So after stating how passionate I am about community nursing I have had a particularly challenging couple of weeks where I had to modify my personal code for nursing. This code includes all people regardless of age, socio economic status or sexual orientation not only deserve health care they deserve easy access to excellent health care. This has led me into situations of great poverty, some questionable safe environments that I would never tell my family about (my husband would never sleep again) but I am reassured by the fact that whatever the situation that person needed nursing in that moment.
So, the week before Christmas I was asked to admit a patient whose only insurance was from the Veterans Affairs Dept, lived in poverty, had limited family support but needed nursing services and possibly physical therapy. Well the place was filthy and the patient was elderly but no bugs (I hate bugs!). Mild dementia was apparent and during the course of my interview, due to the patients past work experience in security I felt led to ask the question "Any firearms in the house?" To which the patient replied, "Oh yes, plenty and they are all loaded and ready". Aahh, dilemma, elderly gentleman, not completely orientated on a good day with the ability to blow my brains out. This was a no brainer, I quickly said my good byes and backed out of the house keeping my eyes on his hands. But I was conflicted, not being able to put myself and other members of the team in his household was/is a deficit to this mans well being. Long chat with the family later, explained if the firearms are removed I would surely return....still waiting to hear A man and his gun are not easily parted.
Second scenario, a patient who I have had on my caseload for over a year, a non-compliant chain smoking COPD patient on O2 (always a good combination). Basically lonely and due to his, lets say, less than pleasant disposition has alienated most of his family. No problem for me, he's not my father, brother, uncle and so have always been able to separate myself from his caustic tongue and tried to give him a bit more company and conversation when I had the opportunity. However, over the last several months, maybe due to early dementia or hypoxia or both his conversation has become very sexually inappropriate not only to me but to other members of the team. I tried subtle hints of acceptable behavior which led to a full blown come-to-Jesus conversation of what he was and was not allowed to talk about. All of this did no good, but my attachment to him and my need to come through for him kept me there. But our therapeutic relationship continued to deteriorate. The past couple of weeks he has been incredibly well, chest clear, down to smoking one cigarette a day and almost normal pulse ox readings. I leapt at the chance and discharged him! Aah dilemma, I am no longer providing services to an individual with a chronic illness where I have had the ability to identify problems early enough to avoid several hospital admissions and there were no bugs so surely, how bad could it be!!!
Third scenario, another veteran (getting a lot of those, love them). Recently discharged after a lengthy stay in the VA for severe abscess that still would require long term wound care. I arrived at the house to perform the admission and the first thing I noticed was cockroaches and not just a few, I have never seen an infestation this bad, they were almost swarming in the house, crawling all over me and over every surface (did I mention I hate bugs!). Sterile, clean procedure.....forget it, just do the best you can. Family seemed oblivious to the infestation and accompanying hoarding (really ever played Marco Polo in someones house to find them!!). Of course I reported to the VA Social Work department and every other agency I could think of, may take them a while to respond. In the meantime, this guy, who I quite liked and had empathy for still needed wound care 3 times a week. So at the next visit I explained I could not come in the house but still wanted to help him (really had nightmares for nights of cockroaches crawling all over me!). So we came to an arrangement, he would come out on the porch and I would do his wound care without coming in the house. Its December....its freezing, so I wrap him up in blankets, expose the appropriate body part, do the care as quickly/safely as I can. I spend the time apologizing why I am making him sit outside in the cold, he spends the time apologizing for the state of his house, its mutual purgatory. Dilemma, I feel terrible making this poor man who has multiple chronic medical issues, including PTSD but I do not want to bring any friends along for the ride to another patient or to my own house.
So, even though I have this personal creed that all peoples deserve the best care at anytime, I have to constantly amend my own code of ethics to do the greatest good for the greatest number of people. Yep, I love community nursing, but I also love wearing clothes you can boil and the right/need to walk away when I absolutely feel I have to.
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