1. Shirk, Marilyn J. MN, RN

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At about 3 pm my "Dr. Strong" beeper went off, indicating that the crisis response team was needed on the post-heart transplantation unit. My office was not far away, and I hustled to the adjoining patient care tower. Betty, the charge nurse, told me that George Purcell, in his mid-40s, had done well for two weeks after receiving a donor heart, but when the occupational therapist had arrived as scheduled, George had had other plans. He got out of his bed, left his room, and in the busy hallway pronounced loudly, "Praise Lord Jesus," followed by unintelligible mumblings. When a nurse approached him to remind him of his therapy appointment, he shouted, "I must follow the path!" George met any attempt to redirect him with an adamant "You're the devil! Get away!" He was pointing his finger and muttering at someone who wasn't there.


Betty had called security and the Dr. Strong team, which is trained in nonviolent crisis intervention, out of concern for George's safety and that of others, certainly, but mainly because a pharmacist and psychiatric resident are part of that team. Betty believed George needed antipsychotic medication.


George hadn't been like this when he arrived. He'd been gentle, fervently religious, and since the transplantation, immensely grateful. He wasn't a big man, but the look in his eyes-wild and glistening, resolute-frightened everyone around him. Staff, wanting not to provoke him, had backed off. We assumed that George's outbursts had something to do with posttransplantation medication, probably the high dosages of steroids. "Steroid psychosis" is not common among transplant recipients, but this team of nurses, therapists, and other providers had seen it before.


Meanwhile, the therapist and nurse's aide stayed by George's side. He invited them to join hands with him and pray. They did. George walked them down the hallway as he prayed, stopping to raise his hands with his companions, and shout, "Say, 'Hallelujah!'" They repeated, with matching feeling, "Hallelujah!"


Security officers and the other members of the Dr. Strong team (about eight of us) were on the scene. All agreed that physically restraining George, which would cause pulling on the two-week-old sternotomy, would be a last resort. His behavior was unquestionably disruptive to staff, visitors, and the few patients whose doors were open, but he was harming no one in his ritualistic journey down the hallway. The crisis team decided to let things be. We would stand by, out of sight, and do what we could to reroute passersby.


About 40 minutes passed. George's intimate prayer procession had advanced down the hallway to the adjoining unit and was headed up another, on its way back toward his room, still some 20 rooms away. After more prayers and hallelujahs, Betty, whom George knew, told him it was time for medication. He gave her a warm smile but repeated that he must follow the path of his Lord and said that only after doing so would he return to his room. He opened the prayer circle, inviting Betty in. She joined it. All of them took their cues from George. They walked when he walked, paused when he paused, and raised their hands in praise: "Hallelujah!"


Many witnessed and marveled at this intervention. It must have looked crazy, all of us just standing by, watching. I thought, Weren't there better options than allowing a patient to complete his delusional mission? I couldn't think of any, even after 20-plus years as a mental health specialist. The staff was doing fine, so I stayed out of George's way.


The end seemed near when George and his prayer circle finally stopped at the door of his room. Then the young psychiatric resident, Doug, arrived. He took one look at the scene and announced to the group, "This is inappropriate." All froze.


George called Doug "the devil." Betty gently disengaged herself from the group and motioned Doug over to the nurses' station. He followed. She told me later how incensed she was that this inexperienced physician presumed that he needed to take control. He could have sabotaged the intervention by agitating George just as he was completing his mission. With professional restraint, Betty explained to Doug that what they had been doing was working. Doug softened. He spoke with the pharmacist and wrote the necessary medication order.


After one last group "Hallelujah!" George entered his room with his small entourage. They helped him to his bed. A nurse gave him the medication. George rested. The unit was quiet again.


The caregivers admitted later that they'd felt absurd to be defying theory and convention by participating in George's delusion. Nonetheless, all who'd participated in the prayer circle and those who watched for more than an hour agreed it had been the right thing to do. What grace and wisdom-the whole team investing so much time, precious and scarce as it is. Hallelujah, indeed.