Wednesday, December 23, 2009

Judged by the Color of their Skin

I have an nonagenarian who is a racist. I don’t think you can use the words she uses to describe people of various ethnicities and not categorize her as such. She’s been my patient for about 3 years now and in this period of time I have been medically impotent in her care. Her severe heart failure goes untreated, she continues to drink, is likely depressed, and is losing weight, likely from the large mass recently found in her abdomen when she came to the hospital recently for a CHF exacerbation.

And yet, if any other provider asks her about my care, she will sing my praises. She tells everyone she can, that excepting one male physician she had many years ago, I am by far the best doctor she’s ever had. And I honestly can tell you that I’ve only managed to do two things for her: help her get the basal cell carcinoma that was slowly eating off her nose removed, and listen to her.

And listening to her isn’t easy. She has excuses for everything, why she can’t quit smoking, why she can’t keep his appointments, why she won’t take her meds, you name it. And you know what, I can tolerate that. I feel my job is to tell her she ought to stop smoking, drinking, etc, that she would likely feel better if we could get her to X, Y, or Z appointment, but it’s her job to actually do it. So I see her periodically and watch her wither away in front of my eyes.

Now I justify my actions to myself by saying this is part of a lifetime of behaviors, that she’s alienated her friends and family over the years, and that it would be foolhardy to think I might intervene in this trajectory. Yet on the other hand, I wonder, is this cognitive disability? Is this her lifelong alcohol abuse? Should I intervene against her will? Should I have intervened years ago? But that would no doubt threaten our rapport and I am uncertain that anyone could make her take her meds, or that it’s ethically acceptable to force her to do so.

But then she starts with the name calling, she talks about her grandchildren who are of mixed race and explains their failures in terms of their ancestry. She fires caregivers that I’ve worked hard to set up in her home because she thinks they can’t speak English and are “just a bunch of foreigners”, though she’s really deaf and sometimes has a hard time understanding ME. She’ll turn around on one hand and say, “You know I like you, Doc. I think we might be related.” And I respond, “I think we’re all brothers and sisters some way or another.” But I know the words don’t sink in. I try and reason with her, and when that fails, to set limits on her behavior. When she was in the hospital, she had some rather unpleasant words about some of the staff and I told her that she could think that but she needed to respect them and her behavior was unacceptable.

You know, part of me thinks that eventually this generation who lived during segregation will die, just like the generation of slave owners who lived on after the Civil War. I can only hope this will continue to diminish as an issue. But in the meantime I think, I am here to serve. I don’t chose my patients, they chose me. As long as she’s not hurting anyone (except maybe herself), I think: If I don’t care for the racists, who will? In our last days, don’t we all deserve someone to listen to us, even when we say or have done some pretty egregious things? I can only hope someone will listen to me someday, even if I refuse to take my meds, miss my appointments, and drink too much, and do me no harm.

NOTE: facts changed to protect the identity of the patient.

4 comments:

Jerry said...

Difficult and unsettling, to be sure.

When I was recently putting together a classroom presentation on ethics, I used the ANA code as one example of ethics in the context of professional standards.

I also rephrased the first provision as simply, "We're obligated to take care of everybody who needs care, no matter the reason."

We don't get to choose our patients, or pick through a list of conditions to find those that we will, or won't, get involved with.

For the purpose of illustration, I also found it helpful to present this as - "Imagine the person, or kind of person, that makes you most uncomfortable. Think about a disease or clinical situation that's also distressing to you. Now put the two together, and ask what your obligation is in such a situation."

Difficult and unsettling.

Or, as my buddy from down in Jersey says, "Ehh, whaddya gonnado?"

Cyndi Cramer said...

I think we need to accept that we don't have to "like" our patients to care for them.
(from a Christian viewpoint, since it is Christmas, maybe we don't need to like our patients to love them?)

It's wonderful if we truly like our patients--but someone has to care for the unlikeable among us, too...

Yes, like you did, you need to set limits for bad behavior. But we don't need to judge them. We have no idea what their history was, how they were raised, their experiences, that made them this way...

Even though we still have a lot of work to do to not judge people by their color, ethnicity, or religion--I think we are becomining more and more open minded as a group in the U.S.
You don't notice the changes in culture unless you really look back to the past and remember how it used to be...and we've come a long way...

DieLaughing said...

If I tuned in, I could probably hear 5 or 6 racist comments a week from a patient or their loved one.

I've grown accustomed to ignoring the them, but the words chip away at my morale.

Just last week, a beloved, albeit surly, patient wanted to "tell me a story" about his CNA. "She's a mixed-breed, you know", he said in a low voice.

My heart sank. I'd come to enjoy caring for this patient and his family for over three weeks, finding them to be a warm and inquisitive bunch. This rotten spot was unexpected and harshly disappointing.

Moreover, his CNA had cared for him with her trademark tender devotion and crisp professionalism. She'd anticipated his many needs, vital-signed him without intrusion, smiled at his corny jokes, and kept him more comfortable than I ever could.

And, yes, the U.S. Census will ask her to check the "Two or More Races" box.

I ignored his remark and got up to leave. He grabbed my arm. "It's true", he rasped more loudly,
"she IS a mixed breed!". I turned to go, slipping my sleeve from his gnarly grip.

"She's half CNA and half nurse!", he called after me. "There oughta be a pay grade just for her! Get me Human Racehorses on the phone!"

I shared the story with the CNA. We laughed. I did contact Human Resources to pass along the back-end of his comment and she'll receive a commendation.

I love surprises.

Alex Smith said...

Thanks Chrissy for bringing up this challenging situation (and to DieLaughing for your warm story). I find patients who make racist statements to be some of the most difficult to work with. The very first hospice patient I cared for made racist comments. I was a third year medical student and had absolutely no idea what to do.

How have I changed? I think I try and understand why they are saying what they're saying. Is it "just" a sign of their age and socialization, or is it something more? For many patients, it is an attempt to gain power in the relationship by making a provocative statement. Are they feeling powerlses in the face of loss, or death - and striking out against other? For others, it's a sign of disinhibition. Having a deeper sensitivity to the underlying reasons patients make these statements helps me to help them...and to renew my sense of compassion.