Improper relationships with patients are in the news.
Mrs M was the patient. She might or might not have been dementing, but she seemed confused and was certainly prone to wandering. She might or might not have been in severe pain from her arthritis , but she certainly had a flail leg after failed surgery. All of which made it difficult for her to live in her isolated cottage with its steep narrow staircase. Somehow her medication had reached alarming levels and might or might not have been making things worse. She was in the cottage hospital for evaluation. Essentially this meant taking her off her psychotropics and titrating her pain relief. After several days no-one was sure what was going on. Does paracetamol take effect within half a minute? Was she skipping down the corridor when she thought no-one was watching? Was she attention-seeking? She was certainly much more peaceful when someone spent time with her.
I was a GP registrar, and on call. The previous evening the cottage hospital had not been busy and the nursing staff had popped in regularly to see Mrs M. Everyone had had a quiet night. Tonight the staff were occupied with a dying patient. At intervals through the evening they rang to say that Mrs M kept struggling out of bed and falling, and asking what could be done. In line with the agreed plan, I authorised further doses of major tranquilliser as I went from visit to visit.
At 1am things quietened down and I went to the cottage hospital to see how they were getting on. Badly. Mrs M was still creating problems the staff could not manage. I had no confidence that yet more medication would help. I could see no hope of going home to an undisturbed night. Mrs M was the only patient in a double-bedded room. After some thought, I asked the nurses to move her bed against the wall, and then we pushed the second bed alongside it. I got in and put my arm around Mrs M. There we lay until dawn, in uneasy repose. Every so often she would make a play for escape off the end of the bed and I would persuade her lie down again.
Next afternoon, the psychogeriatrician came to assess her. Standing on the steps of the cottage hospital chatting to a colleague before going in to hear his verdict, I noticed the door being pushed open. A familiar figure sidled around it, coat over her nightdress and slippers on her feet. I steered her back inside. “It’s all very well for you; you can escape”, she muttered. I could; she, on the other hand, disappeared into the psychogeriatric unit and from my life.
So I have spent a night in bed with a patient. It was unorthodox but not improper, and it solved the problem. Even with the hindsight of 18 years’ more experience I don’t have an alternative strategy.
First published in NASGP Newsletter 'The Sessional GP' in May/June 2007
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