I've sent my second patient in as many months to a nursing home, and it's always a difficult and painful decision. In this most recent case, it is my 69-year-old patient with AIDS, depression, psychosis, and a large mediastinal (upper chest) mass which has turned out to be spindle cell sarcoma, a rare cancer which is very difficult to treat and impossible to cure. Although her daughter has cried many tears over the decision, her brief time at home last week demonstrated for us quite clearly that she is far too complicated and gravely ill to be managed at home, but far too stable to remain in the hospital. Hence our decision.
Even though this patient is no longer in our program, I have been seeing her as a "free care" patient for more than a year, no reimbursement coming to us for my work. Now that she's landed in long-term care, my official job is over, and I will simply visit her as a friend and try to console her for her loss of freedom and increasingly serious illness. Long gone are the days of my weekly visits to her house to fill her med box and chat, almost always leaving with a gift of plantains and fruit. Although our conversations have always been in Spanish, she still has consistently gone out of her way to say "I love you" and "happy weekend", even as her discomfort and pain increased. And when I visit her in the nursing home---no matter how distraught she may be---she will still ask me about my son, wife and dogs, and will, as always, appear to relish the answer when I tell her that they are all well.
I know that I have added quality and love to this woman's life, but I'm saddened that her life may reach its denouement in an institutional and foreign atmosphere, away from the smells and sounds of family life. Can I mourn for another who is not yet gone?