Wednesday, June 10, 2009

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, 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.


Anonymous said...

My personal opinion, based on 40+ years as a RN, is that ability to pay should not be a determining factor in whether care is provided or not. However, you also shouldn't be able to buy care that is not available to the average person. Example would be the ability to go to the front of the line for an organ transplant because you can pay as oppossed to being at the front of the line because you have the greatest need.
I also believe there is an end point and transplanting a 85 year old for millions of dollars that could be spent on immunizing thousands od children should also not be an option.

danielle said...

I personally have had to fight the insurance company to cover visits. I would like to know the medical education that is required to say NO - oh, I get it - NONE!!! Maybe a HS diploma????? I say that only because they obviously knew how to use spell check when they wrote the letter. Luckily I won....but my point it - the power that is given people over other's health and well being is not equitable. All Ican hope is that karma does come to visit them.

One Nurse said...

I have had a difficult patitient that remarkably could be your patients twin. It was probably the hardest thing I ever did, taking care of her and doing it without judgment. Although I will admit some days I had alot of judgment!! I work at a hospital that deals with alot of charity care. I am pleased to say that I have seen in my 6 years at said hospital, each patient gets equal opportunities for care and treatment. However I have also been places that are not so much like that. It is disturbing! It is also hard to see things like this happen, the grateful patient loses and the mean, hateful and unappreciative one wins.
Make our job all that more difficult!!!


A great post, well written. It isnt acceptable for patients to act that way at all.Instead of being all bitter and people hating she should be helping herself, she is basically committing suicide by being so obese to begin with.
Half ton hospital may have been a better option for her.

On the flip side sometimes though it doesn't matter how compliant, or behaved a patient is your going to meet equally bitter nurses who have issues also. In either case its wrong to treat people like crap.

If we matched up the nasty patients with the nasty medics, maybe they will balance each other out? lol.

Reality Rounds said...

This is interesting. I often think of the people waiting months for a liver transplant. They have to be free from alcohol and drugs, or they will be taken off the transplant list. But once they get that new liver, they can pretty much do as they please, and a lot continue to drink.
As far as fairness of treatment, I have also thankfully, only worked at places were money really did not come in to play. The rich patients may have had some more VIP perks, but they certainly were not put ahead of anyone else when it came to treatment.

Anonymous said...

Thank god I live in Canada. Sure we have issues with our health care system, but we don't have these sorts of terrible scenarios.

Deana said...

I agree - excellent post.

I am a brand new nurse and can see already that I will have to work quite hard to avoid being judgmental.

I truly admire your ability to step back and think about it in a sane manner. I don't think the general public has any idea how nasty some of the patients are that we must care for.

Rockenheimer said...

You're a beautiful human being, kid.

KT said...

I actually said this earlier at Nurse K's blog, why should we help someone if they refuse to help themselves?

If only it was that easy. =/

Maybe it would have made a difference if she hadn't shit and pissed on you and verbally assaulted you. A smoker with lung cancer? Fine, as long as they don't verbally assault me and cover me in bodily wastes.

But now I'm going to be grateful I'm in Australia where health is "free" and will (hopefully) never have to see someone die because somebody's cut off their funds. That is truly appalling.

Jennifer said...

"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?"

Not at the moment,.....but give it a year or two,....I'm certain it will be, yet another requirement nurses have to implement!

OB Kenobi said...

I feel your pain, and agree that the whole idea of who gets free care and who doesn't is mind boggling as well as disturbing. I do have to take issue with one statement. "Pregnancy-induced hypertension? Fine: go ahead and get eclampsia, you fat pig; you should've been skinnier before you got knocked up. " In all my years of working with pregnant women, there have been as many 'average' sized women with PIH, if not more, than "fat pigs".

shrimplate said...

I've worked with a couple hundred bariatric surgery patients over the years, and they are pre-screened and trained for compliance.

One of the surgeons, a brilliant older guy, said that morbid obesity is one thing and we all understand that, but there's usually something going on above and beyond that which gets people into the extremely high weights.

A 5'4" woman who weighs in at 350lbs is morbidly obese. A woman of the same height who has accumulated 500lbs is a different sort of cat.

Michaelle said...

I just found your blog and let me say, I hear you. I have been a nurse for 16 years, and have been there and done that.

Anonymous said...

I'm actually a PCT now, but I definitely relate to this post. Last night I had an amputee who was soiling himself in some of the most foul smelling stool I've smelt since I've starting doing this (about a year), and he was truly the most nasty patient I've ever had- and it wasn't the dementia kind of nasty, that I can handle, that I know, at least, is not within his control. He was a man in his 70s, and with his mind. I went into his room and said something to him. He asked me to repeat myself, so I raised my voice, thinking he was having a hard time hearing me. He yelled back at me, a lot louder than I had been speaking to him, "You don't have to scream! I'm not deaf, but I will be if you don't stop talking like that!". Later on he almost punched me out while I was wiping his feces from his rear-end, and he would frequently call me and his nurse incompetent and question where we got our medical training, teaching us how to do what. It was very hard to keep my composure.

As for the ones who have 'done it to themselves'... hey, they're the ones keeping us in business! At least that seems to be the case on my floor, but I work on a cardiac step-down, where you occasionally get pts with just bad hearts, but the majority of them ate, drank, or smoked themselves into the condition that they are in.