PMID: 15917367

Issn Print: 1040-2446

Publication Date: 2005/06/01


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The Patient–Caregiver Cycle

Saloni Sharma

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Author Information: is a first-year resident, Department of Medicine, York Hospital, York, Pennsylvania. She will be starting her residency in physical medicine and rehabilitation at Thomas Jefferson University Hospital in July 2005.

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Excerpt

In the emergency department, Mrs. Eagley's husband lifts up his shirt as he describes his bypass surgery while I attempt to obtain information regarding his wife's recent episode of unresponsiveness. “What about your wife's heart history?” I ask trying to redirect him to his wife's cardiac resuscitation of a few moments ago. As an internal medicine intern with less than two months experience in this role, I am repeatedly baffled by these family interactions. As I am working with the person designated “my patient,” a spouse or another family member seems more interested in discussing their ailments than in assisting in their relative's care. This type of encounter is not unique to the emergency department.
In a family meeting for Mrs. Patel, who is in intensive care for an anoxic brain injury, Mrs. Patel's niece asks about high blood sugars because she has had diabetes for a few years and maybe her aunt has undiagnosed diabetes as well. She focuses on a blood sugar of 200 that a nurse had mentioned while she was in the room and describes her own symptoms when her sugar is elevated. After an explanation of increased blood sugars under stressful situations, the palliative care specialist refocuses the discussion to options for a brain dead patient status post delayed resuscitation. Once again, a family member seems to shift the conversation to her own disease process even in a terminal situation. Is this a way to avoid confronting the gravity of her loved one's illness?
In the outpatient neurology clinic, Mr. Hernandez's wife snickers as her husband names the wrong month during his mini-mental status exam but admits she would not do much better because she has been having memory problems recently. As my attending continues with Mr. Hernandez's examination, his wife locks my glance in her direction and then, points from her mouth to pelvis and says, “I have a yeast infection from here to here.” I am forced to wonder why she tries to refocus the medical discussion to center on her own issues. Is it a search for empathy by a person with limited social contacts outside of her spouse? Is it a hope for legitimization of her own illnesses that may not be as critical as her loved one's illness, but nonetheless debilitating for the individual?
Furthermore, how am I to handle these situations? In a specialist clinic with 30-minute time slots, it is not possible to expand Mr. Hernandez's appointment into a one-hour meeting encompassing his Alzheimer's dementia as well his wife's neurological and infectious disease issues. It is not beneficial to Mrs. Patel's care to discuss her niece's symptoms of hyperglycemia. And Mrs. Eagley's husband's cardiac history will not aid in making decisions regarding the external pacemaker that is acutely sustaining her life. In all of these situations, I have listened to the family member and acknowledged their complaint or piece of history. Just listening and acknowledging their difficulty without offering a treatment plan or any further discussion of the ailment usually leads to a mutual agreement that the individual should discuss this issue with his or her primary care physician. I temporarily relieve the caregivers of the mental burden of their illnesses and we can try once again to focus on my patient. Ultimately, balancing the caregiver's personal needs with the needs of my current patient can be a challenging aspect of medicine that I will continuously refine throughout my career.
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