Sometimes things get really hard.

Sometimes it's really, really hard to view patients as people. Sometimes you just want to smack them instead.

When you meet somebody who is so very unpleasant in every way that being around them makes you want to take a shower with Brillo and then bleach your brain, it's hard to remember that you're there to help. It's hard to remember that your help is not contingent on their helping themselves; it's to be given, period, full stop, without conditions.

We had a patient years ago who was one of those brain-bleach folks. She was bitter, angry, mean...you name it, she'd say it to you. She couldn't strike out physically, so she was nasty with words and bodily functions. She weighed in at a little over five hundred pounds and refused to do anything at all for herself, from answering the phone to cutting up her own meat. Turning her was an adventure we had to undertake several times a day, dressed in rubber gowns, as she'd defecate and urinate on herself and others during the process. She was an absolute frigging nightmare to deal with, and ran through every nurse on the floor in a matter of a couple of weeks.

She was also a "private-pay" patient, which meant she was essentially there through the charity of the hospital. Private-pay patients are either very rich or have no money whatsoever, but we take care of 'em all without asking details. 

Most of the time, the nurses at our facility have no idea what financial arrangements our patients have made; that's handled by the folks in the carpeted areas. In this case, though, it was different, because this particular patient needed a long series of IVIG infusions. IVIG (intravenous immunoglobulin) is hideously expensive--about ten grand will buy you a liter, depending on market rates, and the average person needs several liters over several days to complete a course of treatment. 

This particular patient had already been through two other treatment options, both mindbogglingly expensive, on our dime. The question now was whether we could afford to continue treating her when the expectation of full functionality returning was slim and her commitment to her own care was nil. We all had to sit down as a group and talk about the ethical quandaries involved in treating/not treating her.

We ended up treating her, period, full stop, and rehabbing her for several months at no cost to her.

She was brought up this week by a pal of mine, as a contrast to another patient we'd had recently.

The recent patient was one of those folks you can't help but love. She was also a charity patient, but couldn't have been more different from the first woman. She was funny, and smart, and sassy, and sweet, and had a perfectly treatable tumor on her brainstem. It had affected her ability to move, but not her brain. She worked hard to regain the functionality she'd lost, insisting on feeding herself even though it took a long time and she tended to be messy. She had a small, tight-knit group of friends who came every day just to hang out. She had good family support and had managed to make every single treatment appointment she had.

She died a couple of weeks ago. The carpeted folks decided we could no longer afford to continue to treat her tumor, and she didn't have any other options. She died with her mental faculties intact as her body shut down.

These are the sorts of scenarios that make you want to just sit down and not move for about a year. The first patient got treated, at the cost of Frog only knows how many millions of dollars and how many shreds of patience, for *months*. She got that treatment because, at the time, the economy was going full-bore and the carpeted folks figured we could afford to spend money on somebody who wasn't compliant with her treatment plan or her own care. 

The second patient died because money got tight. She had a much better potential outcome than the first patient; it was only her timing that sucked.

It would be easy to throw my hands up in the air and say, "Fine. You don't wanna take a hand in getting better? Then we won't treat you. Work with the physical therapists and quit spitting at the nurses if you want your IVIG this week." It's easy to feel that People Like That somehow are less deserving than Nice People, even if what they're less deserving of is lifesaving care.

Then, though, you're faced with the question of where to draw the line. Long-time smoker and drinker? Fine: you can die of esophageal cancer, and it's all on you. Pregnancy-induced hypertension? Fine: go ahead and get eclampsia, you fat pig; you should've been skinnier before you got knocked up. Brain tumor of a strange and rare sort? Fine: obviously, you have bad kharma. It's easy to see where blaming people leads.

I've been thinking about this for a few days, now, and I haven't come up with any solid solutions to this dilemma. Should we make compliance with care a prerequisite to receiving that care in the first place? Should we force patients to sign something? Play nice? Be pleasant? At least give a damn? Can we realistically do any of that? 

And then, on the micro level (as my sociology prof used to say), you get the problem of providing care to somebody that you, personally, would rather leave out on an ice floe. I got cussed at, screamed at, and peed upon by a person whom I'd'a rather just left alone, but I had to deal with all of that because I have a commitment to taking care of people, period, full stop.

It's never easy to do this stuff for a living, but this last couple of weeks have reminded me how very hard it sometimes gets.