Wednesday, March 09, 2005

I Am A Witness

This week I'm putting a fair amount of energy into the care of one particular patient named Q. Q has a 10-year+ history of AIDS, Hepatitis C, depression, severe anxiety, a seizure disorder, and a history of IV drug use. She has wandered into and out of our care for the last 6 or 7 years, never staying long enough for treatment of her AIDS to be considered. Her immune system being very compromised, we have not even been able to convince her to take medication regularly that would protect her from myriad opportunistic infections to which she is quite susceptible. Basically, she's one of those people who we have always thought would become acutely and fatally ill, and then have what we would call a "deathbed conversion"---deciding in the face of most certain death that she's now ready to take meds, too little and too late.

That said, Q has resurfaced along with her daughter, begging for home delivery of her methadone since she is too weak to walk, having seizures daily, and losing weight rapidly. My job has been to "rope them in", assess their actual willingness to do the work that needs to be done. With the family history as it's known to me, I can't put too much stock in their potential for success, but I'm doing my part to coordinate the resources so that the mechanisms of the system are set in motion on her behalf. Pleading with me to come to her house for a visit, I've refused and insisted that they come to the clinic, trying not to make it too easy for her. Yes, she's weak, but not too weak to come to an appointment, and always willing to come if we dangle the possibility of a benzodiazepine prescription as bait. This may sound macabre or manipulative, but given the situation and history, we know that incentives and carrots can work wonders with addictive personalities.

Now that we have her ostensibly hooked into care and wanting more from us, we institute visiting nurse services so that the nurse can come to her home every day and physically watch her take her seizure medications, sedatives, and antibiotics to protect her from infection. The nurse has a lock-box in the home to preclude any shenanigans on Q's part in terms of adherence to meds. Next we arrange with the methadone clinic to have the visiting nurse deliver methadone to her home each morning---something she wouldn't miss for the world---thus ensuring that she'll be home for the nurse in order to avoid withdrawal from missing her dose. If she can hang in there for two weeks of this first round of intervention, we add HIV meds to the mix and we're on our way. It's a long shot, but it's the only game plan I have, or death is certain within 12-18 months, perhaps sooner.

Just three months ago, I attended the funeral of a patient who just could not muster what it took to overcome his addiction and his intellectual deficits enough to seize the opportunity for treatment. Ms. Q may be the next to vacate her physical existence, but I'm willing to give it a go first. Another of my patients of whom I'm exceedingly fond (and who is very much like Q in many ways, although much more intellectually savvy) has succeeded in breaking her addictions, and her HIV is now completely suppressed, her immune system almost strong enough to withstand most infections which might have killed her earlier. I would like to see Ms. Q follow in her footsteps. Only time will tell.

The stories are many and I could go on for hours, giving fifty or sixty very interesting and compelling case histories. The point I want to make, however, is that I'm simply a witness to others' pain and struggle. I can't fix anyone and I can't force treatment on anyone. I offer options and I hold out my hand. There are days when I personalize my work---and those are the days when I suffer emotionally and drag myself home, exhausted and spent. Sometimes I hit my stride for a few days and sail along with my witness self intact, watching the action but refraining from reaction to it. The dance is difficult and I frequently falter but I work with what I have and come home and charge those batteries.

Another day is behind me, and for this I give thanks and embrace the evening in peace.

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