Revived after my morning peer support session with Viv, I returned to assess the second crisis patient from this morning, the older woman named Nancy who was currently in the intensive care unit, the ICU, and who had taken an overdose yesterday. The psychiatric assessment I had requested earlier was still outstanding; mornings were busy on the inpatient unit. I reviewed what we knew about her from the file. Nancy’s seventy-sixth birthday was coming up and she lamented the loss of her husband a year ago, and at least three friends so far this year. She was still able to take care of herself and live in her home but she was lonely. Her kids live several hours away, which meant she didn’t see them very often.
Last week on the phone her son suggested she think about a retirement home where she could be with others and go on outings…she didn’t like that idea. Her nurse in ICU predicted that in 24 hours she would likely be medically clear for discharge but was she safe to go home alone? This was a situation where we had to decide if she required an admission to a hospital bed, or if there were other options. In theory this was the beauty of our matrixed team; medicine and psychiatry working together with all the facts. To support this process, I had a bit more time to spend with her to complete an assessment and an opportunity to follow up.
I looked into the ICU room at Nancy. She was laying in the bed with her head turned to the wall. She didn’t take up a lot of room under the covers. I waited in the doorway to determine if she was awake or sleeping before I entered. When she raised her hand to scratch her ear, I confirmed she was awake and stepped over the threshold with a neutral “good morning”. Her head swivelled slowly and she looked me in the eye without expression. She looked tired and sad. “I’m Hattie Crawford, from Crisis Services. I wonder if we can talk for a bit?” She nodded just perceptibly and I took my cue.
As it turned out, although Nancy certainly wished her ‘time’ would come around sooner rather than later, she had scared herself with the overdose. She was embarrassed and sorry to have alarmed her kids, who were on their way to Carter to see her. Her voice was weak but I felt the underlying truth was strong. Listening to her story, I understood her motivation completely. Here was a woman at the very other end of life from Bridie – too bad they couldn’t switch out. Finally, even with Nancy’s very extreme response to her situation, a mental health admission was not what I thought would best support Nancy to get the resources she needed. She agreed. One large tear slid from the corner of her eye and down her cheek. She made no attempt to stop it as she denied any further wish to kill herself.
We talked a bit more about her, her life and what might help support her to feel better. She was clear that she wanted to continue to live in her home but also thought she needed more activity, maybe even meet new people. I described a new Senior Support Team to Nancy. It is available to provide in-home and day program options to engage older folks in activities and ensure they live where they want for as long as they can manage. This team also offers support groups for the inevitable grief and loss that bombards people as their spouses and friends drop around them. Provided the psychiatrist agreed, I told her I would recommend Nancy be discharged once the Senior Team met up with her and had a plan for immediate response. She was also interest to hear that the team had resources to answer questions from the family and provide them with support, and she hoped her family would take advantage of this.
I knew the Team could do all the things I said because one of my peers worked through a similar situation a couple of months ago, and as a result we invited the coordinator of the Seniors Team to one of our Team meetings. I also knew the Seniors Team was keen to do all this because hospital beds are costly and everyone who isn’t in one is saving us all a lot of money. The human side of the argument compliments the budgetary; people generally prefer to be in their own homes. The balance slips when we nickel and dime the services we provide, which I suspect occurs more often than it ought to, if the tales I hear from families are true.
Nevertheless, in Nancy’s situation the home care was superior to anything else we had to offer and I would support this plan. Before I left her, I offered to follow up with Nancy in person if it turned out she was either admitted or was still in ICU tomorrow. I told her I would give her a phone call to check in next week one way or the other. We have learned from listening to our clients that reaching out is an effective addition to our crisis assessments. People are different in their own haunts and getting that perspective improves our understanding. Nancy would get all that, and more. I hoped things worked out for her.
While I’d been working away with Nancy, two more folks were in emerg presenting with mental health issues. These two assessments were relatively straightforward. One was an obvious admit and one was obviously not. In the meantime, the psychiatrist had checked in with Nancy and I learned that with her agreement Nancy was being admitted to a medical floor for another day just to make sure there were no lasting effects of the overdose. If the person isn’t entirely sure when they swallowed the meds or can’t remember what they ate an hour or so before, even a strong dose of charcoal to sop up the chemicals or “gavage” to flush the stomach won’t touch what made it into the bloodstream and older folks metabolized their drugs more slowly.
I agreed with the psychiatrist. Nancy’s situation deserved a more cautious approach. I was also happy that Nancy would be admitted to a medical floor rather than a psych floor. The symptoms they were looking for were medical. An admission would also get the Seniors team to connect with her today, since pre-discharge took a bit more priority to someone already at home.
My work in the emergency department was finished for now so on my way over to the Mental Health Clinic I rolled in to see Nancy on the ward she had been admitted to. She greeted me with a warm smile and held out her tired hand. I grasped it and she held mine as we talked. “I’m sorry I don’t remember your name but I am very grateful for your help. Yesterday everything was so bleak. I welcomed death. Now, today, I feel like I can go on.”
“My name is Hattie” I replied.
“Hattie…that’s short for Harriet, isn’t it?
“Yes. Not many people pick up on that. I’m named after my grandmother”.
“My grandmother’s name was Hattie too” her eyes crinkled as they smiled, clearly her troubles were more recent than life-long.
I smiled back. “I am glad to hear things are sorting out for you. You and the psychiatrist, her name is Dr. Lindsay by the way, made a good decision to stay here overnight. Make sure you tell the nurses if you have any strange feelings in your heart, your belly or your bowels – those will be signs we didn’t get all the medicine out of you”.
“That’s what the nurse who left just said. She also said that someone from the Geri Team would be here to see me soon.”
“Wow, that was fast! You must pay your taxes on time!” We both laughed. “I’ll give you a word to the wise though: they call it a Seniors Team, not a Geri, or Geriatric Team. Don’t ask me why but somehow they see being a senior as more comforting than being geriatric”.
“It’s no mind to me” Nancy replied seriously. “I am glad to meet up with them. My daughter called and she is really upset. I hope they can help her out with this too, and she isn’t a senior or geriatric!”
“Not yet, anyway! Nancy, it was an honour to meet you. You have had a rough few years. You’ve lost too many people you were close to. And it’s been a very sad time for you. But I have a feeling that you are ready now to start gathering up some of those loose threads. Don’t take this the wrong way, but I hope we don’t run into each other again – at least professionally.”
Nancy tightened her grasp of my hand. “Thanks, Hattie”. Despite intermittent prohibitions about inappropriate touch, I leaned forward and hugged Nancy. Ever the rebel! She hugged me back, unknowingly also a rebel. The effect was positive.