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Fluids & Electrolytes
I didn't think I had much to offer my home health care patient, but I unexpectedly met some of her needs that snowy day.
THE SUN GLITTERED on the snowbanks lining the road as I drove to my first home visit that Saturday morning. At least it's not snowing today, I thought, recalling the primary nurse's description of her scary drive to this patient's home the day before. She could barely make out the road through the heavy snowfall and blinding winds. When she got to the house, she learned that the blizzard outside wasn't the only storm this patient faced.
Several weeks ago, our patient Ann was being treated for pneumonia. When the medication her physician prescribed didn't help, she'd been admitted to the hospital for testing and treatment. She'd been relieved, certain that all she needed was some rest and stronger drugs to overcome the illness.
Just 2 days ago in the hospital, Ann had learned the awful news. She didn't have pneumonia after all; she had lung cancer that had already metastasized to her liver and bones. Advanced and incurable lung cancer.
"This should be a quick visit," the primary nurse had told me yesterday. "Her husband is helping her with daily activities. I taught her how to give herself her epoetin alfa injection. All you need to do is watch her prepare and administer it. You'll be in and out in 10 minutes."
I pulled the sun visor down and gripped the steering wheel tighter as the car accelerated up the icy hill. Was it the brilliance of the morning sun or dread that made me miss the driveway?
Why am I so nervous? I thought as I circled back to the patient's house. I've taken care of many patients with terminal illnesses over the years. I know the stages of dying and the importance of helping the patient work through each stage. So why am I so apprehensive?
Because she's only 52 years old, I reminded myself. She's younger than I am, and 2 days ago, she didn't know she was dying.
I parked the car in the driveway near the barn. The snow crunched underfoot as I made my way to the front door of the farmhouse. Before I could knock, the door swung open.
"Good morning," I said. "I'm the public health nurse. I called last night to tell you I'd be coming this morning."
"Come in," Ann said, her tone impatient. I saw the strain in her eyes before she turned away. By the time I stepped inside, she was hurrying through another doorway. "I've got everything ready for you out here," she called back to me.
I followed her to the kitchen and set my nursing bag down on a chair. A vial of epoetin, a sterile syringe, and a packaged alcohol wipe were carefully arranged on the table.
"I didn't want to hold you up," Ann said, short of breath from the brief walk. "I'm sure you have more important things to do."
"Oh, no," I said. "I need to assess you and help you with your injection. I have plenty of time."
After assessing her vital signs, I listened to her breath sounds. "I see you're having some difficulty breathing," I said as I documented her physical assessment findings. "Has your oxygen been delivered yet?"
"No, they couldn't come yesterday because of the storm," she said. "They said they'd be here later this morning." She frowned. "The oxygen didn't make much difference in the hospital."
"I'm sorry," I said, wishing I knew what else to say.
"Can I do my epoetin shot now?" she asked.
"Why don't you tell me what you know about epoetin before we start."
Clearly well informed about her treatment, she told me why her physician had prescribed the medication and what it was supposed to do for her. Then she recited both common and serious adverse reactions. As she talked, her expression softened and her shoulders relaxed. She met my eyes for the first time as she picked up the syringe.
"This part is easy," she said. "I used to help my husband give shots to the cows." Her smile was ironic. "I never thought I'd have to do this to myself."
I watched her draw up the correct amount, clean the injection site, and administer the drug.
"You followed the procedure perfectly," I said, as she deposited the needle and syringe in a covered container and discarded the alcohol swab.
She returned the epoetin to her refrigerator. "I guess you won't need to come tomorrow," she said.
She was right. I had no reason to come back tomorrow and no reason to stay any longer now. But then I looked in her eyes. What I saw was anger, fear, sorrow, and regret.
"How are you?" I asked simply.
"I'll be all right," Ann said. "I have lots of friends, and my church family is very supportive."
With that, her brave facade crumbled, releasing a flood of words and raw emotion. As angry tears spilled down her cheeks, she railed about how little time she had left and how much she had left to do. She had to teach her teenage son how to take over the farm's finances, something she'd always done for the family. And what would happen to her daughter, who'd just started college? Just this morning she'd phoned to say she was coming home.
"It's not fair," she said, angrily. "Beth is just starting to make her own life. I don't want her to give all that up just because I'm sick."
"Maybe she needs to be with you right now," I said. "Wouldn't you like to see her?"
"Oh, yes," she said. "I just don't want this to ruin her life."
"How is your husband?" I asked.
She frowned. "He wants to take me on a trip. Can you believe it? He's always been too busy with the farm. He never found the time to go anywhere." Fresh tears welled up in her eyes. "I didn't think he cared. Now he wants us to go on a trip."
She turned and looked out the window. "Do you see those trees at the edge of the field across the road?"
"Yes," I said.
"That's where I've always gone when things were bad. That's where I've found my peace, where I've worked through all the hard times."
She paused for a moment. "I tried to go there yesterday. I couldn't make it."
I almost asked her if someone could take her there, but I realized that she needed to be alone. "I'm sorry," I said again. I held her hand.
She nodded as she dried her tears. "Could you come tomorrow?" she asked. "Just to make sure I'm giving my injection the right way?"
"I'll be here the same time tomorrow," I said. And I was.
There was so little I could say or do for Ann, no way to change the fact that she'd probably die in a few short months. Yet this brief visit was one of the most fulfilling experiences of my career. By being present, I'd given her permission to tell me her thoughts and fears; she'd rewarded me by opening her heart.
Years have gone by, but whenever I drive down that road, my eyes stray to the stand of trees where Ann found refuge. I'll never forget her or the lesson she taught me. No words are as powerful as a caring touch or as therapeutic as listening.
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