One of Marylou's primary physicians spent a great deal of time with me via telephone and email while Marylou was in the hospital. She was very supportive of us taking her home but then on Tuesday I received this email from her:

Julie
We had our team meeting today. I also had an opportunity to read through all of her clinical notes from the past couple of weeks. The consensus among the physicians and team is that MaryLou's condition is probably too demanding for you to care for her in the home environment. You would need a team of caregivers in the home, and that is not even taking into consideration caring for your toddler and yourself during your pregnancy. THe pulmonary doctor, cardiologist, and plastic surgeon all commented in the notes that they felt she requires more care than could be given in a home. There is concern again that her wound is deteriorating in spite of all our best efforts. We will have to wait for the plastic surgeon's recommendations which were not in the chart yet this afternoon. As far as her anxiety, the psychiatrist and Dr. Olson made some changes in her medicine over the weekend and she said she is feeling MUCH better. She reports that her pain is well controlled. She discharged the physical therapists again but is willing to work with the O.T. folks on feeding and basic grooming. She says she would like to be able to walk and get about, but doesn't think that is realistic. She just wants to be out of pain and well cared for. You and your family probably need to meet and encourage her to tell you what she really wants for the near future. She knows that you all care for her deeply and will do what is best for her.
I wish that there were more we could do to restore her to her prior level of function, but we have had every type of specialist see her to optimize her situation, and she is not improving with her nutrition, wound, or ability to function.
I sincerely hope this information is helpful to you, and you can hear it with the great compassion with which I send it.
Best,
Laura Kezar, MD

My husband and I both responded. My e-mail:

Dr. Kezar,

My husband and I just want what is best for her. I do
know for certain that she desires to live with us. I
also understand that she may be bedridden for months,
if not for the rest of her life. We desire her to be
comfortable and at peace. Part of her anxiety stems
from being alone. I want to alleviate that. I think
that just knowing that we are around will give her a
great deal of peace.

I am not only a stay at home mom and an RN who would
be able to spend my days at home to tend to her and
assess her as needed, but the Lord has also given me
the desire to care for her and a heart for service.
My husband will be at home every evening and on the
weekends to pitch in with everything. We can and will
provide sitters as needed. My understanding is that
Medicare will provide the needed medical equipment and
the nursing care/OT/PT in the home.

We are willing and prepared to modify our lives in
order to have Marylou with us. James has already been
looking at houses with a Mother-in-Law suite, I have
already been thinking about the logistics of taking
care of Marylou and Nathan during the day - such as
feeding them both at the same time in her room.

I do understand and respect the concerns of the
medical team. Are they concerned that doctors will
not be monitoring her on a regular basis like they are
now? What do they propose? A skilled care nursing
home? Marylou does not wish to live there. I talked
to you and the case manager about this before I ever
brought this up to Marylou. Yall seemed supportive of
this option. I am confused and discouraged - she is
excited about coming.

I don't mind being busy all the time. I don't mind
going to bed dog tired at night. I don't mind asking
for help when I need it. I believe we can make this
work. Will it be hard? Heck yes, but I think we
deserve a chance.

I have prayed and prayed that if this is NOT the
Lord's will that this will not happen. I have shared
with you our willingness to make sacrifices in our
life and my realization that yes, this is going to be
a major change and lots of work. Please share this
email with whoever you choose - if you even feel it
necessary.

Please respond as soon as you can.

I will be at Select tomorrow to spend time with
Marylou - I plan on being there from 7:30am till
around 1:30 pm.

Thank you again for your time. Julie Foster
--------------------------------------
And James' response to her:

Dr. Kezar,

This is James, Julie�s husband. First, I want to thank you for the
level of communication you have afforded my family in regards to Marylou�s
care. The time you have taken in the past few weeks is much
appreciated.

I was initially not open to Marylou being in our home, but after taking
into account her condition, her desires and how important she is in my
life, I am now more than willing to give her a shot at getting better
in a more suitable environment.

I read your email to Julie concerning Marylou coming to live with us in
Pensacola. I am a little concerned first in that the team�s conclusion
seems different from Dr. Olson�s. I spoke with him on the phone
Saturday evening and I understood that it was his feelings that as long as
the wound care was manageable then he was ready to discharge her; he said
even as early as the end of this week.

Additionally, I got the feeling from your email that you were concerned
about us having a toddler and new baby on the way. I feel that the
team needs to look at home care and its overall benefits and not home care
specific to Julie and what you perceive are negative circumstances as
far as being �too demanding.� We have not entered into this decision
lightly and would not have offered had we not had the confidence in
ourselves and Marylou that we could do it.

There are no other options on the table at this time in our family for
home care. I am a certified EMT and Hospital Corpsman in the Navy and
as you know Julie is a nurse. We can provide a level of care in a home
that most cannot. We will also use many outside resources in Marylou�s
care; qualified sitters, in home OT, wound care specialist, etc.
Marylou has expressed her desire to not go into another facility after
Select. Our home is all one level with all doors being wheelchair
accessible.

I�m not necessarily trying to make a case for Julie and I, but it has
been my understanding all along from you and your team, that Marylou
needs something to look forward to, motivation to do therapy, engagement
in a non-hospital environment and to be around family in order to have
the greatest chance for improvement.

I disagree that Marylou�s condition is too demanding for home care,
rather, the longer she stays in that room, the slower her progress will
be. She will not refuse OT for me and Julie, being around her
great-grand-children lights up her spirit and the one thing she is most excited
about is being with her dog, Blossom, again. We�ve had her since my
grandfather died and she misses her a great deal. The healing power of
being in those circumstances has got to be a priority.

Sincerely,
James Foster

She then sent each of us a response on Wednesday (the day before Marylou's death):

Dear James
You are very welcome for the time I have spent with Marylou and
talking/emailing with you guys. I certainly think that we could have
all reached a consensus on what was best for Marylou had we been able
to
sit down at a table to talk in person. Email is never a good way to
communicate about such important matters. Unfortunately, the
circumstances are such that it is our best option for now.
Please do not read anything judgmental about the prior emails. I was
trying to summarize many pages worth of clinical notes and several
different discussions into something that could be communicated by
email. All of the different doctors put their opinions in the chart,
and I was trying to synthesize the different concerns.
After receiving Julie's last email, I feel totally reassured about your
ability to care for Marylou in your home. I sense your commitment, and
I believe that you have a thorough understanding of the complexity of
her care. I also think that the two of you are uniquely qualified to
do
this. As you might imagine, most people would not have the ability to
care for a family member in this condition.
We were not saying that having children in the home is a negative
factor. I think several team members just worried that it might be
overwhelming for Julie at a time when she needs to take good care of
herself and the children. Based on what you guys have told me, if it
becomes overwhelming you will be able to get more help.
Based on all you and she have told me, I think that your home will
provide Marylou with the best chance for a good recovery and quality of
life. I believe that being around you and your children and her dog
may
entice her to become more active so that she can enjoy her life more.
She is such a remarkable woman. Many of us feel drawn to her because
of
her charisma and strong personality. We all want what is best for her,
and I now agree with you that going to your home is best. It is not
what is easiest, but it certainly looks to be what is best. She is
blessed to have family like you. I feel fortunate to have known you in
this small way. It gives me a sense of hope for some of our other
patients at Select.
Laura Kezar, MD

Julie

Please do not be disapopinted or confused. I just felt like I needed to be completely frank with you, and I knew we had a relationship that would allow that honesty. Hearing these things in your email helps me to realize that you have thought this through very carefully and you have the knowledge, skill, motivation, and personal calling to follow through on this. I can't say that I have ever dealt with a family member as knowledgeable and motivated as you and your husband. I am glad to hear that you will be okay with Marylou if she just wants to be comfortable in the bed, surrounded by people who love her. I think she feared disappointing you if she did not get back on her feet. It sounds like you are willing to honor whatever are her wishes.

I suspect the other physicians also feel that you are like most of the other folks we deal with, who have no idea what they are getting into. If they had a chance to meet you and talk with you, I bet their concerns would be allayed.

The most important thing is to do what Marylou wants, so if she wants to come to your home, then we will support that. We can meet with you for any family teaching you will need and we will make sure you have appropriate equipment in your home. We will just need to make arrangements for your education, although I doubt there will be much that is new to you.

My prayers are with you and your family.

Laura Kezar
_____________________________________

Almost all the family was in agreement about her coming - all except James' parents. We are dealing with this issue as best we can right now.

I gave all that background to explain to anyone who reads this a sense of how very much I wanted to help Marylou. Up until a few hours before her death on Thursday, she expressed a desire to get well and keep on keeping on. I was willing to fight tooth and nail for her until the time came when she told me that she was all done fighting.

This is my account of her final day - which I will be forever grateful to have been a part of. My Lord God is an awesome God. He is soverign and holy. The way I am going to share that day is by attaching the e-mail I sent to Dr. Kezar this morning.

Dr. Kezar,

Thank you so very much for your kind words. I also
thank you for the very supportive e-mails to James and
I on Wednesday regarding taking Marylou with us to
Florida. We felt confident and at peace with the
decision to bring Marylou to Pensacola.

The BEST possible scenario happened for Marylou on
Thursday - she went to be with the Lord. She is now
healthy, whole and in complete peace.

I was given the greatest gift of all on Thursday - the
distinct and rare privilege of being with her on her
last day here on this earth.

I had such peace in my heart as well as in my mind
while driving to Bham from Montgomery that morning (my
sister-in-law was taking care of my toddler for the
day while I spent the day with Marylou). I arrived to
Marylou's room at 7:15am. I was concerned to see the
edema in her extremities. I joked with her that she
was going to make me come to Birmingham every day if
she kept that up. She laughed. She said it was a
good thing that I was there so I could get to the
bottom of it. I laughed. I asked her if she was
ready to go to Pensacola. She said yes. I asked her
if she thought she could tolerate the 4.5 hour
ambulance ride. She said yes. I joked that maybe
they could turn on their sirens and make the trip in
2.5 hours. We laughed. Our early morning time was
normal - except for the edema, her weakness, and her
cough which sounded much worse than it did the
previous Wednesday when I was there. Although I
offered her breakfast, I knew it was not important
that she declined. She was having a hard time just
swallowing water. I asked her if I could change her
brief. I knew it would be more difficult with all
that water weight. We managed just fine. She helped
as much as she could and I was confident that I would
be able to handle it at home if she still had that
water weight when she came to Pensacola.

Soon Ann, Dr. Olson's nurse, came by. We had a nice
visit with her. I followed her out when she left the
room and told her that we were going to take Marylou
home with us. She was supportive. More confirmation
that made me feel even better about it.

Then Dr. Kelley came by. He struck me as an
interesting man. He was very nice and didn't mind all
my questions. We didn't talk about anything 'serious'
in front of Marylou. I followed him out also and told
him of my desire to take Marylou home. We addressed
all the needs she would have and he too, gave me a
positive response. I learned that he went to
Dartmouth college for his undergraduate degree. I
told him that I had worked in the PICU at Dartmouth
for 2 years. I learned he lived in Pensacola for 26
years. I asked him about referrals for doctors for
Marylou. He was quite helpful. I was so very
encouraged. Then he asked me why I was taking her to
Pensacola. I told him that I felt that it was her
only chance at getting better. I told him that yall
felt that everything that could be done for her had
been done and I wanted a chance to take care of her.
He then proceeded to tell me that she wasn't going to
live much longer. I didn't argue, but I said that
there was a chance she could, given the right
circumstances. He said that in his 35 years of
practice he didn't give it much of a chance. I asked
him how long he thought she had to live. He said 3-4
weeks at the most. I was surprised to hear that, but
I accepted what he said as a possibility. He started
asking about her code status. I told him that she was
a full code but that she signed a living will and that
if all that could be done had been done she wouldn't
want to be kept alive. He told me that we needed to
think about changing her status to a DNR. I told him
I would think about that. I heard Marylou's voice at
that time and went into the room. She said she felt
sick and was going to throw up. She was already
positioned on her right side and sitting up high
enough - so I grabbed a bucket, a wet wash cloth and
was able to help her through that episode without too
much difficulty. I remember thinking at that VERY
moment that it would be a good idea for Marylou's room
to be in the 'Florida room' of our house because I
could hear her call if she were to get sick and I was
in the kitchen cooking or in the living area with the
kids. Once again, I felt even more peace and
confirmation that I could indeed handle it in
Pensacola if she were to get sick like that sometimes.
She felt better after she threw up. The nurse gave
her some IV phenegren and she was out like a LIGHT. I
tried several times to wake her and get a response out
of her. She would kind of open her eyes, but
wouldn't/couldn't answer me at all. The nurse assured
me that it was the medicine and that in an hour or so
she would be awake. I even went to find Ann, Dr.
Olson's nurse, while Marylou slept to have
confirmation. I found her and got that confirmation.

I went back into the room and just sat and waited for
her to wake up. I called my husband and told him
about her swelling. He had just been there to see her
on Saturday and Sunday (mothers' day). He said she
did not look to be swollen at that time. We chatted a
bit then I got off the phone. Mentally I was thinking
about all the things I could be doing at home while
she napped. I could have changed a diaper or two,
cleared the breakfast dishes, started a load of
clothes. Heck, I was going to have some free time.
After about 45 minutes (about 10:30am) after the first
time she threw up, I decided to reposition her and
give her a bed bath. I thought that might stimulate
her and wake her up. I was in the middle of her bath
when she did wake up. The first words she spoke to me
were, "let me go.", "Please let me go." I asked her
where she wanted to go. She said, "let me die." I
was surprised, but not shocked. I told her that she
could go - anytime she needed to go. At first, I was
thinking that she was just confused. The nurse had
checked her vitals while she napped from the
phenegren. Her O2 sat was 96 and her pulse was 113.
In my head I knew she wasn't going anywhere of the
sort, but I went along with it - just in case. Then
she began to speak the same words but with urgency. I
prayed for her. She responded to the prayer, saying
"In Jesus' name, Amen" and "God's will be done". I
called her stepson, Jeff (who is also a pastor) and
told him what was going on. He said he would be there
later to pray with her. I proceeded to tell her that
it was fine to let go - I asked her if she had changed
her mind about wanting to live. She said yes. She
then started telling me to, "move it." I discovered
she was talking about the wedge keeping her on the
right side. I removed the wedge so she was on her
back with her head still elevated. I asked her that
if something were to happen to her would she want to
be on a ventilator. She said no. It kind of got a
bit funny - I had already prayed with her, I had
already told her several times that she could go any
time she wanted. I asked her if she felt that the
Lord was calling her. She said yes. I said, "you
mean like today, tomorrow?" She said today. I was a
bit bewildered but started to realize that maybe it
was time. I continued to pray and I told her how
loved she was and how thankful I was that she was a
part of my life. At one point when she said to let
her go I actually stepped away from her bed and said,
"goodbye". She said, "goodbye" too. I just stood
there for a few seconds, felt a bit silly, then walked
back up to her bed and put my hand on her leg. She
opened her eyes and said, "I'm not gone yet". I
laughed and said, "Marylou, it's not up to me. It's
up to the Lord. It will be in His time and I don't
think it is going to be today". It wasn't too long
after that that my husband called. I told him what
she was saying and he wanted to speak to her. I held
up the phone and Marylou told him she loved him. She
answered yes to a few questions and then she told me
she was going to be sick again. I grabbed the bucket,
pulled her over as much as I could toward me on her
left side and she threw up again. This time it didn't
all come out. I heard gurgling in the back of her
mouth. I couldn't pull her over any more, I think I
was hurting her by how much I had pulled her over
already. I eased up on my grip on the back of her
right shoulder. I knew right then that it was likely
that she would indeed go to be with the Lord that very
day. I called my Mother in law and said something to
the effect, "if something happens with Marylou right
now, would you be OK with it if I don't let them put
her on a ventilator?" She said of course and asked if
she should come to the hospital. I said yes and to
call everyone to come that could come.

It was about 2:20 when she peacefully passed out of
this world. She said no to nausea medicine and no to
pain medicine when I asked her after she threw up that
second time. Her pain patch had been taken off
sometime in the night due to the possibility of resp
depression during sleep. She died peacefully. No
moaning, no groaning, no grasping for breath. She
just breathed for a couple of hours and then stopped
breathing. It was beautiful. Her sister, her three
step children, her pastor, my father in law, and I
were there with her during that time.

I spoke to Dr. Olson yesterday morning. Although I
knew beyond a shadow of a doubt that what happen on
Thursday was meant to happen just the way it happened,
I starting experiencing some guilt. Did she aspirate
and die from that? What if I had gotten her way over
on her side to throw up, what if this, what if that?

Dr. Olson assured me that her heart had been showing
signs of distress over the previous few days. Dr.
Russell had heard something (a rub?) and that her
edema was due to her heart not pumping like it should
have. He also told me that the nausea and emesis
might have been associated with an MI.

I feel better knowing all that. I suppose that is
selfish of me - to want confirmation that something I
did didn't cause her death prematurely. It is my
nature to over analyze and question everything.

I have peace though. I have joy and satisfaction
knowing that she responded positively from our time
together during her final weeks of life. Spending
time with her brought me more joy and satisfaction
than it could have ever brought her though.

Her funeral is tomorrow (Wednesday)- 10am at Jefferson
Memorial on Hwy 150 in Hoover. I know you have clinic
but just wanted you to know when it was so you can
think about her at that time if you are not too busy.

Thank you again, Dr. Kezar. You made such a
difference. She thought very highly of you - as do I.
She had such trouble remembering your last name
though. It brings a smile to my face to recall her
struggling with it - Dr. Keister (one of my favorite
wrong pronunciations of Marylou's.)

Life goes on here - I feel a little empty but certain
that she is in a much better place.

I feel that the Lord planned what was to come that
day. He spoke to my heart through Dr. Kelley and
prepared me ahead of time. He also placed Karla, a
respiratory therapist, behind the curtain to work with
Mrs. Bray while Marylou and I had that conversation.
Karla heard everything. I was so wrapped up in our
little world that I had no clue that anyone was in
there. She was my 'witness' for when I told Joyce
(the charge nurse) not to take action once they
discovered her rapid decline. She came out of nowhere
and said, "I heard their entire conversation. She
told her granddaughter that she was ready to go. We
don't need to do anything."

The Lord also that I needed to see and experience all
this with my own eyes and heart and mind. I am a
doubting Thomas. I would have forever wondered what
had happened and whether or not someone screwed up.
The Lord provided me with all the proof I would ever
need that Marylou was indeed ready to go be with her
maker. I had always told Marylou that I would respect
any decision she made. She had talked about wanting
to keep living up until that very day.

I know this has been long and there is probably lots
more I could share, but I feel that it is mostly
covered.

Thank you again.

With sincere gratitude, Julie

_______________________________________

So there you have it. I have been forever changed by this experience.

Her funeral is tomorrow morning at 10am. James, Nathan and I will leave for Bham around 4 this afternoon.

The funeral will be a celebration of her life with a strong presentation of the gospel.

Marylou lived a full life in the Lord. She thrived on His word, she depended on Him for everything. I am honored that I was given the opportunity to be with her during her last day on this earth.