Carrie, the wound care nurse, took me aside before she saw my patient. "You'll need to give her a couple of milligrams of morphine before I change her dressings," she said.
A couple of milligrams of morphine for a patient so light and emaciated I could lift her clear of the bed by myself? I raised an eyebrow and Carrie nodded.
I helped turn the patient, then moved to the other side of the bed so I could take a look at her decubiti while Carrie changed her dressings.
There were four spots where the soft yellowish white of bone showed through. Her buttocks were degloved of skin, as were her upper thighs. She was so thin that we could see the outline of her hip joints through the skin that had long since ceased to hang off her body. When someone is starved long enough, that flaccid look of quick weight loss disappears.
Her nephew, a twitchy guy with a constant sniffle and long sleeves even in August, had been caring for her for five years. According to the other nieces and nephews, he didn't feed her often enough or take care to clean her up more than once a month. I don't remember why she ended up with us, or even what her diagnosis was, but he'd come along with her and spent all of his time in her room, sitting on the couch.
Later that day, after the pain of the dressing changes had worn off, I helped bathe her. And noticed old burns, about the size of a cigar end. And old scars, from God only knows what, on her arms and lower legs. And bruises. Of course, she'd bruise from the slightest touch, but still....
So I called Adult Protective Services. I told them what I'd seen and got transferred to a geriatric nurse case-manager, who'd actually know what I was talking about. She agreed that it was time somebody checked out the living conditions this woman and her nephew had and told me they'd send somebody out in a week, after my patient had been discharged and had headed home.
A month later the patient was back. This time she ended up on a different floor for what was basically in-house hospice care. She died less than twenty-four hours after being admitted. The cause of death on the medical examiner's certificate was listed as heart failure. The examiner noted that the patient was emaciated and that her alimentary canal was completely empty, and postulated that an electrolyte imbalance brought on by dehydration and starvation had stopped her heart.
The APS people were nice enough to contact me a few days later and tell me that they'd found no evidence, on a home visit, of abuse or neglect. The nephew had told them that his aunt was sleeping and was not to be disturbed, so they interviewed him alone.
They told me to contact them if I had any further concerns and gave me a case number. I thanked them, then suggested that they concentrate their efforts on the clients who were still alive.
Her family had known about this for five years. She was in our hospital the first time for two weeks. I was the one who called APS, two days before her discharge.
This is the sort of thing nurses have nightmares about.