The down side

I've been struggling today with the recent development of clinical depression in one of my patients, and the role we played in "causing" it. This lady is 85, presents with right-sided neglect, and decreased sensation on the right side, but she has full range of motion and good strength. In certain routine daily activities, the right side automatically comes into play, as it also does during therapeutic intervention that we structure to bring her awareness to that side. However, there is more on this patient's problem list. We believe there may be some visual field problems and referred her to the orthoptist- we're waiting for the appt. There are definitely some visual perceptual problems including figure ground, object constancy, and depth perception deficits. She perseverates a lot, and cannot easily divide or alternate her attention. And as if all that weren't enough, she has both expressive and receptive speech aphasias, although she gets the general idea during conversational speech, and sometimes manages to get out what she actually means to say.

Put all of this together, and we had to have a case conference last Thursday with her family to say that the prognosis is not good-- that even if she makes improvements with functional transfers and walking, she will need 24 hour supervision due to the cognitive deficits. Although she'd only been with us a little over 3 weeks at that point, we felt it only fair to give her family time to absorb this, ask any questions they might come up with, and begin to make a very difficult decision about whether they could look after her as a family, or tell us to begin the process of finding her a place in a residential or nursing home. Now, although this patient did not by any means follow along in the meeting, point by point, it was clear she understood the concept that we were discussing a "home" for her, and were saying she could not go back to her own home. She was very distressed by this, and kept repeating "But they love me, we all love each other. " (Referring to her family.)

Prior to the case conference, she was always motivated for therapy, always bright and pleasant. On the Friday following the case conference, she came with us to the gym for therapy, but was rather agitated. She then had the weekend with no therapy, and apparently, according to nursing staff, her family has been visiting a lot less frequently. So this poor lady knows we were talking about a residential/nursing home for her, probably doesn't understand why, doesn't understand why she can't go back home, has little to no control over her environment due to her long list of problems, and may very well feel like her family is pulling away/abandoning her. On Monday, she was a completely different person. We were told by the nurses she wasn't sleeping at night, she's not eating, she can't sit up straight in a chair, is tired all the time, couldn't be roused to keep her eyes open let alone get her transferred into a wheelchair to come to the gym for therapy, and kept repeating "I wanna go home, I wanna go home, they love me." Tuesday, the same, at which point I said to the nurses, the SHO, and anyone else who would listen, this lady needs help urgently, she's showing signs of clinical depression directly related to what we told her in the meeting. Today, the matron of the ward came to me for an update on all the patients, and I repeated myself again, and apparently today this lady's been delirious, so they finally paid attention to what I was saying.

Although I've been reassured that we did the right thing by including her in the case conference, it would not have been right to keep her ignorant of discharge plans because she would have to have been told eventually and would have had the same reaction then, I still feel awful. Just horrible. It's night and day, her emotional health and personality before the case conference, and now. But I guess even if we'd only told her family, so that we could continue to make progress in therapy, all that progress would have been lost when we did tell her. Well, that and we could never have predicted she'd have this reaction in the first place. You just never know with stroke patients, the brain can be such a delicate thing, and maybe the only thing she was holding onto in what is now a confusing world for her was going back home, where everything would be alright. Seems to be how a lot of our patients feel, actually, although for very few of them is it actually the case that they go home and everything is alright.