Wednesday, January 03, 2007

Notes From a Home Visit

So, he sees his dead family members in his bedroom---especially at night---and they talk to him.

"Is he really hallucinating or is it just a culturally accepted Latino way of connecting with dead ancestors?" I pose this question to the Social Worker/Nurse who accompanied me on the visit to assess the patient's mental status.

I have written about this alcoholic hypertensive man in previous posts. He refuses most offers of care, takes few of the medications I prefill for him in a med box, and basically watches TV, visits with a few neighbors, and collects cans to trade in for nickels across the street at the package store. I know his kidneys and liver are going, but does he really understand?

He left school in Puerto Rico after the 3rd grade. His father gravely ill with cancer, it was my patient's premature responsibility to earn enough to care for the family. The sugar cane fields became his school, the plantation owners his schoolmasters. Now, fifty years old and illiterate in even his native tongue, the English-speaking world is a place upon whose fringes he exists, eeking out a lonely and narrow existence.

If he seemed content, I would feel more comfortable, but his depression is palpable, and his isolation apparent. He repeats himself so much, latches onto certain phrases and sentences, sometimes not responding to my original questions, circumventing my clinical inquisitiveness through redundancy. I lose my train of thought and then repeat my question or frame it differently in hopes of a more revealing answer. He is not a great historian. To wit:

"When did you last have any alcohol to drink?"

"Well," he pauses briefly and looks at the wall. "I had three glasses of water this morning and then cooked some pork and rice. After that I mopped the floor."

It took a few more questions to elucidate that he had a few beers on New Year's Eve.

"Do you understand that every beer you drink damages your liver some more?"

"I don't drink anything strong---just beer. It doesn't do anything bad, but it really hurts under here." He presses just below the right side of his ribcage in the area of the liver.

"That's your liver. I can feel that it's enlarged," I say as I palpate the organ.

"It's just my stomach." He looks away.

Where do I go with that statement? Can I convince a 50-year-old man with the education of an eight-year-old that his stomach is on the left side and that the pain on the right is his liver? Will he care? Will he listen? Should his brother take charge and have him hospitalized against his will? Should we just leave him be?

No answers come to the fore, so I'll abide by that age-old adage: "Don't just do something, sit there." Until I get a better idea, I'll do my best to keep him alive and let him guide my actions. And when the shit hits the fan, be there to pick up the pieces.


Lisa said...

I don't really understand. If you didn't go to him, would he be reaching out to get help? Would his family bring him into a clinic? I just wonder if his refusal of help has to do with his depression. Is it possible that this is an attempt at natural suiside?

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

Well, he's the kind of person who'll wait until he's in organ failure, and then he'll go to the hospital, but kicking and screaming, most likely. He is clinically depressed, unwilling to engage in psychotherapy, holed up in his apartmnet, lonely and alone. Some people commit slow suicide by self-neglect or self-abuse. I just keep throwing him a life-preserver......