81.  ANOTHER HORRENDOUS SITUATION

I want to add a postscript to my work of this past week...a case I saw on Wednesday, which apparently affected me very much...so much so that I haven't been able to put it into words until now.  The patient and his wife were temporarily living in a large renovated white apartment house in a section of the city with which I was not familiar.  It took me quite awhile to find the building and then to locate the correct entrance door.  Then I walked upstairs and down a long corridor looking for the numbered door.  I knocked and waited for several minutes.  When I got inside, I was immediately engulfed in hot air...the room was stiflingly hot, at least 90 degrees F.  I took off my coat, boots and sweater, but I couldn't doff my wool-lined slacks or the warm tights worn next to my skin for extra warmth in winter.  I soon became exceedingly uncomfortable.  The wife explained that they had no control over their heat.  The patient was sitting up in a chair because he was too weak to walk over to his bed.  He was a large, tall man dying of cancer of the mouth, metastized.  He was grotesque in appearance, with his mouth hanging open and his swollen tongue protruding.  He couldn't speak, but his expressive eyes told me immediately of his great discomfort and despair.  His face was misshapened; his feet and ankles swollen.  I was absolutely horrified to see a human being in such distress.  When I touched his forehead I immediately knew he was feverish and probably dehydrated.  He seemed to be in pain, also.  I took his temperature under his armpit, and found it to be 100 degrees F.  I asked his wife to crush two extra-strength Tylenol and administered these with water through the G-tube into his stomach.  Within ten minutes the patient appeared to be more comfortable.  I noted a foul greenish discharge from his mouth, and knew there was infection present.  He had not voided since last night.

This couple are Medicaid recipients and have moved from place to place frequently.  They have no regular physician, but were last seen two days ago in the oncology clinic of the city hospital.  I finally located the physician there by telephone; he was most kind and understanding, but didn't want to admit the patient to the hospital yet.  He asked me to arrange for Hospice services in the home.  I called the VNA and spoke with the supervisor who said that the admitting process for Hospice would soon be underway, and for me to inform the couple that a hospice team would arrive in a day or so.  I said that the couple was in dire straits, and needed a hospital bed and home health aide assistance right away, that two days hence would be too late.  I reviewed the patient's medications with the wife, who seemed to be trying hard to care for her husband, for the apartment was neat and clean.  She was; however, very small in stature and unable to either lift him or assist him safely in walking.  I considered trying to assist him to his bed with her help, but realized that there was too great a risk of his falling down.  I left there feeling very frustrated and sad that it would take so long to make this dying man comfortable.  I wasn't able to sleep well that night, as visions of that poor man floated before my eyes.  He and his wife seemed to have been abandoned by the community.

I have since learned from staff nurses that the patient with the advanced cancer of the tongue had been admitted to the hospital shortly after my visit, where he died a merciful death.  I felt relief that he was no longer suffering, and that my initial assessment had been correct...he needed to be in the hospital receiving pain killers and comfort care for the terminally ill...not left sitting up in a stifling room with his tiny wife trying to administer to his overwhelming needs all by herself.  I wonder what different information was given the physician by the hospice team which prompted him to readmit the patient.  Possibly this physician had worked with the hospice team previously and trusted their judgment over mine.