Where's the Love?

ORIGINAL POST DATE: 12/30/08
The hospice for which I work has recently undergone some very significant changes. Many have to do with new Medicare regulations put into place, and others have to do with recent business negotiations and outcomes. In the time period since this all began, I've seen alot of good people come and go at my workplace, particularly some very good nurses and CNA's. I've tried to roll with the punches as best I can, but it's been a very hard road for me.

Part of the reason for this is that I happen to be one of those people who takes the "mother bear" approach to my patients and their families. While I know, of course, that most of our employees are highly qualified and skilled in their hospice roles, still, I tend to consider the patients on my caseload to be "mine". I put alot of emotional investment into caring for them, not in a lunatic sense, but in the sense that they are my responsibility, and I take my responsibilities very seriously. I believe in honoring their wishes as much as is possible, and I believe they have the right to choose that all of the laws say that they do.

However, due to the changes in our company that I mentioned earlier, the supervisors have made numerous changes to our caseloads. Our nurses have had their patient load completely shifted around, having to familiarize themselves with entirely new patients, sometimes fifteen to seventeen at a time. The CNA's are now scheduled more on a logistics basis rather than a caseload basis. We go wherever is closest to our "area" based on who is working and who is on PTO that day, etc., and have maybe a couple of regular patients. But, even those can be taken away from us at a moment's notice and assigned to another CNA in the blink of an eye. All this is to cut down on overtime and mileage pay.

During this time recently, Mrs. A. was suddenly removed from my schedule without warning. At the same time, they also changed her RN case manager as well. Mrs. A. had just recently lost her husband, after which she gave up her home to her son, and helped her daughter, who is a single mom, to buy a home of her own. She moved in with the daughter, and there she sat, alone all day, in a strange place while her daughter worked and her grandsons were in school, tied to her oxygen machine, physically limited by her worn out body, and unable to do much but watch soap operas and pet the cat.

I have no illusions of grandeur, believe me, but my visit was the highlight of Mrs. A.'s day. I had been taking care of her for almost two years, and althought they warn us not to have an intimate relationship with our patients, she and I knew everything about each other. We had found a kindred spirit in one another, and even in our faults and on our bad days, we respected each other immensely. Mrs. A. and I truly had an unconditional love. I knew instinctively when she wasn't feeling well. I knew when to intervene and when to leave her alone. To her, I was the greatest comfort she could receive in this important time in her life, because I knew her so well.

After being told that I would no longer be seeing Mrs. A. anymore, that, in fact, I would not even be allowed one more day to see her and explain my impending absence, I called my supervisor to plead my (and her) case. The supervisor had worked for us before as a case manager, but had left two years ago and returned to this position. She knew nothing about Mrs. A. on a personal level, and apparently, judging by the outcome of our conversation, didn't much care. She was only doing what she was told by her own supervisor.

As I explained to the supervisor about the recent major changes in Mrs. A.'s life, and told her how I felt that changing her CNA and nurse right now might not be the best care move for Mrs. A., I came to the part about how she had given up her home to her son and his family so he could be free from debt, and the supervisor interrupted curtly with the remark,"well, that was her personal decision and we can't be responsible for her personal decisions." (This turns out, by the way, to be this supervisor's true personality and her attitude whenever any of us questions any of her decisions. She bites back like a snake. It is probably also one of the reasons she was selected for this position, instead of the other nurse who applied; they needed someone tough who wasn't going to crumple under pressure, so that their financial goals would continue to be exceedingly met.)

I was shocked. At this point I had not yet realized this was this supervisor's true personality. When I worked with her as an RN case manager, she was not this way. She was always ultra compassionate, and very respectful of her patients' wishes. This was like a punch in the stomach to me. I couldn't believe they were just making a decision on patient care based on budgeting issues at such a critical moment in this patient's life. Mrs. A. was in a true decline, though the physical manifestations had not yet occurred, still I knew. I knew the emotional agony she had been going through all of these months. She had made some decisions about how to help her children, done her business, and now she was just waiting for the right moment to die.

My continued supplications did no good, of course, and I was ulitmately told, "well you're OUT of it now, so that's not your concern!" I eventually ended up saying a few things that were out of turn. It was nearly impossible for me to keep my calm and remain professional when this person was clearly attacking me personally for caring so deeply about a patient with whom I had such a long time relationship. I did apologize for my reactions, and no immediate consequence was given, but indeed I have been paying for it in little ways ever since. I now try to avoid this supervisor at every cost. I'm not afraid of her. The truth is that I have lost respect for her, and I'm afraid that the next similar situation that arises, I will say much more than I should, or did the last time, with greater consequences.

My one question in all of this turmoil? Where is the compassion? Where is the love and dignity and respect that is supposed to be hospice? I know these are hard times financially for everyone, and that hospice, in particular, is suffering greatly due to budget cuts and Medicare regulation changes, etc. If this patient was a fairly new admission; if I had not been taking care of her for so long; if this were not such a crucial turning point in her life and her physical conditon, I would have understood. I understand logistics and budgetary decisions. What I do not understand is weighing the two and choosing budget over the patient, when it is so clear that the patient needs consistency and familiarality at this time in her life. That is what will bring her comfort, and isn't comfort what we are trying to provide?

The day after the CNA change, the patient's daughter called to complain about the switch. She works in the medical field, too, and is sort of like a "mother bear" herself, so I'm sure her complaints were fairly strong. In the end, they returned the original RN case manager to the patient's care, but they refused to return me to the case, despite the daughter's pleas. I am 99.9% certain this was entirely due to my exchange with the aforementioned supervisor, her way of letting me know who was boss, and that I did not "win".

It's a shame after so long at this job, with so much experience, and having earned so much respect from others in my field, even though I am "just a CNA", that we sometimes have to go back to the dark ages where there are some people who view CNA's as just mindless peons who need to shut up and do what they are told, and not be so silly as to think they have an opinion, or any input as to the care of their patients. We are the ones who are there with them every day. We know everything they think and feel. We know every crack and cranny in their skin, and alot of times everything in their hearts, even when they can't speak to us.

As a Christian, I know I need to forgive the ugly supervisor, but it's hard, especially since Mrs. A. has recently died, and I didn't have an opportunity to attend her parting services. Due to agreements made between her and her husband long ago, the services were private, just family, and I'm sure the daughter was only going by her wishes. The time I would have spent with her in the final days of her life was the only opportunity I could have had, and it was taken away from me, and from the patient. She died perhaps not knowing if I even still cared, though, knowing her like I do, I think deep down she must have known I did.

You can legislate, and budgetize, and organize all you want, but one thing you cannot control is love.