1. Lee-Ribas, Kenna RN, LM


When doing good feels bad.


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The grandmother lies asleep in the narrow dining area, cocooned in a pilling polyester blanket with satin edges the color of white bread, her hospital bed facing the kitchen island. A hired caregiver keeps watch over her as adult grandchildren fade in and out of her days. She watches from the distance of the dying, separated from them by both bed rails and dementia. She takes up a small area of the narrow bed, more like a four-year-old than a matriarch, her skin as thin and elegant as rice paper.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration (C) Anne Horst /

I wake the grandmother to explain that I am there to put in a catheter and she "responds appropriately," which means she whispers "that sounds nice" when told that she won't have to be moved so often for changes. According to the caregiver, she cries out each time they move her, more from fear than pain. Pain can be treated; fear is more challenging, more slippery. The caregiver daily weighs the seeming cruelty of frequent changes against the skin breakdown worsening in the dampness of the incontinence pad-this catheter is a last resort for easing the distress of the grandmother's remaining days.


She does well, even makes a joke, while I do a preliminary exam. She does well with the gentle requests to move her legs "just a little more open, like that, very good," and with the "now you'll feel my hand touching your thigh, now you'll feel my fingers on your labia"-giving just a tiny involuntary flinch as I open her wide enough to see the opening. The grandmother has borne children; she has been seen and touched here before.


But in the time it takes for me to turn back to my sterile field-in the moment I am taking off the nonsterile gloves and opening the new ones, carefully pulling them on-the grandmother has begun to whine: "why, why are you taking so long?" Her eyes are squeezed shut. The caregiver and I cheerfully describe the bright purple of the gloves, our care so that she doesn't get an infection, how nice it will be to not have the pad changed so often. I ask her if she has ever had a catheter before, and she petulantly spits out, "not in forever!!"


The grandmother has disappeared; now the ghostly body houses only the four-year-old, who does not like the cold antiseptic touching so deep between her legs, and calls out loudly, "cold!! too cold!!" By the time a rigid tube is going inside, it just feels too wrong.


"Stop!! stop!! please stop take it out oh please take it out." Her legs pull together, but weakly, the child's will not matched by the decrepit limbs. My body and instinct want to pull the partly inserted catheter out and swaddle her legs together safely, to let the child be comforted. But my experience tells me the more merciful action is to finish what's begun and hope that the blessed forgetfulness of dementia will restore the grandmother's wholeness to her.


It is too late, child. The grandmother said yes to this, and for her sake you are violated, and my grown-up voice becomes faster and more stern: "just a minute more, almost done, hold still, I hear you, I'm sorry, I know you don't like this but it will be better in a minute." It probably takes no more than six seconds, but the begging and the sobs are not over for a long time.


Slow breaths dam up my own tears: "I am so sorry [horizontal ellipsis] you won't feel it after a little while."


"Please, take it out now!! I don't like this. I don't like this." I signal the caregiver to give her an extra dose of pain medication, an extra anxiety pill. The child takes them but stares accusingly.


There is no apology adequate to the violation of a child, no tenable response to this pleading four-year-old, her fading red-rimmed eyes full of raw hurt. My guilt will suffocate me if I cannot find some way out for both of us, so in desperation I call on the grandmother.


"You have children, don't you?" I remind her, testing the water.




"Well, did you ever do anything they didn't like but you knew it was for their own good?"


"Many times," she sighs, remembering.


"Well, I think the catheter is like that. You don't like it, but it will help you in the long run."




"I'll have a nurse come tomorrow, and if it's still bothering you, she'll take it out then. But I'm asking you to wait and see if your body can get used to it, okay?"


"Okay," whispers the grandmother, but even as the word is passing through her delicate lips, her eyelids draw closed, and she returns to the sleep where she knows who she is, where no one can touch her.