1. Irvine, Cyndy BSN, RN

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As I turned into the driveway I could see an old white farmhouse, a barn with fading red paint, and a grassy orchard of fruit-laden apple trees. I braced myself for resistance-my supervisor had said that Mr. Miller, the elderly farmer who lived alone here, was afraid he'd be put in a nursing home and had been adamant about not visiting a doctor.

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Two people stood on the front lawn waiting for me, a middle-aged man and an elderly, white-haired man wearing faded denim overalls. The younger of the two, a neighboring farmer who leased Mr. Miller's hay fields and kept up the place, had called the public health department to request a visit from a home care nurse because Mr. Miller had recently lost weight and become weak. He was 85 years old and a widower. He had no children; his nephew, who lived down in Iowa, had finally persuaded him to agree to a nurse's visit, but only if it was brief.


As I introduced myself I could sense Mr. Miller's unease at being an object of scrutiny-he stood stiff and straight as his fingers rubbed the ears of the collie standing by his side. As we discussed his health and living situation, I tried to make it clear that I hadn't come to judge his patched overalls or to inspect his buildings.


Mr. Miller answered my questions politely but hesitantly, as if he was groping for the responses that would assure me he was getting along well. He was well oriented and denied having any pain, incontinence, or difficulties eating or sleeping. He was frail, his overalls were loose on his frame, and he seemed pale and unsteady on his feet. It was hard to imagine him living alone in safety much longer, but I tried not to let him see this in my eyes or hear it in my voice.


His neighbor brought him a folding chair to sit on. As he let me take his blood pressure and listen to his heart and lungs, he held his head high, diverting his eyes like the collie had when I petted it under the chin.


His blood pressure was low and his pulse irregular. We talked about this and my earlier observations, and I emphasized that he should let his neighbor take him to see a physician for a thorough examination. He listened, and after a long silence he reluctantly agreed, looking at me intently and asking if I thought he'd end up in the nursing home. Feeling horribly insincere, I struggled to reassure him that we were all just trying to figure out what would be best for him.


"It's been 85 years now," he said, his voice trailing off as he waved his hand toward the orchard and the hay fields spread across the valley. "I wouldn't know where I was if I didn't have this. Or this," he added, looking down and patting the collie's head.


The next week I heard that Mr. Miller had been diagnosed with heart disease, anemia, and osteoporosis; he was increasingly frail and at high risk for falls, and it had been decided that he would be safer and better cared for at the nursing home. He had been moved there a few days earlier.


I went to visit him in a sterile turquoise room with a shiny white floor. The view from his window was across a gravel garden to the other wing of the brick building. I told him I was sorry how things had turned out, that I knew it wasn't what he had wanted. He was quiet; his pride was gone, and he seemed resigned to his situation. When I asked if there was anything I could do, I heard the irony in my words. He didn't say it, but I felt I'd betrayed him. Although he'd agreed to his placement, I knew he would rather have lived out his life at home, and died there alone, than spend a prolonged life in this new and safer environment. He was soon transferred to a nursing home near his nephew in Iowa, and that was the last I heard about him.


I've often thought of Mr. Miller. I did my job and complied with a system designed to protect patients. But I'm not totally comfortable with our intervention. I recall working in the hospital ED and mourning a patient we had tried unsuccessfully to save. And I find myself still mourning Mr. Miller, one we did save.