B. Betty, RN
A past patient of mine and I had altering ideas about his ideal state of health. He was an older gentleman in his 60’s but appeared much older because of his smoking, drinking and decades of self-neglect. He was a wheel chair bound frequent flier back in the hospital for a second toe amputation with possible foot involvement secondary to his uncontrolled type II diabetes, vascular disease and 100 pack year x 40 years smoking history. He was angry. He was angry that he was on a sugar-free and low carbohydrate diabetic diet, angry that he was getting another amputation because “the damn doctors screwed up my foot.” Angry that he was no longer allowed to go outside to smoke because of the hospital’s no smoking policy. Angry that he was ordered dressing changes three times a day to his legs and foot that caused him discomfort. He was chronically short of breath and oxygen dependent. His blood sugars were baseline high 200’s, and he was completely non-compliant. He was abusive to staff-a total PITA (pain in the ass). For some reason, he was my favorite patient. He was a challenge. His chronic crabbiness reminded me of my dad.
He was a personal lesson for me about being in the moment, being non-judgmental, allowing others their own story. He was a reminder about how to be present without being controlling and honoring other people’s truths. He pushed my buttons. He yelled and was mean just to watch the nurses jump and get flustered. I smiled and gave it right back to him. He respected me (sort of) for not kowtowing to his roar. I discussed the WHYs of no smoking, food choices, diabetes, amputation, smoking effects on vascularity and all their roles in both the diabetic ulcers and the need for amputation.
He knew all this in an intellectual way but his heart wasn’t in it. I gently (in my blunt way) told him that if he continued down this road, he was going to die from complications from his bad habits. He stopped being snarly for a few moments and teared up. He cleared his throat and said, “Yea, so? I have nothing left to live for since my wife died. My kids hate me. They blame me for her dying. She’s didn’t want to keeping going to the doctor so I didn’t make her. The kids won’t talk to me, so who the F*ck cares?”
That was it. That was the defining moment for both of us. He was busy fighting us so as not to have to feel his own grief. We were too busy trying to get him to comply and labelling him a difficult patient that we all forgot why he was there, or humanity behind the disease.
Healthcare is completely ‘goal’ and “outcome” based. Because reimbursements are dictated by the Joint Commission’s set of standards and goals, we have lost sight of the complicated humans in our beds. Humans cannot be algorithm-ed into compliance. There is not a holy grail of health, no matter how nicely we try to tie it up in bows or threaten monetary punishment to institutions. We have made institutional goal attainment the ONLY outcome allowed.
Not every patient wants to be wholly well. Not every patient is whole enough to achieve such an outcome, to begin with. One’s health journey is just as spiritual as it is physical. Our spiritual pain can cause our bodily disorders, more likely thus than the other way around. Until we adjust our own sights we will not get our patients to see the facts or truths of healing “our way.” We must be in tune, unrushed. We need to truly understand perception, social conditions, environment. We must SEE our patients in all their glorious, messy, complicated, unscientific impracticality if we are to be any help to them at all.
Sometimes we will simply be the face of kindness that becomes the seed for wellness. Sometimes we will be the hand that guides them forward. Sometimes we will be one more person to whom they lash out. Never the less, our goals for their health cannot be pushed or forced, no matter how much our institutions will try to do so. We can assess, we can recommend, we can evaluate. We will never be able to strong arm humanity to do our will, whether it’s ‘best’ for them or not. Sometimes, the most therapeutic option is to listen and validate. We touch lives by touching souls.