Nina Gaby is a writer, visual artist, and advanced practice nurse who specializes in addiction and psychiatry. Her essay “Yours” appears in the Spring 2020 issue of the Intima.
Lisa Jacobs’ story “Doctoring and Disobedience” (Spring 2020 Intima) was gratifyingly evocative, reminding me of promises I had made to myself as a nursing student and then a psychiatric nurse practitioner. Trying to satisfy both ones own ethics while following the wishes of the family or the legal rights of a guardian makes for often difficult treatment decisions. As we can see in Jacob’s piece, these challenges can rip systems apart, especially when the system itself is not handling things with the guiding principle of good patient care. As Jacob describes of the team caring for a patient who was not to be told she was dying: “[Ruth] Had no clue the internal medicine docs were pitted against the surgeons over her, or that her favorite nurse had stormed off the unit in a fury.” I was often that nurse, storming off, until I became an independent practitioner, able to make my own decisions. But that did not eliminate the numerous confounding factors.
An old patient, ‘P,’ had come back into my life. Significant psychiatric disorder, some developmental delay, and now dementia. A patient known to me for years from another setting, a very different situation from Jacob’s patient but the similarities around patient empowerment struck a strong chord.
In the outpatient clinic where the patient was now referred to me, our nurse did the medication reconciliation, got vitals, and came in to tell me that the patient’s guardian¬¬ as well as the current caretaker who was also with them, said I could not talk to the patient about medications. “Well first of all,” I answered, “I started ‘P’ on those meds a decade ago, and secondly, it’s my job to talk to patients about their meds.” I was already revved up–as if treating someone like they weren’t allowed to understand or question their treatment plan made good care, or as if I could not tap into the prior relationship? The nurse grimaced and said that the caretaker is on her last nerve and the guardian can’t have the patient at their home. If the patient loses it and refuses the medications, becomes agitated and possibly violent, the caretaker might quit. I muttered something about ethics and my old patient’s right to informed care, and the nurse ushered the three into my tiny office.
‘P’ was cooperative, remembered me well despite the dementia. I was careful, approaching that I would be the med person again in a roundabout way, then did a little simple teaching. The four of us chatted, determining that a dose change for one of the ‘as needed’ anxiety meds made sense, and then the patient was sent by the guardian to the waiting room. Before leaving I asked if there were any questions. ‘P’ hugged me and said no, everything was okay.
“I told you not to bring up the medications,” the guardian said after I closed the door.
“It was really good to see ‘P’ again,” I deflected, needing to move on to my next patient. “Let me know how things go with the PRN, we can tweak if need be.” I was satisfied despite the look on the guardian’s face.
The next day the caretaker called to tell the nurse that ‘P’ did become agitated after the visit, initially refusing the meds. But, “miraculously” accepted the PRN and calmed quickly. So at least I did that right, I thought to myself. But my advocacy could have resulted in a very different outcome.
And here is where the two stories diverge. When do we protect? When do we overstep? When is it more about us than them? Was there really an issue here? These are always important questions in nuanced medical decision-making. What I appreciated most about Jacob’s piece is that she carefully explored the dynamics of the system and her own internal struggle with how the patient was being handled before she acted.
As Jacobs writes, “The truth can save lives.” I agree, and understanding whose truth is the most critical distinction.
Nina Gaby is a writer, visual artist, and advanced practice nurse who specializes in addiction and psychiatry. Gaby has worked with words, clay, and people for five decades. Her essays, fiction, prose poetry, and articles have been published widely, most recently in Psychiatric Times, The Rumpus, McSweeney's, and The Brevity Blog. She was chosen as runner-up in Quarter After-Eight's Robert DeMott Short Prose Contest and in The Diagram. Her artwork is held in the Smithsonian, Arizona State University and Rochester Institute of Technology. Her anthology “Dumped: Stories of Women Unfriending Women” was published in 2015. She exhibits her mixed media widely in the Northeast, and maintains a clinical practice in psychiatry. In addition to a Master's degree in Psych-Mental Health nursing, Gaby holds a bachelor's degree in Fine Arts, offers trainings, workshops, and has taught at several universities. Find out more about her work at www.ninagaby.com.
©2020 Intima: A Journal of Narrative Medicine