An occupational therapist here describes her account of care given to an older man experiencing distressing memories at the end of his life. This is one in a series of stories that the Point of Care programme is presenting on the issues that staff face in trying to ensure a positive patient experience. The views given in this article are those of the author and do not necessarily represent the views of The King's Fund.
How should we best support and comfort dying people who are plagued by distressing memories? I'd like to tell you about one instance that has stayed with me over the years.
I was working as an occupational therapist in a small rehabilitation unit, where most patients were more than 70 years old.
Some patients had been referred by their GP, but most came from the local acute hospital. Patients generally had complex needs that the hospital had been unable to cater for and to discharge safely within their normal target dates. Older people enjoyed coming to our unit as we had more time for them.
I remember going to complete an initial assessment of a newly admitted patient who had septecaemia. One of our targets was to prepare a discharge plan based on the patient's feedback, medical information and information on personal circumstances passed on from the general hospital.
When I arrived on the ward to complete the initial interview, I spoke to the patient's named nurse, who looked upset, and said the patient was 'toxic' and 'shouldn't be here', as he had been discharged to us without proper assessment. In the patient's room, I found a mature, experienced health care assistant sitting with the patient, holding his hand and looking straight into his eyes. She was listening to him, tears streaming from her eyes.
I sat down in the background to make my assessment and observe what was happening. The patient was clearly distressed and in state of great anxiety. His eyes were focused into the far distance, recalling an event.
He was saying how ashamed he was feeling, and described a 17-year-old soldier lying dead in a trench. He kept repeating 'he was only 17'. He seemed to feel really guilty about this, as though he thought that if he had acted differently the soldier would not have died.
We listened to what he had to say, but he did not get any calmer.
The patient spent hours at a time in this state. We both stayed with him and I tried to calm him down by orientating him to his environment, but this worked only for short periods of time. Both the health care assistant and I felt strongly that he needed to have others present with him in his distress. This was supported by the nursing staff, who allowed a health care assistant to remain with him full time.
I suggested that psychological services should have been involved immediately in supporting this patient. I also think that a servicemen’s charity that I'd heard about on the radio might have been able to offer advice and counselling to staff and patients on processing painful war experiences. However, a referral to psychological services was not considered as the patient’s distress was defined as a 'medical condition'. Instead, a chaplain from another unit was sent to see him.
Forty-eight hours later, the patient was transferred back to the general hospital, where he would not have received the attention we had been able to offer him. He died soon after.
I feel so sad that the end of this man's life was so painful.
I have noticed that when patients are very ill or close to death they sometimes no longer have the emotional defences to keep painful material from their lives at bay. This unfinished business starts to resurface when their defences are low.
I think that part of our role as professional teams should be to think about the psychological welfare of this large group of patients, a generation of people who may have never talked before about their experiences in the Second World War. We owe it to them to be prepared with appropriate information and referral procedures and to give them comfort and support when they need it most.
remember me Maria Raiti-Buttazzoni form the Royal Brisbane Hospital in the 1970's
just stumbled on your name and thought I would say hello