by Kimberly Spering, MSN, FNP-BC

Have you ever felt days where, despite your best efforts, patients just followed their own course? Whether or not this would lead to potentially worse outcomes? These are the days when you “do what you can do.”

I made my umpteenth visit to a particular patient. Chronic COPD, CHF, dementia, and medical “non-adherence” (not MY diagnosis) to boot. Which, honestly, is a way to say, “the patient doesn’t follow the prescribed therapy.”

There are reasons for that, yes. Poor (or no) insurance, misunderstandings of what these medications can do, lack of communication, side effects, etc. The list goes on.

At my last two visits, the spouse was in the hospital for a CVA and acute asthma exacerbation. She was the key person to make sure that the patient took all of his meds. Once she was hospitalized…well, it wasn’t happening.

Neighbors were coming in to pour his meds into a cup. But no one observed him taking them. No one could tell me if he was using his oxygen or not. They did tell me that he still smoked on the porch.

He said today, “I feel OK.” And he did today, despite his SpO2 of 86% on room air. After obtaining permission to go upstairs to get his oxygen, I brought it down, putting it under his nose. 
“Tell me why you don’t want to wear your oxygen.”

Turns out, he doesn’t want to bother carrying it downstairs. He’s not “deliberately” forgetting, but it’s not important to him.

I take a deep breath (on the inside), steady my voice, and tell him, in all sincerity, that I am worried what may happen if he does not use his oxygen. That I have concerns that he is not using his Duo-Neb consistently. That I fear what happens because he is not taking his statin or Plavix (med bottles missing…patient post-stent/MI).

We discuss end-of-life wishes. I gave him a Spanish “5 Wishes” document & discuss end-of-life care.

He tells me that he wants resuscitation, but no breathing tube. I describe what a code looks like – including the need for an ETT tube in the majority of cases. “Well…then I want the tube, too.”

Despite his COPD, chronic combined CHF, dementia, etc. He wants full resuscitation. That’s OK. It’s HIS choice. 

I describe potential scenarios of a “code blue” status. The likely futility of resuscitation, even in a witnessed environment. I talk about what life may look like after resuscitation. Truly…few patients are told about what to expect.

He looks at me, expressionless.

I tell him, I want to make sure that your wishes are followed at the end of your life. No one knows when that will be. But I will be your advocate. Slowly, he comes around and describes his wishes.

Oh, and yes, all of this is in Spanish. With a medical interpreter, who, God love her, is as patient as can be.

“I’m doing fine. I don’t need anything,” he says.

While my laser-sharp eyes and hearing look for ways that he needs additional help, I am left with the simple knowledge that, “I can only do…what I can do.”

I may not be able to prevent his exacerbations of COPD or CHF.

I may not know for certain that he iws taking his medications consistently.

I may not know for certain that he is not using his oxygen 24/7.

I may not know for certain how much he smokes.

However, I can say that I DO know that I did my best: educated him on the risks of smoking, educated him on the symptoms of a COPD/CHF flare-up, and communicated with his other health care providers about the visit and upcoming challenges.

Some days, this is all you can do. And I’ve learned to be at peace with it.

Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.