Patient Remembrance

A recent patient (P) of mine was a peripheral co-worker of my mother's. They both worked in different departments of a large institution.

I recognized her immediately but, fortunately, she didn't remember me. I'm always ill at ease when acquaintances of my parents meet up with me and express their own grief.

As the day went on, people from this workplace came and went visiting P. Well, someone inexorably knew me. Sigh. The news spread like wildfire through the waves of visitors and I was stopped a number of times in the hall to answer questions about my life, how my family is without my mom and to listen to how sad they were, how much they miss her etc.

Don't get me wrong, it's comforting to know that so many people were affected by mom. She was an amazing special woman. She was, without a doubt, my closest friend.

It just makes for an uncomfortable workday.

I'm training someone in the end stages of orientation. This person was practically running the group and so I was able to avoid more of the prolonged interaction.

It wasn't until the end of the night that I had to re-enter the room solo.

P. saw me and thrust out her hand.

"Kate! There's another Kate on the floor whose mom worked with me. It was so tragic her dad died and then her mom... Oh.. What was her name? Oh.. Not Kate.. that's the daughter's name.. What was her name?..."

I sighed.

"Her name was M___. I'm Kate ___. The only Kate on the floor."

P. stared at me for a moment then burst out in sobs.

"Oh.. your mom was the sweetest lady ever. We all miss her so much and think about her every day... blah blah blah blah."

I found myself comforting a hysterical patient for over forty five minutes about the death of my own mother; a woman whose name she couldn't even remember!

To cap it off, P. sent candy and a card to the unit after her discharge thanking everyone personally for their care. "Sue was so kind and helpful. Janet was so smart... etc" But she didn't remember my name! I laughed and laughed. It was so poetically ironic!

I sure ate some candy though.

Quality of Life

We have a patient on the floor, a social admit. Adorable. She’s completely independent, mobility-wise, and wanders the floor constantly, asking that her ever-present Styrofoam cup of prune juice to be reheated. She flirts with all the men, telling them they’re the spitting image of Clark Gable, sugar lips and all.

From the desk, I see her make her revolution around the unit. She pauses next to the room with the moaning confused man with a hip fracture. I see her raise her hand to the doorframe. She makes no move to go in or even peek. But her hand trembles and she’s obviously affected.

She continues on to the end of the hall, looks out the window at the pitiful view, then returns to the desk and asks me to heat up her prune juice. As far as I can tell, she doesn’t actually drink the stuff but promise her a new fresh cup and she beams.

She makes several rounds, pausing outside noisy rooms and staring out the windows at the end of the corridor. This time of year, the trees are naked and the sky is grumpy. She’s riveted though. She always comes back to the desk and chats with me. It’s the same short conversation throughout the night. She doesn’t feel like doing the dishes. Can they wait until the morning? She’s tired and wants to go to bed.

Despite her fatigue, she makes another rotation. Whenever one of our staff passes in her in the hall, they call out her name with a bright hello. She beams and tells them that they’re the spitting image of someone famous. I look like Ann Margaret. Preeti looks like Pocohantas and Aimee’s Linda Blair.

We talk about patients and quality of their life. This lovely special little old lady has been able to affect the quality of life of everyone on this unit. Talk about giving back. We’re blessed to be a way station on her journey.

Manly Food

One of my patients last night was eating voraciously. In addition to an enormous meal from the hospital kitchen, he devoured 3 TV dinners, 1 PB&J sandwich and two pieces of toast and jelly.

Around 0200, he called out for another snack. After discussing it with his nurse, I brought him a couple of saltine packets.

A tirade spewed forth.

"I'm a MAN. I've traveled the world and have a MAN's appetite. I'm not a little boy and don't want no little boy snacks!"

He threw the crackers at me and said he wanted a MAN's snack.

I asked him what he wanted and he told me:

"a chocolate sundae."

I wonder how he feels about quiche.

Thursday Interview

My first (and thus far, only) medical school interview is this Thursday. I had hoped that I would have heard from another school by now. I'm incredibly stressed that this may be my one and only chance.

I decided to splurge and spend $30 more on a hotel room within walking distance to the campus.

My aunt- the crazy (in a fun way) one who took me on my first trip abroad (Turkey) wants to go with me. My youngest uncle lives nearby in an institution for developmentally disabled and she wants to visit him while I'm on campus.

I'm torn. It'll be nice to have someone there afterwards to talk about the experience but I'm afraid that she'll be critical of my weirdness beforehand (you know- waking up 4 hours early to obsess over my hair, clothes, review possible questions/answers etc). Besides, she doesn't really sleep. I learned that early during our Turkish adventure. I'm working the night shift all this week and will probably want to rest most of the day before the interview.

One of my favorite patients died yesterday. I found out through the hospital grapevine that he had been readmitted at the other hospital in our system for pneumonia and quickly crashed. He had been a quadriplegic who just conquered all obstacles. He ran his own business, drove and just celebrated life. It breaks my heart that someone so strong and inspirational is gone. RIP Dwayne. You'll be missed.

Faces

Last night, one of our lovely confused LOLs grasped my cheeks with her hands and told me that seeing my face made her feel better.

Aw. Shucks.

Then she tried to bite my arm.

The Catheter Interrogation

First thing this morning, a urologist came to place a supra pubic catheter bedside. The patient had been retaining crazy amounts of urine and neither his nurses nor his orthopedic surgeon could place a foley in him. So urology was consulted.

The doctor had called in a list of supplies that he'd need bedside by 0530. Apparently he was rather rude to the evening secretary about it, saying 'everything better be ready", in a 'you people always mess up' sort of way. But I know the evening secretary is something of a sensitive whiner, so I took her report with a grain of salt.

He arrived examined the patient and then decided to try his hand at placing the foley first, giving me and the patient's nurse a new list of supplies. We have coude catheters in different sizes and foley kits stocked on the floor so much of his list was immediately manageable. But he wanted Urojet (lidocaine) syringes too. We don't have them in our McKessen so it was a short process to get them up to the floor. He needed to write an order, I faxed it to pharmacy and then immediately ran down to pick them up.

He was NOT HAPPY.

Though it took 10 minutes tops to get them (5 of which were taken by him arguing about writing the stupid order), he was incredibly put out. I heard about how ridiculous we were, how he doesn't have time for this stupid delay.. etc, eye rolls and disdain galore.

Fortunately for the patient, he was able to successfully place the foley. Whew.

A few minutes later, I stopped in the room to check on the patient and I noticed that his collection bag had over a 1200 cc in it.

I remembered reading somewhere that draining the bladder too quickly can cause the patient major discomfort so I pointed it out to his nurse. She was busy doing her end of shift med pass and instructed me to ask the urologist if she should clamp the catheter.

So I did.

I thought he would attack me.

He completely lost his temper and flayed into me.

"That's the stupidest thing I've ever heard! Why do you think to clamp the catheter? Why?" and then he waited. It took me a moment to realize that it wasn't a rhetorical questions but that he actually wanted a response.

I tried told him that I had read somewhere that it could hurt the patient if the bladder emptied too quickly but as soon as I started talking he restarted his rampage.

I was mortified. I tried to explain that I was just an aide and the messenger for the nurse but he kept at me. I can't remember everything that he said; I was flustered and just trying to escape. I remember him saying that they don't teach nurses to be doctors and thrusting a new order at me, written in block letters as though I were in grade school, DO NOT CLAMP CATHETER. It was the only completely legible order he'd written thus far.

He ended up staying to yell at me for longer than it took him to place the foley.

So much for his valuable time....


I'm totally re-writing one of my evil book characters in his honor and he's (the character) is going to suffer.



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Impatience.

There's a nurse on our unit who come in nightly to regale us with tales of how awful her husband is. She dyes her hair only because he prefers blondes. She can't eat this or that because he thinks she's fat. He won't help her at all. He expects her to support them with her night shift and then take care of everything like chores, shopping, all aspects of child care while he sits on his duff and watches television during the day. She's always so tired blah blah blah.

Tonight's tale was about how he controls all of the money including her wages using direct deposit into in accounts that she has no access to. If he's feeling generous, he allots her a $5 weekly allowance. If she ¡misbehaves!, he'll take the money back.

First, I think she's totally full of crap. I don't doubt that the husband is a total jackass, but I'm pretty sure she stretches the truth unrecognizably.

She comes in with her stories and everyone fawns over her.. "oh he's awful!" "He should be shot for or " "You should kick his ass to the curb" and she preens under the attention.

I usually try to avoid engaging with the more manipulative staff but she put me on the spot and directly asked me what I thought in front of the rest of the crew. I tried to prevaricate but she was a bloodhound, asking me over and over.

I finally turned and told her that I thought she was spineless, that if she had such an issue with his money control to deposit her paycheck into her own damn account. He didn't hold a gun to her head when she signed up for direct deposit.

After that, she answered every phone call with "U8, Spineless speaking." Seriously, how old is she?

I would love to be a fly on the wall when she goes home and regales her husband to all of the stretched stories of how awful everyone is toward her at work.

On a more positive note, tonight was hellishly busy but I was working with my two all time favorite nurses and we totally rocked it. I love how efficient, sensitive and cool they are with the patients. Over the last year, I've learned so much from them about how to work with even the craziest, most difficult patients calmly and effectively.

Around 0300, "Dr. Armstrong" was paged to U7, one of the more dangerous pysch floors. We then heard thumping and shouts in the south stairwell. Unperturbed, Jackie, not taking her eyes off the IV line she was priming, strolls over and flips the lock on the door knob. A "Dr. Armstrong" is the hospital code for a combative patient. Moments after she locked the door, we heard a thud and more yelling.

Later, we discovered from the nursing supervisor, that one of the patients actually kicked in the door of the secured ward and escaped into the stairwell. I only caught some of the details in passing. Apparently, the patient had enough time to defecate on the stairs before pushing past the security guards to escape downtown. He assaulted one of the police officers chasing him and is now in jail. It capped the already crazy night.

Settling In..

Well, I'm getting used to my new apartment. My neighbors are musicians. Yep. Alt Rock. Sigh. Toulouse is not amused.




I love it nonetheless. Here are the aforepromised photos.





There's been a delay on the house closing. Lawyers. Hopefully, we'll finally finalize it this week. In the meantime, I've been popping up there to check on it and take advantage of the laundry. Yesterday afternoon, I was vacuuming and heard "knock, knock, knock" on the door.

I opened it up and, lo and behold, there was the mayor of my small town holding a small ceramic bowl.

I invited Mr. B in and we chatted for a few minutes. Apparently, his son bought the house and the mayor was unaware of the delay in closing. He was wandering around the property last week, found my collection of wheat pennies in the garage and took them home. When he found out about the delay, he wanted to return the money. He was embarrassed. We walked through the house together and he mentioned some things that 'John-John' wanted to change and asked about the family. I had never really known him, his kids were older than me, but he was my brother's little league coach and shared booster club responsibilities with my mom and several aunts and uncles.

After he left, I burst out in laughter. I was robbed by my mayor! It struck me as incredibly ironic.

Work has been remarkably smooth. The nightmare patient that I had mentioned last time was only with us for a few days and since then, our census has been mostly comprised of easy ortho patients.

No more news on the medschool application front. I'm still 'under review' at all of the other schools. The waiting is impossible. BAH.

New Digs

I'm settling into my new apartment. It's a tiny studio in an old Victorian house with ceilings higher than the room is wide...

I'm using an old refurbished library study table for dining.

I last rented a mother-in-law basement apartment, draped in grapevines and filled with books, that I christened the li-burrow. I haven't yet thought of a clever name for this new place. I'll post some more photos when I finally organize the living/bedroom. It's filled with boxes now and not very inspirational.

We have a patient at work. I'm not able to express the turmoil that this patient throws the hospital into when (s)he is here. I've been on the unit for over a year an this is the second visit. It's an incredibly stressful time for nursing staff, manager and hospital administration. This patient only comes to our floor for reasons that I can't go into without violating HIPAA. I can only say that they're unique and awful. I'm not experienced or clever enough to adequately change the details and still portray the magnitude of this person's effect on us. We get extra staff and the nursing supervisor relocates her center of command to our floor for the duration of the patient's stay. It doesn't help with the stress levels of the nursing staff. My manager hand selects the staff assigned to the room. Though he picks his most reliable, most patient and most experienced, it's not an honor.

The last time, the patient stayed 2 months. I'm not looking forward to another two months of complete anxiety before every shift. Bah.

I received my first med school interview offer. I'm thrilled but my loneliness yesterday was amplified in my hunt for someone to share my excitement. I mentioned it to my coworkers but they were more concerned that this means I may not be there next year. My brother disapproves of my ambition (I'm too old) and my west coast friends couldn't talk last night.

I'm still excited though!!

Isolation

All five of our isolation rooms are sequestered in one hallway on our unit. I was walking back from helping woundvac dressing change and found myself stopping in each room to chat with the patients. I knew them all well. I chatted with Dean* (MRSA) about his kids; Ira* (VRE) shared his news about his UNOS status; Frances* (MRSA) asked me for a cigarette and we laughed together at the inside joke; and for a few minutes, Robert* (CDIFF and MRSA)and I competed to see who could get the most Jeopardy questions right. He won. Stupid "Sports Venues".

I headed back to the desk and, out of curiosity, checked to see how long my friends on the I-ward had been here. At July 7th, Ira was the newest admission. Three months. Like the others, he's settled in. He has his favorite snacks in the kitchen fridge, a mountain of pillows to burrow into, piles of linens, dressing changes and unopened Nepro spilling out of cupboards and closet. Photos of his dog are on the wall and an extension cord keeps his cellphone and nook within reach.

After her transplant, my mother lived in the hospital for 11 months. We settled her in as best we could with soft throws, poster-sized photos of family on the wall, homemade hospital gowns, radio, magazines, toys, anything that we could think of to make it more comfortable. She hated it. She had no interest in anything but getting home.

I don't see that with my I-ward friends. Both Robert and Frances have been on the verge of going home several times over the months but they got stressed, become enraged and argued with the discharge planners. Then they had relapses, Robert became septic and Frances' tissue flap reopened.

Over the weeks, I've learned bits and pieces about my patients lives. Ironically, the time they spend in the I-ward is less isolating than their home lives. They each have a different story but, without exception, they are lonely and enjoy the 'perks' of living in a hospital: constant company, all the food they can eat, any need/desire filled by just pressing a call bell button.

Over the last year, I've noticed a steady increase of 'social admissions' to our unit. I think it's due to the aging local population, the depressed economy and the cutbacks at the nearby psychiatric hospital. A lot of its inpatients have been reevaluated to outpatient status. The recent flooding also destroyed 2 nearby nursing homes and countless homes.

It's scary and sad to me, that the awfulness of being in a hospital is actually preferential to what awaits outside.

Though my mom never made it out of her hospital stay, she had something better to look forward to, to work for. We all, up until the very end, had hope and desire that she'd make it home. In that way, we were fortunate.

No news on the med school application front.

Changes (and cleaning)

I know that I've been subtle about my frustrations with the folks at work. (tongue in cheek) A UA on the third shift has given her notice and I volunteered to step in. My manager is very thankful that I'm helping out and I'm really thankful that I get to work permanently with a stronger team.

I'm going to miss the greater opportunity to talk with patients during 2nd shift. I've found, though, the last few months I've been scrambling so much to do both the secretary's and aide's work I didn't have time to spend with patients anyway. I'll be glad to wear just one hat on this new shift.


On the cleaning note, I was out of town this weekend. I spent Saturday and Sunday up at my family's cabin. Coming home, I found my cat sitting on the window sill behind the kitchen sink watching the squirrels on the deck. Like she did all last winter...



As I turned to make a cup of tea, a mouse, A MOUSE!, ran across the stove and down into one of the burners. UGH! What's the point in having a pain-in-the-ass-she's-lucky-she's-so-cute cat if she doesn't mind roommates of the rodent extraction? I HATE rodents. Always have. I barely tolerate chipmunks and squirrels outside and the thought of them in my house makes my skin crawl. Their sharp pointy teeth that never stop growing are creepy. Besides, all of my work in Yellowstone has made me uber-aware of awful diseases (hantavirus, LCM etc) spread by little pointy toothed vermin.

I immediately pulled the stove out from the wall and, using a bottle of bleach, began scrubbing every surface I could reach. In my entire kitchen. For 3 hours. Then I went down to the 24hour drug store and bought a couple of traps. So far, I've only caught one and let it go across the street in the woods. My uncle mocks me for not killing them. He says that they'll just come back. But I can't rationalize killing something just because I hate them. Otherwise, all old drivers who go half the speed limit and don't use their turn signals...

Panegyric

The weather this weekend has been misty and gray. The trees quiver with the weight of the moisture on their leaves. With every gust of wind, the dew patters to the ground to echo the footsteps of my ghosts as they run through the woods.

One year ago yesterday, I decided to change my mother's care to palliative. It was the day before her 55th birthday. After some contemplation, I had decided not to wait until after her birthday to sign the paperwork. Though it had felt like I was giving up just when I should have been celebrating her life, I had finally recognized that she had given up long before and I just wanted her pain to ease. I didn't want her to have to struggle through her birthday.

Over the last year, that decision, all the decisions over the course of her care haunt me. I question if I should have waited, if I should have made the decision weeks earlier. I wonder if my self-interrogation stems from the melancholy that I feel right now, struggling with the convergence of her birthday, her death, my birthday (the 20th) and the anniversary of her funeral. I probably won't ever know if I made the right choice for her and that abrades me. I hope that as time passes, the erosion resembles less the calving of glaciers, monstrous pieces felled in a swoop, and more the gentle tumbling of sea stones.

Last night, a husband, surrounded by his family, decided to transfer his wife to hospice. The time spent in her room with her family was like a crampon squeezing my heart but they seemed desperate to have someone they trusted, who had cared for their wife, there to reassure them of their decision. I stayed because her daughter wouldn't let go of my hand and I couldn't bring myself to extract it.

The staff lounge was awash with comments like "it's about time" and judgments about the family's decision, a typical occurrence during these transitions. I completed her paperwork and then took a 5 minute bathroom break to rinse my grief from my eyes.

My sadness for her family and their coming sorrow, my sadness for the other six patients that I've transferred to hospice, particularly those who had no loving family to take on the burden of loss, and my memories of my beautiful vibrant charismatic mother sit like lead in my chest.

It's ironic that those who are most vocally critical of the choices that families make are those who have had the least experience dealing with any major decision, loss or grief and the least experience with the patient and her medical history. There were nurses who had never worked with the patient, never read her chart, never met her or her family who felt comfortable deriding the family and what they perceived as an unnecessary delay of the inevitable.

With a few questions carefully chosen to prick holes in their balloons of certainty, I made my point that this was a complex situation that could not be boiled down to an imprecise diagnosis and that making these types of decisions isn't easy or simple for clinicians who've been in the field for decades, let alone the families who are newcomers.

I started this post intending it to be a panegyric for my mother and the incredible staff at the Kindred LTACH in Wilkes-Barre, PA. Throughout the last months of her life, they nurtured the joy that she felt being around people- not an easy thing to do working in a hospital. Despite their many responsibilities and her inability to respond, they took time to visit with her and amuse her. They also supported me completely as I tried to navigate the bayou of treatment options. When my mom reached her limits and began to withdraw, I requested and they unhesitatingly joined me, her physicians and an ethical committee to discuss withdrawing treatment.

I am grateful that they demonstrated the power of empathy in softening the uncertainty and distress a family feels in these circumstances. Though, as an aide, I have no medical authority to ease the doubt and fear someone has in making a decision, I can follow the example set by the folks at Kindred. I hope that I made the family's trauma easier last night. I hope that I will always remember as vividly as I do now what it felt like grieving, frightened, unsure and dependent on the guidance and understanding of doctors and nurses.

Temples

I have a cousin who is addicted to crack. Our family has struggled to understand how he could have made the choices that forced his life into a downward spiral. We discuss what approaches to take, limitations to set, anything to help Beck come back. But he doesn't want to. He lies, manipulates and steals, neglecting his children and watching his debt grow.

It's heartbreaking to see my aunt weep, grieving at the loss of her son and fearing for the welfare of her grandchildren. Their mother died of an overdose two years ago and Beck has sole custody. Though his house could be featured on an episode of Hoarders and his electricity and water are periodically shut off, he doesn't fall below the threshold of what is unacceptable to Social Services and so his children remain with him.

I see his jittery hyperactivity and the tracks on his arms when he comes to ask me for money; his electricity, water, phone etc are about to be shut off. I see the boy I played with as a child, catching snakes and salamanders, climbing trees and building forts.

My patient tonight, a woman with liver failure, is febrile and having seizures from alcohol withdrawal. Sedated, she didn't move when I took her vitals and washed her up. I was tender, reverent when I rolled her to her side to clean stool from her bottom and salve with protective ointment. Though she was alone, I could see the child that she was and the people who love her despite the abuse she gave to her own body. I hoped that my cousin would be treated gently when he crashes and is brought to a hospital unit like mine.

I swam tonight, alone in a crook of the river. I could feel the water against my body and the freedom of my limbs. I flew, buoyed by the water, unhindered by gravity. I love my body. It is the only house that the essence of me will have. I am amazed sometimes when I look at my arm, think about its function and then raise it purposefully, only to demonstrate to myself that my mind has control of it. I'm telekinetic with my own body. It does what my mind tells it to.

I could wax poetic, citing Descartes and his mind-body dichotomy, but I'm a Spinoza girl. I see the physical connection, calcium released and synapses firing, between my thoughts and the movement of my arm. It works beautifully and I don't want to mess it up.

I'll have a glass of wine with dinner and a scotch on special occasions. I love the taste, the dimension, the artistry that can be found with alcoholic beverages. I've even been happily intoxicated on occasion.

There's a turning point, a threshold that people pass when they immerse themselves completely into habits that destroy the function of their body.

I wash bodies for a living. Every day, I help someone to eat, walk, communicate or clean themselves. I hold reverence for their bodies and the function those bodies have in housing the special being that makes the individual. I'm gentle even when the patient is not. It's a gift to be there cushioning the body, encouraging someone to respect the majesty of their own body when they don't see it themselves.

I treat the open wounds of my patient tonight. I hope that she wakes from her sedation and recrosses that threshold into a place where she respects the gift of her body. I hope that my cousin rediscovers his own gift before he destroys it completely .

The Fountain

People often ask me at work why I want to go into medicine instead of nursing. I often say in partial jest that I don't like poop. The other, non-jesting half raised it's head last night.

An elderly patient was admitted with a broken hip from a local nursing home yesterday morning. Throughout the day, XRAYs were taken, EKGs performed and Ike* was medically and cardiology cleared for surgery on Monday. It was an arduous exhausting day for the poor, confused man.

As the evening progressed, Ike began to become more confused. Sundowners syndrome is a common phenomenon with some disoriented elderly people. In Ike's case, he became spatially disoriented and lost control of his bowels.

His nurse, Tina and I noticed his incontinence and gathered the supplies needed to clean him up; washcloths and towels, bedclothes, a new gown and Proshield, a skin protectant. We rolled him to his unfractured side and I began the cleaning process.

Afraid that he was going to fall, Ike began howling and let his bowels loose. It was Old Faithful. For several long moments the stool shot up into the air, splattering the sheets, the bed rail and my shoes. I quickly grabbed the clean towel and, in a futile attempt to dike the flow, placed it against his backside.

After the fountain tapered off, I gingerly took the towel away and resumed my wiping. Whoosh, the geyser erupted again spraying the front of my shirt. I snatched the bedpad and all the washcloths and again tried to dampen the flying stool.

This cycled continued for at least 20 minutes, all the while Ike was howling, Tina was trying to reassure him and I was trying to trench the lake of poop. It was awful. Tina was rubbing his back, whispering to him and avoiding my eyes. She snickered a couple of times but for the most part, stalwartly restrained her laughter. I'm sure that I was a sight; covered from shoulder to toes in poop and frantically using anything handy to stop the pool from cascading to the floor.

Later, as I wiped the streak on my cheek away in the staff room shower, I couldn't think of any of my more noble reasons for preferring medicine to nursing.

*all names and details have been changed to protect the identities of anyone who may be totally embarrassed by the occurrences that I described.

Ethics of Eating

There's a patient on the unit, a friendly undemanding young woman. Except for her diabetes and the cellulitis that brought her in, she has no other major medical issues. Which is surprising because she's beddridden due to obesity. She would need to lose over a hundred pounds to reach a BMI of 100. She's too heavy for any of our bariatric lift equipment and, though she rolls well in bed, two of our nursing staff have been hurt cleaning up her incontinence.

In his very first order set, the hospitalist requested Physical Therapy and Occupational Therapy to work with her 3x daily. The amazing strong gentlemen of our PT department were able to bring her to the edge of the bed (not an easy task for anyone on an airbed!) and do some ROM exercises with weights! We were so happy and proud of *Dolores. Then...

She refused. Every time someone would try to help her to the edge of the bed for meals, encourage her to use her little hand weights or ask her to try any form of exercise, she would become angry and uncooperative. She would throw the weights onto the floor and become unresponsive.

*Dolores is not this patient's name. All details have been modified to protect identities of both the patient and the hospital staff.

It's been six weeks since she arrived at the hospital. Her infection has cleared and she's medically well. The nursing home she came from no longer has a bed and other nursing homes/rehab centers won't accept her until she demonstrates some willingness to work on regaining functionality.

Our dietary service limits the concentrated sugars and carbohydrates she's served but her mother keeps her well supplied with candies and soda pop despite our requests that she not.

Every time I work with Dolores, I'm frustrated. As an aide, I have little autonomy in my work with her. I cannot refuse or limit her HS snack without a calorie restriction order. I cannot force her to use her weights or incentive spirometry. I cannot search through her mother's tote to prevent the mars bars or cherry coke from entering the room and Dolores' digestive system.

I've always adhered to Kant's categorical imperative (the second formulation). Shadows come though, as Kierkegaard predicted, because people are freakin' LAZY. Unchecked, people don't behave rationally. Dolores' laziness has become pathological.

Do we have a responsibility as healthcare givers, to set limits and enforce regimens on those who refuse to adhere? It becomes a catch-22 when someone refuses care but is too weak/ill to go home. What do we do when they're refusing care and refusing to leave?

Do we have the right to become enforcers, trumping their free will in these situations?