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