Yet Another Nursing Dilemma

Of course as nurses we often have daily dilemma's because caring for people can be messy, does not always fit into any ethically correct template, all those variables of people, family, diagnosis, living arrangements, emotional state, motivation or lack of it play into the outcomes of the nursing plan I devise at admission.

I have this patient, lets call her Alice, she lives with her mentally challenged brother who is high functioning but certainly not capable of making any of the household decisions.  Alice has COPD caused undoubtedly from her addiction to cigarettes.  She is admitted to the hospital on average once a month due to an exacerbation of COPD, is on 6 liters of O2, still smokes at least a pack a day.  Alice has type 2 diabetes caused undoubtedly from extended use of steroids for her COPD and an addiction to fast food, she is low income and so I have organized meals on wheels to be delivered every week, she is completely home bound so I also organized a food pantry to deliver to her every week.  She orders out fast food to be delivered daily.  The end of the money always comes way before the end of the month.  She cries and cries by the 20th of every month that she has no funds to feed her or her brother even though the fridge and freezer is full of donated food she does not want to eat.  She is estranged from most of her family due to her unhealthy lifestyle, they are all exhausted with trying to help her, so Alice is basically alone with her brother.

Alice has pulse ox consistently in the high 80's on O2 and her blood sugars are regularly over 250 in the morning if she takes them at all.  There are many other diagnosis including colitis, depression, fibromyalgia, cataracts to name but a few.  She sees her physician monthly (when she is not in hospital) but he has all but given up on her because she never follows instructions.

For the past 18 months I have been seeing Alice, twice sometimes three times a week to monitor her physical status and teach/encourage her on smoking cessation strategies, compliance with a diabetic diet, and most of all O2 safety in the home (I am so afraid she will blow up her and her brother when smoking during O2 use).  Nothing has changed, if anything her physical condition gets progressively worse.  And in the midst of all this, we became friends, I like Alice, she likes me.  We start and end our visits with a hug.  She has my cell phone number memorized (not always a good thing!).  And so I continued to go and attend to her needs, and I know her physical therapist was working as hard as I was to help Alice reach her potential, all to no avail.  This week I realized I had become another one of her enablers.  It would have been easier if Alice were obnoxious, verbally aggressive but she is not, she is sweet and grateful and has no interest in participating in her plan of care.  I am no longer helping her in anyway.  So after a case conference with the team and her family doctor this will be the last week I will see Alice.

She cried when I told her, she scowled when I honestly told her why, she does not want to change but she does not want to lose her team.  Unfortunately when Medicare is paying all the bills you cannot have it both ways.  Above all that I realized Alice needs a new team, fresh eyes and she also needs to see accountability in her poor sick addicted life.  I am torn about this decision as I am certain it is the right direction to go but I also struggle with Alice's perception that I am abandoning her.  I continue to explore the benefits of keeping a nurse patient relationship therapeutic, sometimes its not as easy as the text book says it is!