Shrinks Get it Wrong Sometimes - August 28, 2007

I work in a nursing home for a few hours each week in the South Bronx. It's near Yankee Stadium, a particularly daunting area of the city for unarmed, skinny guys wearing a tie and carrying a "How Do You Feel Today?" workbook. I started working there when I first got my license to practice, a common strategy among new Psychologists. Before you get to graduate school, you think that you'll one day just throw up a shingle and the phone will start ringing off the hook. Good professors disabuse you of that fact quickly and help you to identify real jobs that pay a modest salary while you network and build up a client referral base. In New York, many new graduates take jobs providing therapy to the geriatric population, ultimately decreasing their time over the years as private practice begins to unfold.

I've been at the same nursing home (also called a "Skilled Nursing Facility") for over 4 years now, although I have visited others. They are, for the most part, very depressing environments. The long and narrow hallways have patients lying on gurneys and sitting in wheelchairs, calling out to family members who never visit. The nurses are overworked and underpaid and are often forced to ignore screaming patients after having checked on them six times in the past hour for what they call "phantom complaints." Bedpans are everywhere and I've even had a patient throw one at me after I told her I couldn't write her a prescription for pain killers.

Most of the patients are depressed about spending their remaining years outside of the home. At some point they become too sickly to be cared for by their families, and most people in this part of the city can hardly afford home care. My job is to try to help many of the people here find meaning with their life, to help them "see the bright side" of having 24 hour care at their disposal, and to face the fact that they are, in all likelihood, in the final stage of life.

Erik Erikson, a famous Developmental Psychologist and Psychoanalyst, describes the life cycle as a series of psychological crises that are to be resolved. The first, "Trust vs. Mistrust," begins within the first year of life. The infant ideally learns through a nurturing mother figure that others can, within reason, be trusted. This establishes the foundation for positive and healthy interpersonal relationships in later life. The last stage is known as "Integrity vs. Despair," which is the stage for the patients at the nursing home. Essentially, a person looks back on his life at this stage and says either "I did the best I could with what I had, I lived as best as I knew how and my life was fairly well-lived," or "I am full of regret. I did not do what I wanted, my life was wasted." In reality, most of us hold elements of both mindsets, but if we can get close to the former, we experience significantly less psychological distress and greater overall life satisfaction.

After four years, only five patients remain on my caseload. I started with over 40. Some I have treated with success, others have resisted treatment or have intractable conditions (such as a blazing psychosis that won't allow them to open up to me), some begin to suffer from Dementia and are unable to effectively communicate, while others have passed away over the years. Unless you are specializing in geriatrics, they don't teach you much in graduate school about coping with the death of a patient, unless he or she commits suicide. It's assumed that your patients will all be alive when they are done seeing you, even if they're not psychologically healthy.

A few weeks back, my last patient of the day was "Andy." Andy is in his mid-80's, with a history of psychosis, although he has been stable for many years. While his memory isn't what it used to be, he is still cognitively sharp and is quite a chatterbox when his mood is at least somewhat upbeat. He'll talk endlessly about family, sports, and his girlfriend on the 3rd floor with whom he has lunch every afternoon. Today however, he was somewhat reticent, with a tinge of anxiety in his voice.

"Andy, how are you today? It's nice to see you."

"Doc."

"Right, I'm Doc. Catch me up on your week, man."

"Doc. Doc, there's something wrong."

"Tell me."

"I feel it, it feels like I'm dying. I know."

Because of all the residents at the nursing home are older and physically compromised, I do a weekly check-in with one of the nurses to see if there are any major changes in the patients' health. As far as the nurse knew, Andy was fine.

"Andy, I checked in with the staff, and they say that nothing is wrong with you. If you keep taking your medications and follow doctor's orders, there's no reason you can't live many more years."

"Doc, you're not listening."

"No Andy, you're not listening. Trust me, your nurses told me so."

I'm right, of course. I'm a Ph.D. I checked with the staff, he's fine. He's got a history of psychosis, he's being paranoid. This place is disgusting and I want to go home.

I leave Andy after about 20 minutes of what feels like unproductive arguing. One week later I'm back in the Bronx. "Dr. Dobrenski," the nurse says, "Andy expired."

Expired. The Politically Correct term for dying in a medical setting. I hate it. It's like he's a jar of fucking mayonnaise or something.

"When did this happen?" I ask.

"Last night. We don't understand it. He was fine. He died in his sleep."

I didn't understand it either. I called my mom from the nursing home. She is a retired nurse who spent most of her career working with the aged. I told her what happened and asked for some help in understanding it. My mom generally will take any and every opportunity to make fun of me and enjoy a laugh at my expense (when I was 18 she called me and pretended to be the hottest girl in my high school and asked me on a date, and then she and my stepfather laughed their asses off when I came down dressed in my favorite Duran Duran-type outfit). However, like most moms, she can hear her kid's distress, and immediately goes into helpful mode.

"Mom, how does this happen?"

"I don't think it's something you explain, it's something you experience. People know their bodies better than any doctor does. They can sense something is wrong, like an aura. Whether or not it comes up in a blood test or an MRI or CAT Scan is irrelevant, some people just know, like your patient did. I know you were good to him during your last session together."

No mom, I was a preoccupied, self-possessed prick who ignored Andy's last words to me and dismissed him like the fuckface I am.

"Mom, I gotta go."

I spent the next two nights drinking wine and pondering how much of an asshole I am. I proceeded to do the same for two more nights, adding thoughts about my own mortality and how I hope I don't end up with someone like me as their shrink if and when I'm Andy's age. I hate the nursing home because I'm scared of it, I'm afraid I'll end up there. Alone. I talked about it with colleagues and friends, and of course my therapist, who told me that I have a few responsibilities at this point. The first is to forgive myself for being human and fucking up, like all professionals do at one point or another. I also have to start to understand and embrace my own mortality, to recognize that I won't be under 40 forever, that I will be old and need to be taken care of, and to be prepared to deal with Erikson's final stage of life.

"All of us need to be prepared," she said.

I have a lot of work to do.

Posted by Rob Dobrenski at 8:00 PM

Print Friendly · Digg it · del.icio.us · StumbleUpon · Netscape

Comment Policy:

Anonymous comments are allowed. All anonymous comments and comments from those not registered with TypeKey are moderated. They WILL NOT appear until they are read and approved by a moderator.

It is strongly encouraged that you sign up and login with a TypeKey account. Once you do that, your comments will be immediately posted.

Comments

excellant.

Posted by: Anonymous at August 28, 2007 10:26 PM

you're going to be an awesome RM writer

Posted by: kakutogi at August 29, 2007 08:53 AM

Have you ever heard the term "Nearing Death Awareness"? Personally, I believe that an elderly or terminally ill individual can be aware of their imminent death. It's up to the people around them to listen for the clues and signs (non-medical) that can indicate the end of life. Interesting stuff!

http://www.amazon.com/Final-Gifts-Understanding-Awareness-Communications/dp/0553378767

Posted by: rhone_rhanger at August 29, 2007 11:18 AM

Wow.

Posted by: McNerd at August 29, 2007 11:20 AM

I thought that this piece was very impressive upon your part to admit even in writing. I hope that you pass through this period with at least some relative success.

Posted by: Anonymous at August 29, 2007 04:19 PM

Second on the wow.

Posted by: m at August 29, 2007 06:36 PM

i like the line about how we're not jars of fucking mayonaise

Posted by: zach at August 29, 2007 10:55 PM

Man, you are by far the most honest, interesting, and best writer on Rudius. As fun as reading about wacky things Japanese people do is, or reading about how some guy got really drunk and passed out naked somewhere (again) is, your writing really hits close to home, and seems like it really comes from the heart. This piece really hit close to home with me, as I refuse to come to terms with my own mortality. Thanks for putting this story out there.

Posted by: Charlie at August 30, 2007 02:25 AM

That's very deep. Moments like that are what makes me afriad of studying Psychology, even though I truely want to.

Posted by: Ninja at August 30, 2007 03:28 AM

that was a great piece. Sad, though. Do therapists really have their own therapists as well? that must be interesting, since you were trained to do everything he/she does.

Posted by: Ploin at August 30, 2007 11:29 PM

My Grandfather had dementia for a few years before he passed away. Before he actually went tho, my Gram said he woke up and his eyes were as clear as they ever had been when he looked at her, then he was gone.
I think one reason we ignore when people say their end is near, is because we want to believe they're just being paranoid. Even at the distance of a patient, we don't want them to be lost.

Posted by: wayward at August 31, 2007 02:03 AM

For Dr. Rob and whoever else abhors the expression "expired"...
In fact, first definition found in Merriam-Webster, expire means to breathe one's last breath: die. It's not only correct, politically and otherwise, it also serves as somewhat of a euphemism for the medical community.
I'm sure there is some psychological element that the good doc could tell us about, using terms such as this as a coping mechanism to steel yourself for death?
Imagine being in that environment, elbow deep in death daily... constantly contemplating the fragility of life because of witnessing so much death.
Ugh, exhausting... let them have "expired" even if it sounds like a spoiled jar of Hellman's to the rest of us!

Posted by: DidiStriker at August 31, 2007 11:02 AM

Fantastic piece. Very thought provoking. You are by far the most interesting writer on RM. Keep it up.

Posted by: kristine at September 1, 2007 08:55 PM

wow, good piece, sounds like the fear of death
is setting in prematurely though, hah.

Posted by: Matt at September 2, 2007 10:58 PM

Question.

You only felt really bad about it all after you knew he died, yes?

On the one hand...I'd wonder if you thought it was cold at all to have treated him that way if he hadn't died. Was the way you acted right even in that case?

I don't particularly want to be too mean today, so I'd also make it a point to say: you checked history and medical opinion, and you went with what you felt was sensible at the time. What the hell kind of doctor chooses what makes no medical sense or could end up harming a patient?

Throw around "Could have, should have" as much as you want, but don't dismiss yourself so harshly. The medicine we have today comes from the "Could have, should have" moments of the past.

I guess the feeling I want to convey is, it's about the same as you beating up on yourself for not saving somebody who dies of old age.

I don't find this a criticism from me, but it may be something you consider yourself: have a hard think about whether it's right to treat a person the way you did (since you didn't really specify) regardless of whether they're dying or not. That should give you some answers for yourself, and hopefully reaffirm whether you're really feeling right or not.

And 'scuse me if I'm just rambling.

Posted by: DC at September 3, 2007 04:44 AM

This is why you need to buy Long Term Care insurance; it is cheaper when you are young and it will provide the financial support you will need one day to get the care you will need on your own terms.

Posted by: future colleague at March 5, 2008 04:03 PM

I have an unhealthy fear of death, which is the primary reason I actively avoid working with the geriatric and terminal populations. They say it is important for each clinician to know their boundaries, but this whole death thing may prove to be problematic down the road. I can't wait until I can regularly afford to see an analyst.

Posted by: Therapeutic Ramblings at March 14, 2008 05:19 PM