, where the hands changed, where the blanket's position changed, and the changes were the signals, the visible signals of the invisible transition, and the nurse's job was to see the signals and to respond to the signals and to communicate the signals to the family, and the communicating was the thing, was the nurse's last service, the service that said: it is time, come now, be here now, the breathing has changed.

She adjusted Lin's pillows. Four pillows now, the fourth beneath the knees, the arrangement specific to Lin's body, to Lin's pain, to the particular geometry of Lin's spine as it adjusted to the disease, and the adjusting was Thea's hands, Thea's knowledge, Thea's ten years of learning how bodies lie and how bodies need to be supported and how the support changes as the dying changes, and the changing support was the nursing, was the hands-on expression of the care that the architecture held, the room holding the care and the nurse providing the care, the room and the nurse collaborating, the collaboration the thing that Miriam had designed for without being able to design, because the architect could design the room and the room's conditions but could not design the nurse, could not specify the nurse's hands and the nurse's reading and the nurse's knowledge, could only provide the conditions in which the nurse's hands and reading and knowledge could operate, and the conditions were the architecture, and the architecture was the room, and the room was working, and the nurse was working, and the working was the collaboration, the collaboration between the designed and the human, between the built and the living, between the architect's intention and the nurse's attention.

Thea stood at the foot of the bed. She looked at Lin. She read Lin.

The hands were loosening. The hands that had gripped the blanket for weeks were loosening, the fingers relaxing, the knuckles losing their whiteness, the grip easing, and the easing was the signal, was the beginning of the release, the beginning of the transition from holding to opening, and Thea noted it, noted it in her mind, filed it in the professional catalogue that she maintained, the catalogue that tracked each patient's progress through the dying, the catalogue that was not written but remembered, held in the nurse's body the way the building held the patient, structurally, silently, with the patience of a thing that knows its purpose and performs it.

She would watch. She would read. She would be here, in this room, in this building, in this architecture that Miriam had designed and that Thea inhabited and that Lin was dying in, and the being-here was the nursing, and the nursing was the care, and the care was the room's purpose, and the purpose was being fulfilled, the purpose performing, the building and the nurse and the patient together in the room, the three of them held by the architecture, the architecture holding all of them -- the designer's intention and the user's practice and the occupant's dying -- held in the same space, in the same light, in the same walls, the holding the thing, the holding the architecture, the holding enough.