Moments of Clarity

WARNING: This post contains language that may be offensive to some people.

What made my night so busy last night was two of my patients who were incredibly combative - Mrs. Roman and Mr. Chi. Mr. Chi punched me twice - once in the arm and once in the breast. And I don't believe a word of what they say about people losing muscle strength as they age - that man had an awesome right hook!

Mrs. Roman scratched my face, spat at me, and attempted to bite me. Both of these patients, I should explain, have dementia. Neither of them spoke English as a primary language. I pick up these types of cases all of the time and find them heart-breaking. First of all, I try to imagine living with dementia - that has got to be frustrating and frightening much of the time. And add to that the perspective of not being able to communicate with others and hearing what people around you are saying as jibberish - that must be so terrifying.

I live in a metropolitan area and actively enjoy breaking down language barriers through using translators and taking advantage of whatever little I know of a patient's primary language. But with dementia patients, the language barrier is much larger. Neither a translator (unless the family translates) nor my broken version of their language seems to suffice.

Back to the punching, spitting, cursing (we'll get to that), pinching (oh, yes, Mrs. Roman pinched my arm, too) and such...

I go out of my way to be extra calm, friendly, and affectionate with dementia patients. For those that don't speak English, in particular, a gentle warm hand resting on their hand can speak so much more than words can. And even with the spiting and cursing, I maintain my calm.

When the fists appear however, I become a firm and strict mother-figure. Last night, catching Mr. Chi's fist in my palm, I calmly but firmly stated, "No." I left the single word hanging for emphasis a moment before continuing. "Hitting is not acceptable." I got a glare in response but he stopped using his body to communicate with me. Despite the struggle, I was able to get the task done - whether it was changing his diaper or listening to his heart.

Every time I entered Mrs. Roman's room, I either got the cold shoulder or a shower of profanities and insults.

Mrs. Roman: You bitch! [She knew a few words of English that came in handy.]

Mia: That's not a very nice thing to say. I know you don't like it, but if we don't change your position in bed every few hours, you'll get a bed sore and they're very painful.

Mrs. Roman: You crazy!

The skin on Mrs. Roman's feet was so dry that it was cracking. I rubbed lotion into my hands to warm it before applying it to her skin. Despite this precaution, Mrs. Roman yelled out.

Mrs. Roman: You stupid!

Mia: Mrs. Roman, I am just putting some lotion on your feet. They're very dry.

As I applied the lotion, using a gentle massaging motion, Mrs. Roman stopped ranting. But continued to give me the cold shoulder as I tried to make conversation. I'd worked with her a few days earlier. She'd been combative then (that's when I got pinched), but had not been giving me the silent treatment. This was new.

When I left the room, I went to review the doctor's notes from the day. The doctor had had a long conversation with Mrs. Roman's daughter about the goals of care. Her daughter agreed that her mother did not want a feeding tube put in to have her medications and foods forced on her through - in fact, it was highly likely that she would pull it out. (Mrs. Roman was refusing all of her medication and refusing to eat). But Mrs. Roman's daughter still wanted her mother to be a full-code, making her ineligible for palliative care.

An hour later, I peaked into Mrs. Roman's room to see if she was sleeping and she called out to me.

Mrs. Roman: Honey, honey, come here! [I think Mrs. Roman refers to all of the nurses as "honey"]

Mia: Hi Mrs. Roman. How are you doing? What can I do for you?

Mrs. Roman (sounding apologetic): I crazy.

I rested my hand on Mrs. Roman's for reassurance. In addition to the dementia, Mrs. Roman has a history of psychosis.

Mrs. Roman: I take tablets now. Two tablets.

Earlier, Mrs. Roman had been on agreement that she would take only three tablets at a time. However, she had been refusing all medicine over the last 24 hours. So I was happy to get to pick even two of the dozen she'd refused.

Mia: Okay, great. Let me go get them for you.

As she held the cup with the two pills in her hand, Mrs. Roman told me about her daughters and her grandchildren. After telling a few brief stories, she paused, cup still in hand.

Mrs. Roman: I want to go home. Not today. Tomorrow.

Mia (softening my gaze): You want to go home?

Mrs. Roman: Yes.

Mia: I'll let the doctors know.

Mrs. Roman (smiling slightly for the first time all night): You good girl.

Was this a moment of clarity? Was the refusal to eat an acceptance of her terminal diagnosis? Or was she depressed and thus attempting suicide in the only manner she was able? Was this a moment of inner wisdom about her prognosis and was this the best way she knew how to communicate it? Or did she literally simply want to get out of the hospital?

Many people view an end-stage patient's desire to leave the hospital while still acutely ill as a way of saying that they are ready to leave this world - a belief that home may be both literal and figurative. And I have always believed that even with patients who are somnolent as they approach their death, there is an inner, wiser self that lingers. I don't doubt that this is true for dementia patients as well.

A note explaining the combativeness of these patients: Dementia patients are not normally combative. Neither of these patients were combative prior to the illness that brought them into the hospital. Both of these patients had developed infections which, as it does to healthy elderly patients, caused delirium on top of their dementia. If you know someone who has dementia whom suddenly becomes combative, they should be assessed to determine if they may have developed an infection.

There is so much medicine has yet to learn in order to fully understand dementia. It is unfortunate that in this case, the disease itself prevents the patients from describing to us what is going on in their minds. I wish for both Mrs. Roman and Mr. Chi as many moments of clarity as their illness will permit and for those moments to be spent among loved ones who will appreciate them all the more.