Horrified, I watched helplessly on the esplanade as a fuzzy, yellow gosling struggled to right itself from his back in the high water of the Willamette River. Four feet away, his mother placidly treaded water, making no attempt to help.
The Willamette River runs swift and cold, with a notorious undertow. Impulsively, I considered jumping in to save the gosling, but the imaginary headline on the evening news played inside my head:
Crazy Nurse Drowns in Failed Attempt to Rescue Gosling. Pictures at Eleven.
Luckily, the gosling righted itself and swam away with its mom and siblings.
Safe on Shore
I feel a similar sense of helplessness caring for the occasional cancer patient (and sometimes a family), drowning in profound grief expressed as anger.
They present at each appointment with unending lists of complaints. They antagonize their families, find fault with every caregiver, and disparage the home cooked meals generously provided by neighbors. They complain until you contact the oncologist on their behalf, only to find this patient refuses the prescription you are requesting every time his doctor offers it.
Your co-workers snigger when you tell them; they've made the same phone call for this patient. You have "heightened indications" (a term borrowed from TheONC blogger Deborah Boyle's video interview, The Evolving Science of Grief) that your patient is stuck in the grief process at anger, expressing it by making everyone around him crazy. These patients are not violent, nor verbally abusive to nurses. The problem is the amount of energy they require, without solution. Eventually this may cause nurses to emotionally shun them, like the goose watching her gosling drown.
How can you help these patients without drowning along with them?
- Enlist the help of nurse navigators, social services, and spiritual care. Some patients will refuse or sabotage this help, but ensure that it's offered. These experts have experience dealing with these situations. Enlist their help.
- Resist triangulating yourself between the patient and family, or patient and oncologist. Encourage the patient to interact with caregivers directly by scheduling her own appointments, rides, and prescription refills.
- Using input from the nurse navigators, social services and spiritual care, create a care plan for this patient. Through consensus, gain buy-in from staff caring for him or her. Some patients benefit from consistent staff assignment -- however, beware of establishing "favorite nurses."
- A characteristic of dysfunctional grief/anger is playing people against each other. Ensure the care plan is ethically sustainable for the nursing unit. Other patients know when another receives "special" treatment. Keep things fair.
I think about the goose watching her gosling struggle helplessly, accepting that he may drown. It's difficult to reconcile this image with the role of an oncology nurse. Not every patient will die a good death, but with a little help, some, like the gosling, may right themselves.
What suggestions do you have for nurses with patients stuck in the grief process?