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Friday, February 13, 2009

At the end of the day you're another day colder...

I don't like to share work anecdotes that could potentially link specific patients back to me for obvious HIPPA and human decency reasons. I wait until they are long gone from the building, no longer my patient. And I still change some of the details. Now it's been long enough for this one:

I had a patient who was in his mid to late eighties and has been living on the street for years. He came to us for an upper respiratory infection. He was quiet and barely made eye contact when I introduced myself. "I jus want to sleep, ma'am," he said, closing his eyes. Within 24 hours we realized he had a case of scabies. Another nurse and I helped him to the shower. He was frail, with paper thin skin, and almost cachectic looking. When I helped him undress to do the scabies treatment I drew in my breath sharply. Without his four protective layers of clothes his body bore a striking resemblence to the haunted photos of concentration camp survivors. He was a real life walking skeleton. That was when we noticed the mass on his back. The nurse practitioner and I shared a look. The man did not notice.
As the week rolled on, sleeping in a real bed and eating warm food began to liven Mr. S up. In his good moods he smiled and joked and wore a baseball cap. When he was angry the small man became so sassy and entitled that it was unintentionally comedic. "Damnit, woman!" he would scream, as I tried to hide my smile, "I wanted eggs for breakfast! "

For weeks I changed his dressings and medicated him against seizures while we waited for MassHealth to come through so he could go to a nursing home. We joked when he was in his pleasant moods. He could never remember my name and instead would simply ask for "My nurse. The little one." Meanwhile, the mass on his back went unchanged and he developed blood in his stools.

The whole team found ourselves in an ethical dilemma. The man was very old, and had come in for a URI. One of the docs argued against having anything followed up. "It's a can of worms we don't want to open. It's not why he's here." Another argued, "he has a right to know." We scheduled a colonoscopy. Mercifully someone finally realized, "let's ask him if he wants to know."

As it turned out, he didn't. He said, "I'm old. If it's my time, it will be my time." He refused to go through any kind of testing, he refused all procedures. Another week went by and then suddenly, without much fanfare we got a phone call and he was leaving.

The private ambulance arrived to pick him up but he wasn't ready to leave. And having to get ready put him in a sour mood. "Your coat?" I offered. "Now what am I going to do with a coat?" he asked, putting on his eighth sweater. The EMT waiting for us was the most patient I've worked with in the capacity of non emergent transport.
He never once sighed, never rolled his eyes. In fact, when Mr. S got particularly rude with me he and I exchanged a smile and a nod. We kept him waiting for about twenty minutes, and once I had Mr. S in the hall he began to tear into the EMT demanding that he "go on, I'll meet you there by cab." Mr. Amazing EMT was kind, firm and waved goodbye as he and Mr. S got on the elevator.

I was relieved but nervous. What if Mr. S didn't get in the truck? My fears were grounded. He did get on the truck, and even got off and into the nursing home. But a few days later he eloped. We got the phone call, but no Mr. S. I wonder if he's okay. If he's eating. If it was cancer we saw on his back. If he'll ask for help if he needs it again.

But the thing that always gets me about Mr. S is this: what if he had said he wanted to know? Or what if he wasn't actually mentally able to make that decision about his health? Who would have won? Would we have had the mass biopsied? Then what?
We were lucky, we got taken out of the choice because we gave it to Mr. S. But he could very well have demanded to know. And then demanded treatment. Treatment that probably would not have saved him in the long run but would have made his quality of life miserable while costing a ton of money. Or what if he couldn't have told us? What if he was mentally incapable? Would we have listened to doc #1 or doc #2? Run the tests or not?
For now, I don't have to think about it. But someday I know I will.

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