THE POINT OF CARE

THE POINT OF CARE . . . “Independence”

Independence

Earl Stewart, Jr., M.D.

I recently covered a colleague on the Dayfloat Service, which, at our program and I believe at most, is set up to provide coverage for those residents on Wards who need it when they are scheduled to be off, particularly on the weekends, and who are absent from inpatient services due to weekdays in clinic.  For me, being a creature of habit and a lover of consistency, I was a little reluctant at first considering what the experience may bring—not knowing patients well, feeling like an outsider looking in on the teams with which I would be scheduled to round, and having patients have to deal with something that has become quite banal in the team-based structure of today’s medicine of getting to know yet another face of someone dealing with their care.  Such would render even the most amenable of patients uncomfortable.  Patients often expressed to me throughout the month upon introducing myself that they see so many doctors they just can’t “keep them all straight.”  Little do most of them know that for the Dayfloat Resident providing coverage for their care, especially for teams with large censuses, we have to work hard at keeping them all straight.

I joined a team in my last week on Dayfloat taking care of what I anticipated would be a very pleasant 89-year-old woman who had been admitted for multiple medical problems:  recurrent UTI, the flu, a fall, and dehydration.  My colleague, when giving signout the afternoon before, mentioned how she was just pending placement at a nursing home at that time so she likely wouldn’t be “that active.”  Well, we’ll just say she was active in another sense of the adjective.

As soon as I walked into her room the following morning, she was, to say the least, complaining.  She complained how she felt the nurses were not responding to her needs.  She complained about how all they do is just sit at computers and type now, noting that her mother and aunt were “real nurses.”  She complained about the case manager not showing up over the weekend to meet with her family at the time she requested.  She complained about not having a bedpan immediately after she asked for it.  She complained about the food.  I soon realized that this was not going to be a usual, “run-of-the-mill” pre-rounding experience.  But then she did something that took me aback.  Immediately, almost in an instant, after the endless stream of complaints ceased, after I explained to her who I was covering, she had the most wonderful things to say about him.  She loved him, it seemed.  She exposed how she came in to the hospital with four different problems and that my colleague “saved her life.”  She even became somewhat tearful.  I motioned to do the usual textbook thing when that happens which is to gesture with silence, offer tissues, and allow the patient to become composed.  It stupefied me that this elderly woman who initially appeared to me to be a handful of sorts with her enduring complaints in the blink of an eye, almost magically, became lovely, and I said to myself at that very moment:  she’s splitting like crazy.

The remainder of the day entailed convincing her that she was medically cleared for discharge to a recommended skilled nursing facility and, like she had done before earlier in the hospitalization, she appealed her discharge and declined that facility.  Unfortunately, which she knew, the appeal of her discharge before failed and it was becoming somewhat of a financial conundrum as her insurance would not cover the remainder of her hospital stay.  We called her family, which primarily consisted of a nephew and his wife, who explained to us that her personality had ostracized her entire family.  She never married.  She never had any children.  He was all she had, and it had been evident to him that she could no longer take care of herself.  Upon explaining to her further that she was ready to go, I realized that leaving was, in fact, not the issue.  I realized that even the accepting facility was not the problem.  It was the fact that she felt that she was being told to go somewhere instead of sitting down herself and arranging it herself.  To most of us, that would seem a little absurd, but, to me, this elderly, debilitated, and likely once highly functioning female was now thrust into a season of her life where she would be dependent.  Her complaining, her protesting too much, her demands, and her screaming bloody murder at almost everything that was said and done to and for her likely stemmed somewhat from an underlying diagnosis of Borderline Personality Disorder, but it more so appeared to be an issue of her no longer being independent.  She was afraid.  She couldn’t call the shots anymore, and that obviously scared the daylights out of her.  She demanded to be heard and understood by someone in her enduring affirmation that being dependent was not something she wanted and would accept.

Patient autonomy and the personal independence of patients meet this constant interplay in the later years of being elderly.  We in medicine work overtime teaching medical students and interns about respecting a patient’s autonomy but we don’t speak very much about a patient’s independence.  We often encounter this somewhat inconspicuously lying under the papers that our case managers’ files for rehabilitation and nursing home placement, but I find that we don’t spend enough minutes of the rounding experience discussing issues of dependence vs. independence with patients enough to place them at ease when we present them with the option of rehabilitation or nursing homes, which, in the geriatric population, is very much a necessity.  This patient had 89 years of doing for herself, living by herself, and, likely, being by herself  and she obviously felt threatened, even by  the compassionate nature of our healthcare providers, telling her what and how to do and where to go.  Independence, especially 89 years of it, finds it quite difficult, I’m sure, to be dependent all of a sudden at the stroke of a nursing home acceptance.  In formulating our assessments, I contend that devoting a little more time and credence to understanding and appreciating the geriatric patient’s years of functionality and independent living and how it trumps any rapid conclusion that just because one is elderly dependent living is inevitable is what it takes in placing them at ease.  There are those patients of the geriatric season who are silently lying in waiting in our hospital beds for recognition of the days gone by but, occasionally, as the patient referenced here, some will very vividly demand to be heard.

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