The Meaning of Life

Yesterday I had a three-hour shift. It is one of my regular small shifts which are arranged when the nursing home cannot fill up the schedule. Except that it wasn't a regular shift.

I entered the nursing home, expecting an easy-going shift. Usually, all I have to do is watch my patients and help them get lunch. I like this type of shift as it leaves me time to spend much-needed individual time with patients. For these people, I also need the time, since two of them have been physically fighting any chance they get. This day seemed like no other day. Everyone was very calm, which is very beneficial to especially patients with dementia. I discussed the patients with my colleague from the previous shift.

"Well, everything is calm and peaceful. Patient A is on a walk with her family. Patient C has been experiencing shoulder pain and we're keeping track of heart rate and blood pressure to rule out cardiac involvement. So far it seems OK, but keep an eye on him. Oh, and did you read the recent emails?"

I answered that I've not been working lately so I didn't read the emails.

"Patients D and E have passed away. Patient D died a week ago and is already at the undertakers. Patient E died last night and is still in his room. The room is locked."

Patients D and E. The patients who were fighting ever since E got here. Two patients in four days, no wonder it's calm. We talk about them for a bit. You never get used to deaths. I talked about this before after experiencing my first deaths. My opinion hasn't changed and I've been told that it will never get easier. Still, this is a very confronting way of deatg, with the patient still being present.

At the nursing home, life goes on. We can't stop every time someone dies. So I tak a bit with my patients and help them get lunch. Two plates less than usual. After lunch, many family members come visit the patients. I don't know many of the visitors. Two women enter. They look lost. "Can I help you?" I ask. They appear to be E's family. They ask me to open the patient's door. As I do this, I see the patient. He looks peaceful. His wife is very sad, his daughteris more relieved. I can understand their feelings. The patient has made it very clear that he never wanted to live the way he did for his last months. Still, it doesn't make his death OK.

I leave the room so the family has some privacy. In the living room, it is very calm, almost too calm. But not for long. Patient C needs to go to the bathroom. I help him get to his room. He tells me his left leg hurts. I find out that his pain, previously in his left shoulder, is now in his left side, radiating to his leg. His pulse is 115. I get a colleague who checks his blood pressure (normal). She decided to call the nurse, though, as his pulse and pain are a cause for concern.

My three hours are up and my colleague takes over. I leave the nursing home. I don't know how patient C is doing. Patient D and E are still dead. It left me thinking a lot about death and the meaning of life. What do I want out of my life? Why does it even matter? Will I ever be able to answer these questions?

Medical Ethics

Ethics is a word commonly associated with medicine, especially the negative adjective form - unethical. A lot of things are unethical. Providing opportunity for abortion and not proving this opportunity. Not informing your patient about upcoming procedures. Most aspects related to medical ethics are regulated by law. Where I live (don't bother asking, trying to keep up the illusion of privacy;)), there is a specific law protecting the staff and patients of psychiatric hospitals. The dementia-care part of the nursing home I work at is also considered a psychiatric hospital, so we have to abide by those laws. I did not receive any information about the law yet (which is crazy, but that's another story), but I did learn a bit about it. When we install a motion sensor to increase the patient's safety (because of an increased risk of falling, for example), we have to fill out a form, signed by a physician. This is because it limits the patient's freedom. No problem so far.

Another rule is: never ever lock a door unless on doctor's orders. Again, because the limitation of freedom. Here's where it gets interesting, from an ethical perspective. One evening I was independently running my 'home', as we call it. About ten 'homes' have access to the same hallway, which is password-protected to prevent the patients from going outdoors (by the way, it's also where this happened). Conclusion: the hallway is safe. Still, it is inconvenient, because your patients are not together and can wander through that part of the nursing home. That's why some staff members elect to close the door so everyone is contained, which is easier as they know where everyone is. An illegal action, which is also unethical.

Up to that time, I learned to think about rules in a practical sense, because it was clear that I couldn't work there if I followed all rules. Not that it's a bad nursing home, but coworkers don't like when you say that you can't watch the patient drink their med solution because technically, it's not allowed. But overstepping both legal and ethical boundaries, no way. That day, a particular co-worker asked me to lock the door because "I couldn't work like that, right?". That's what is so scary about overstepping boundaries: when are you sacrificing your patient's well-being for your own comfort?

I think there should be stricter enforcement of rules and laws. I practically have no choice but break some rules, but it is much clearer if no one ever has to. Because sometimes unethical decisions are made based on work load or social pressure. But there is still responsibility. So, politely but without hesitation, I said no. No, I will not compomise my patient's freedom for my own good. Will I make the same decision in five years, or will I get tired of searching everywhere and just lock that door? I don't know. I hope not.

Why I Hate Medicine

Now I know this goes against what I said before, but some parts of medicine are almost unacceptable. They are nearly unjustifiable, regardless of the good moments. I do not know how solve the problems, nor do I pretend to know. Still, even with my limited health care experience, I can see there is something seriously wrong.

Just like anyone properly preparing for university, I read about how (in my case) doctors experience their profession. I am surprised by what I read. Apparently, a lot of great physicians quit their jobs because of the increased workload. More patients in less time means not taking the best care of your patients or skipping breaks to have more time. With the first option there will be less gratitude and satisfaction, the second option is a sure way to a burnout. Either way, the original rewards of medicine are limited because of the workload.

In addition to this, the education of soon-to-be doctors is not exactly patient friendly either. I am sure there are many avoidable mistakes happening during the education of medical professionals. I am glad I did not make any serious mistakes yet during my seven months of dedicated improvisation, but to be honest, I'm also surprised. So how can all of this just happen?

My guess: money. Doctors are expensive. There are a lot of people who want to become a doctor, so this shouldn't be an issue. The only reason left is that increasing workload limits the costs. This seems to make sense: nobody would be thrilled to not increase workload but charge patients instead. Either way, the patient loses. And isn't the patient the center of medicine?

In an ideal world, doctors have enough time for patients so they can take good care of them. To achieve this, a doctor now has to agree to earning less and less. A great risk, considering the costs involved in education. I never wanted to become a doctor for the money, but is it worth having to worry about income? I do think so, but medicine is not only about passion anymore. It's about planning and scheduling and finances (and I haven't even covered law suits yet). That's what I hate about medicine.

Life or Death

Actually, life, death and everything in between. It is one of hard things when dealing with vulnerable people. Sometimes people are unmistakenly alive in every aspect. They are independent and lucid and completely able to do what we consider to be normal. Then there are deaths.

Deaths are, without exeption, very tragic. A friend's mother, still far too young, dying after a car accident, a little boy dying of cancer, but also the woman with progressed Parkison's who can't move, can't speak, can't think, can't understand. Yes, it might be better for her and for her increasingly worried family. But that does not make any death OK.

But is death really the worst thing imaginable? There are a lot of gradations between life and death. In a lot of circumstances, death is obviously worse. I cannot imagine a world where a good quality of life is exeptional. I know there are times and places where it is a luxury and I am very thankful to have such an easy-going life. But even in my limited world, certain ethical questions are raised. Is a poor quality of life better than death? Who gets to make decisions like that?

Personally, I draw the line at being sane. I would be able to live with physical handicaps, but dementia could very realisticly drive me crazy. The thought alone of losing my memory and the safety of reasoning... I don't think I would want to live like that. But when do you decide to die? When you are still lucid, you are not yet at the point where you think life is pointless. Then, when the dementia has progressed, nothing you say makes sense as you lose the skills to think long-term. This is probably why so many people are in this debilitated state of confusion. Or would they be OK with their bodies deteriorating until death?

I don't know how geriatricians deal with this. I'm not even sure whether I could be one. How can you go against your moral standards every day? Life can be so mean.

Family

October 11th, 2011
After school, I head straight to the nursing home. I had been called while at school: did I mind to pick up a short shift in a few hours? Of course, I couldn't say no. I never say no to extra shifts because I actually enjoy my job (and I don't have to do my homework for a few more hours). Also, it was an afternoon shift. I like the afternoons best as it is the only time of the day there is not much to do, which means you have time to play games and have conversations with the people you have to disappoint too often. "Sorry, no time, I will come to you ASAP." Today, I have even more time than usual. One patient has to go to the dentist to have her dentures fitted and the family specifically requested for a staff member to be present. Would I mind going with her?

Thirty minutes later, the patient's daughter arrives. She is also coming with us. I wonder why she requested a staff member to come along. The transport is completely arranged and there was nothing specific I needed to do. But by then, I had already learned that requests from family make sense most of the time. I introduce myself to the daughter and we prepare to leave.

We sit in the taxi. The daughter starts talking with me. Do I work there full-time? I tell her I still go to school and hope to become a doctor. She is enthusiastic about this. I seem to enjoy my work very much. I confirm this and we discuss health care in general. She tells me about her son, who is both mentally and physically impaired. From her way of speaking I know she loves her son very dearly, but she is still struggling with lost dreams. Dreams of her son becoming independent and being healthy and achieving whatever he wants. She wants her feelings to be heard and acknowlegded.

When we return to the nursing home one hour later, I know why I had to come along to the dentist. Although it seemed like I didn't do anything - technically I was completely unnecessary - I think I know why I had to come. In the 90 minutes we were gone we, as in the daughter and I, had an ongoing conversation. The patient with dementia enjoyed our companion but could not actually take part as her dementia had progressed too far. The daughter was very uncomfortable with this and just really needed to talk to someome.  Sometimes, matters are more complicated than they seem. Especially when dealing with patients of their families, things are rarely straightforward. They don't teach you that in any school. Still, it is important. The family probably won't remember my name, or if I knew everything without asking for help, but the impressions of that day last a long time.

Why I Love Medicine

About three years ago I decided I want to become a doctor. Before then, I never really considered to go into medicine, for no particular reason. Then, suddenly, all my interests came together. I have an endless fascination for biology (the human kind, not the endless plant talk!). I always enjoyed science, from mathematics to physics to biology, but my test results have always ranged from exceptional to below-average, without any consistent trend, because I perform much better on oral exams. I like thinking and have always wanted a job where I could keep learning. It all made perfect sense intellectually.

And then I got my job at the nursing home. In a way, it changed my vision on medicine completely. There are things you just miss when you're in school.

The supposedly grumpy old man, whose face lights up when he sees you because you 'are careful and patient'. The lady who barely seems to have anything left, who one day proudly shows a picture of her great-grandchild. The moments when patients with dementia are relatively clear and calm and content. Or when you suddenly have the time for some one-on-one time for a less time-consuming patient who needed help but didn't dare to ask for it 'because everyone is always so busy. Those moments are far more important than my difference in aptitude for math and biology or other unimportant matters. It's the small moments in the chaos of medicine. I even consider nursing if med school doesn't work out. Try to explain that to my rational self.

The New One

It's been six months since I started working at the local nursing home. Originally a summer job for six weeks, but I never left. Gradually, there is a transition from being 'the new one' to being experienced enough to solve most problems independently. I can imagine this transition is faster than in most professions because of something most health care professions have something in common: there are not enough people to carry the workload.

During the first few weeks I was surprised about the amount of responsibilities I would have, as I was completely untrained and inexperienced. During evening shifts, I am alone, attending to about 8 patients. I need to know what they can and cannot eat and drink. Without any medical training, I need to be aware of the consequences of diseases. I was also unpleasantly surprised about finding out how easy it is to access patient records. No background checks before I was hired and no limitations to browsing through information of every patient I worked with. Why would they ever do that?

As I worked more, I had a lot of contact with more experienced nurses and assistents. Sometimes I would hear them complain about a colleague who was completely unmotivated and made no attempt to hide it. Still, that person had not and will not be fired. Why? There is no one to replace them. I realized this was the reason why I get so many responsibilities: they have no choice. Not enough trained personnel. The access to patient records is also related to this problem. Patient records are essential in providing good care. When temporary employees are considered substitutes instead of helpers, they do need the access.

The most important question in this situation: is it really a problem? I do think it is. The steep learning curve may be necessary and there is supervision during day shifts and there is always someone available when questions arise. This is not unlike medical school and I have learned a lot during the last six months. My real concern is the vulnerability of the patients with this construction. People are hired too easily. 16 years old? No problem! History of abuse? As far as I know, they would not find out. If they do hire someone who does not belong in a nursing home, this person is only fired in case of serious misbehavior, because there needs to be replacement. During evening shifts, you are alone 90 percent of the time with 8 patients. In my opinion, this system carries a large threat.

Just An Ordinary Day

A woman I don't know comes walking towards me across the hallway. "Help! Hėėlp! I'm being abused!"
I am at the psychogeriatric part of the nursing home. In other words, the place where patients with progressed dementia have a safe environment adapted to their specific needs. In theory, because it is hard to manage a group of patients often harmful to themselves and others.
The woman, who has now reached me, is clearly upset. I quickly screen her, as I learned to do over the past months. I look at her and try to assess her mental status. Her incoherent answers to my simple questions tell me she does indeed suffer from dementia. (Important lesson: never assume. I can imagine that upset family members would appreciate a different approach.)
"Hèèlp! Police! Oh, finally. Someone who can help me. Let's go to the police station together."
I try to calm her and convince her that it is not a good idea to leave the nursing home. From the fact that she starts trying to hit me, I conclude my approach is not working. I find out where her room is and take her there. As if a switch was flipped, her mood changes instantly. No one is abusing her anymore. She continues wandering around the building like nothing had ever happened.

Just ten minutes of an ordinary day. They left me thinking. Only then I realized how vulnerable this group of people it. The chance that she was actually abused is small - she also talks about how she should get home to her little kids - but still. If she was abused, would I believe her? Probably not. Everyday there are many concerns like this. Even if it is just an ordinary day.

Day One

July 2nd, 2011
Nervously, I step inside the room. The smell of bodily odors is even stronger than it was in the hallway. Before me lies a patient in bed. She seems to be staring at the wall. The nurse I met this morning - now my colleague, introduces me to the patient. No response. I am told that the patient has Huntington's Disease, a hereditary, degenerative disorder leaving her unable to speak, move or even think. This explains the apparent lack of response. I feel uncomfortable and I wonder how I should react. But even more, I wonder why I ever wanted to work in a nursing home.

Two months earlier I was looking for a job for the summer. Since I had decided that I wanted to become a doctor some years ago, I looked for a health care related job. The local nursing home had a position for 'patient care' available - there was never any clarification beyond that. I applied for the job after deciding that I was fine with everything they could ask me to do: washing people, cleaning up rooms (and poop), it was all worth the experience in patient care. After all I figured that someone needs to take care of these things and I know there are great nurses who thoroughly enjoy their profession. To my surprise - somehow I did not expect to be qualified - I was hired. A training day followed, where we learned the basics of dementia and patient lifts. After this, I received my work schedule. I was eager to start.

After this short and awkward introduction, we get to work right away. Soon enough I find out that I am indeed expected to wash patients. But first I can watch and assist a couple of times to get used to everything. Within three minutes, the patient is undressed completely. I watch the nurse, who routinely but kindly washes the patient. I try to hide the unwelcome, but almost inevitable sense of disgust when watching the cleaning of the patient's intimate parts and just hope I succeed in observing with a facial expression as neutral as possible.

As the day progresses, I find out more about the eight patients I will spend the next six weeks with. The poorly controlled diabetic with two fingers already amputated. The woman who has been blind for over 40 years and still struggles with this from time to time. The friendly old lady who came in for rehabilitation after a broken hip. She just heard that she is never able to return to her home due to progressing Alzheimer's. I try to help them the best I can. They are glad to have someone to talk to, someone who listens. I have never been much of a listener, but now I feel the importance. I tell myself to remember this:

-Listen to your patients. Pay attention to their needs. Never, ever get so busy you ignore this, because it is supposed to be your priority.

Eight hours later I had survived my first day at work. I felt very humble surrounded by so many sick and debilitated patients. I did question my abilities more than ever - am I able to provide the care these patients need? Will I be able to feel comfortable doing this job? How on earth will I ever be able to make life or death decisions as a doctor? I hope the next six weeks will provide some answers. Maybe.