To Cudgel or Not to Cudgel

cudgel \KUH-juhl\, noun:
1. A short heavy stick used as a weapon; a club.

transitive verb:
1. To beat with or as if with a cudgel.

Good ol' dictionary.com. Almost always food for thought, grist for the mill, and fodder for blogging.

Apropos of yesterday's post, the concept of cudgeling is something worth consideration. When a patient refuses to take his or her medications, misses appointments either through avoidance, sabotage or outright self-neglect, how far does the earnest medical provider go to cudgel such an individual into action? As described yesterday, I managed to frighten my patient enough that she decided to restart her medications. Pummeled by visions of amputations, dialysis, blindness, and imminent myocardial infarction, she felt an impetus to take her metformin and pay a little closer attention.

The "scare-'em-to-death-technique" may be effective in the short-term, but I do ask myself if it actually engenders real change from within, or simply cudgel the patient into compliance out of fear or a simple desire to please the provider. Some patients respond well in the moment, but time has shown that change not necessarily coming from within may very well not remain fixed and strong.

Motivational interviewing is a non-confrontational technique of counseling aimed at assisting clients to recognize their potential problems, the potential consequences of those problems, and how those consequences might be avoided by way of self-directed change. There is a small voice in my head that this may be a way to increase one's skills to direct non-compliant or passive patients towards change while avoiding the techniques that simply use fear and warnings of dire consequences to alter behavior. How does one convince a very sick person that their illness simply cannot improve without their active participation? How does one help that patient decide whether or not to take proactive steps towards change? When does the earnest nurse just let go?

Of course, I have certainly found myself in situations where there was little to do but watch and wait. In yesterday's post, I mentioned the gentleman who I simply cannot protect from his own self-neglect as he heads down a path that will probably result in the most dire of consequences. Can I save him? Absolutely not. Does he want to be saved? Certainly not. Will I just watch him self-destruct? Seems that way.

To cudgel or not to cudgel? That does appear to be the question. The answer is apparently a double-edged sword.

Non-Compliance, Apples, and Surrender

She calls to say that her stomach hurts, her blood sugars are high, and she vomits every time she eats. I haven't heard from her in weeks. Since she's so bad at refilling her prescriptions, I keep her meds in my office and fill med boxes for her every few weeks. Her only responsibility is to bring in the empty boxes so I can fill them up again. I do this for about seven patients who can't manage it themselves.

I tell her I'll be over in an hour or so.

I arrive at her home. Her apartment, which I've been to before, is unchanged from last time except for the addition of a computer (and her adult son who is now living with her, surfing the Internet and ignoring my arrival). Her home is cluttered but nicely decorated with countless images of red apples: pot-holders, tiles, photos, towels, mugs, refrigerator magnets. It's a cornucopia filled only with apples. I find it oddly comforting today.

I ask to see the three med boxes that I filled in December. She drops them on the table. They seem to still be filled with pills and capsules.

"You haven't taken anything since I filled these last time?" I ask.

"Oh, I took a few here and there," she says.

I poke through the boxes and see that, yes, she's taken her Levothyroxine and Lipitor and nothing else. She must have a predilection for meds that begin with the letter "L", I think to myself.

"Now, why haven't you taken your meds?" I ask. "You're vomiting because you aren't taking what we prescribed for your stomach, and your blood sugars are high because you're not taking your diabetes medicine. Plus, your stomach probably hurts because your blood sugar is high, so there's alot going on here. Are you at least using your insulin?"

She looks sheepish. "I've been so depressed, I haven't wanted to take anything." She smiles very endearingly. "Yes, I take my insulin, but the needles are so big!"

"The needles are 1/2-inch, my dear. I'll get you 5/16th-inch needles next time. But look, we can get the social worker over here to talk with you, but you have to take your meds. If your sugars are high and your stomach hurts, what good are the meds doing you? We've talked about the complications that diabetes can cause, and I don't want to see you on dialysis and blind with amputations and a heart attack."

"You're frightening me," she says.

"Good. I think I need to frighten you once in a while," I reply, smiling. "As for your depression, it may also be worse because you haven't taken your antidepressants for three weeks. I really want you to feel better, you know. Will you take them now?"

"I think so. But my stomach......"

"Let's see. You went to the gastroenterologist, who recommended some tests. You missed the ultrasound, then you missed the endoscopy. After that you didn't come back to see him and then you forgot your appointment with your primary doctor, even though we called to remind you the day before." I look at her, exasperated but disarmed by her smile.

"We have to start over. First, take your meds, use your insulin, check your blood sugar four times a day, and then come in to see the doctor. Can you do that?"

"I want a insulin pen. I'm tired of all these needles." She crosses her arms.

"You want an insulin pen? Let me make sure it's covered by Medicaid and I'll fax a prescription today. How's that?"

She smiles like a child and thanks me several times as I put on my coat and gather my things, heading for the door. I'll leave her with her silent son, her belligerent and pregnant daughter, and the ubiquitous apples.

"It's my pleasure, truly. I just want you to be healthy and not get sick."

I close the door behind me. It feels like snow. I drive across town to the next patient's house. He's not home and I'm not surprised. I knock on his neighbor's door. No answer. Damn. He's a tough one who I've written about before. The poster-boy of non-compliance. Another patient of mine who could have been his identical twin followed the same path and his esophagus exploded. I guess some people never learn, at least not in this life, anyway.

What's an earnest nurse to do? Cajole, beg, teach, illustrate, lead, insinuate, joke, threaten, frighten, ignore, dread, expect, relinquish, surrender. I think I like surrender best. Surrender to the depression, the anxiety, the trauma, the disintegration of family, the loneliness. Surrender to the giving up, the disenfranchisement, the poverty, the powerlessness, the disempowerment, the recalcitrant illness. Yes, surrender to it all and then decide to keep going anyway. To surrender does not mean to give up. It simply means to acknowledge that there are things in this world which one cannot change and to choose one's battles carefully. Like the Serenity Prayer says, "and the wisdom to know the difference."

As I push through some of these more challenging days, interacting repeatedly with traumatized people unable to fully hear my counsel, I remind myself that my job is to simply lead the patient towards health, but like the proverbial horse led to water, I cannot make them drink. Nonetheless, I continue to offer the cup of hope, the cup of solidarity, the cup of possibility. And when all else fails, there's nothing like surrender.