Tuesday, January 03, 2006

What More Can I Do?

You are a middle-aged man with poorly-controlled diabetes. You inject heroin and cocaine periodically. Since your veins are shot, you often inject using a technique called "skin popping" wherein you inject under the skin rather than intravenously, sometimes developing infected abscesses in your arms that have to be surgically debrided. You have massive lymphedema (picture elephantiasis) of one leg, and ulcers frequently open on your legs and arms. You go to methadone every morning, but they're going to discharge you because your toxicology screens keep coming up positive for opiates and cocaine.

I'm worried that you may lose your leg or die from an infection. I have the visiting nurses see you every day to dress your wounds and administer your medications and insulin. As far as the open wounds, I now have you connected at the Wound Clinic. Since transportation is an issue, I actually pick you up and take you personally to your appointments so that your treatment is expedited. I also serve as translator. When you're sick I come to the house to visit you, and I keep your primary physician updated regarding your status. When you miss an appointment, I reschedule it since you don't have a phone. The visiting nurse and I consult about you almost every day. Only a handful of patients in the United States have this type of intensive and personalized healthcare delivered to them at no cost. I wish you could grasp the reality of that.

Despite all that I do, you still miss appointments, avoid the visiting nurse, skip medications, make excuses, and increase your chances of harm to yourself. I don't know your complete history, but I imagine there is a long story rife with psychic trauma, perhaps violence, abandonment, addiction, family stress, poverty, mental illness, and learned helplessless. I have no idea what experiences brought you to this point. From my standpoint of relative normalcy and stability, I cannot really understand your life, but only empathize with what it must have been like.

I want nothing more than to spare you frightening and painful outcomes which are lurking around every corner, but I can only do so much. Compassion fatigue is real, no matter how traumatic the patient's past. There's a point where I have to decide that I'm working too hard for you, doing too much, enabling you to not help yourself. Where do I draw that line?


Anonymous said...

said patient so obviously does not want to live. let him go.

Medicoglia, RN said...

So many who try very hard to be compliant and keep appointments etc don't have any help and need it, then there are people like this. I just don't get it. A horrible past is no excuse. It's a miracle I survived my childhood at all, but I go to my appointments, I take my meds, I take care of my diabetes and asthma; maybe not to the satisfaction of a nurse in every instance, but I do try and the slip-up is rare. This is just mind blowing to me.

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

While it may be mind-blowing, it is common behavior among disenfranchised, poor, and otherwise traumatized individuals. Self-destruction can come in many guises, and substance abuse is only one of them. I am still trying with this guy, and am not yet ready to throw in the towel.

Anonymous said...

Ont the one hand, i read this and think you're an unusually kind and caring person to work with this patient. Which you obviously are.

OTOH I can't help but play the "comparo-game" and wonder whether you couldn't help more, help better, make more of a difference... if you dropped him (or just treated him like a "normal" patient, which is the same result). There are SO MANY deserving patients and as you correctly noted, very few of them get this type of care who need it. Is he your best focus?

I don't envy you your decision.

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

Commenting some weeks later, I have not abandoned this patient but I have left him in the care of his family and the visiting nurses.

After he received his check at the first of the month, he disappeared on a binge of cocaine and partying and had no insulin or meds for days on end. He regularly falls out of care, and it is people like him who I often have to retract from in order to pay more attention to other patients who are more willing to do their part. It's a tough balance. He was a squeaky wheel for a while but now he's oiled with cocaine and has dropped out of sight.

Anonymous said...

Refer to Diabetes for
useful information

Anonymous said...

There is no right thing or wrong thing you can do in this situation, you are wrong no matter what you do to one group of people or another. A tough life for you if you ask me, a credit someone is at least there, whether it is you or family.

The one thing that remains consistent if we are "here to help others" is that we must accept that if we want to help we must learn how to as much as anything else, especially if we already understand that drugs can make people do things that otherwise they would of not normally done.

Fallen Angel - If it is mindblowing for you then it is best to keep opinions to yourself. Not everyone is as strong as you are. What sometimes is seen as an excuse to one is a reason for others.