Friday, February 26, 2016
More than a notion
“She needs a nursing home,” someone said.
It was all matter of fact; the way such things are always mentioned on rounds with those frail elders who've slipped into the cognitive abyss. And I didn't know all the details. I mean, not enough to go arguing and pushing back on a plan that had been rolling forward for this hospitalized patient for the last week. So I responded with a simple word. “Why?”
“Dementia,” I heard them say in response. “Like, she's delirious 1 minute and then sort of inappropriate the next. It's weird. And honestly, it's mild but the problem is that she lives alone and doesn't really have anyone to help.”
“Why is she delirious?”
“Part of it is adherence to what she needs for her health. The other part, we think, is some underlying dementia. She does have someone to make decisions for her, though. Even though they can't really take care of her like we'd like.”
“No one around to see about her?”
“Well. No family that can give her what she needs. So we're pursuing nursing home placement but it's drama since she's majorly pushing back on it.”
“Dang. So she's aware enough to let you know she's not feeling that plan, huh?”
“Yeah. We just want to safely discharge her, Dr. M. So her durable power of attorney will have to sign her in against what will she has remaining.”
Now that? That punched me in the gut and made me gasp a bit. “What will she has remaining” felt like we were playground bullies. Something about that grabbed me hard and said, “Pay attention. Go and talk to her. Think.”
Oh, and let me be clear: The team that was caring for this patient before was thoughtful and empathic. I know I had the luxury of being the Monday morning quarterback. The delirium portion was mostly resolved so I was looking at her through fresh lenses. Fresh enough to feel unsure about sending her to a nursing home.
And so. When we went in there, I listened to her speaking. This woman was older than my mother and stated proudly that she was a “Grady baby,” meaning she'd been born in this very hospital. That always resonates differently with me when I hear it from my Grady elders. In a city of transplants, the true-blue natives enamor me. She was true-blue.
And so. Admittedly, there isn't some really elaborate story that follows. I'd imagine the preamble of it all serves as a bit of a spoiler alert that she was, indeed, as sharp as the proverbial tack. And while I can't say that there weren't a few wrinkles in the fabric of her cognition, I can say that none of it was substantial enough to rip her away from the place she'd called home for the last 50 years.
And that? That's the thing. That is the piece I put my kickstand on when thinking of her, discussing her and laying out plans with my team. This notion of uprooting people with very, very deep roots and recognizing that it's a big fucking deal.
Pardon the f-bomb.
In 2006, Harry and I had a young toddler, Isaiah, and were expecting our second child, Zachary. Harry, who has a background in real estate investment, had found this amazing home in a wonderful in-town Atlanta neighborhood, literally walking distance from my employer, Emory University. The schools in the area had great reputations and the entire environment was everything we'd dreamed of having. It certainly had some “fixer upper” necessities, but that didn't deter my husband at all. And his faith in the potential this house had was enough to get me on board.
The home we were in at the time was lovely, for sure. That said, it was significantly further from all that we do both professionally and personally. Getting closer in would be game changing for our family. And no, we didn't need more space or anything. But this? This house was uniquely special. An opportunity just presented itself and, even better, involved my better half utilizing the skills that he'd been fine tuning for the last several years, negotiation and renovation. We didn't look back.
No one knows what the future holds, economically or otherwise. But barring any major changes, we came into that home—now our current home—believing that, God willing, we'd grow old there. I imagine myself slowing down and easing out to that same mailbox someday. Asking Harry if he fed the dog or picked up eggs or even if he wants a cup of herbal tea. And us sitting in our sunroom where the kids watch television now, shaking the hand of some young woman that one of our boys desires to marry. Then later, holding the hand of the grandchild or grandchildren that come from that union, walking through this very neighborhood to do the things that I'd been doing since I was a pregnant thirty-something.
So after that, I picture my mind getting foggy. Not full on foggy, but foggy enough to cause some people to do a double take. Still okay enough to take a shower and make some grits and sweep the porch and feed the dog. Fine enough to wave at the mailman and grab the bills and even get on line and pay them one mouse click at a time. But maybe just off some. Not able to remember which Bush or which Clinton is president or even how to stay on track with every day conversation. Then, I pray, that there is someone who is ready to step in and see about me, you know? To be a go between in the gap of what I can still do but the fog of what I can't.
If, for some reason, that person or those people aren't readily presenting themselves, I think about someone having me in a cold, sterile hospital bed that some 911 call sent me over to on a whim because I'd fallen and couldn't get up. And then I think that, kind of like when people were put on ships and taken to the western world against their will, it must be awful to suddenly be told that you are never, ever going back to live at what has become the only home you really, truly know. Especially if my wits were still about me enough to feel that loss.
So yeah. I think of that and hope like hell that my doctor or doctors or nurse or nurses or social worker or social workers come busting in that room with their hands all splayed out screaming to everyone to WAIT, WAIT, WAIT and THINK, THINK, THINK before just signing that form to send me off and away from the home I spent my whole life building. I want them to look hard, go find someone, anyone or some kind of resource to help me. Or at least try, man. At least fucking try.
Because 30 years from now, if you take me up out of my house without warning, I won't want to go either. And I swear on my sister's life that I will fight you tooth and nail with what will I have remaining. Yes. What will I have remaining. Damn right I will.
My patient said she wanted to go home. Her insight wasn't poor and, as it turns out, there are some people around who could see about her. She was a bit forgetful and tangential but she still knew that Cam Newton was going to the Super Bowl and that he was a hometown hero, straight out of southwest Atlanta where she'd lived her entire life. And she wanted to be home to watch that game on her own damn couch where she could clap her leathery hands and drink a light beer.
And you know what? If I have any say in the matter—and I do—that's exactly what she's going to do.
Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
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