Is Every Patient Deserving of Compassion?

*Patient details have been changed to protect patient privacy*

So I've had this nagging thought bouncing around inside my head for some time now. Are all patients in the hospital equally deserving of compassion? It's a weird question, given that nurses are pretty universally known for their caring and for their compassion. Some outside of the hospital might be surprised to hear that as nurses, we actually don't have an unlimited supply of compassion, and that we struggle to perform our job while dealing with personal biases.

I'll give you an example. Some time ago, I was working with a new nurse, and she was informed that she was going to be getting a patient from the Emergency Department who had been involved in a car accident. The patient's injuries were significant, but not life threatening. It was amazing to me to watch this nurse prepare herself for the arrival of the patient. She literally came alive, firing questions at me, getting the room ready, bustling around and making sure that her other patients were all settled and comfortable as she knew that her new patient was going to monopolize her time for a bit. Trauma patients are frequently that way...they're time consuming due to their high degree of pain, injuries, and mental stress in dealing with whatever event landed them in the hospital. It was neat to see this new nurse getting in the zone in anticipation of receiving this challenging patient. It gave me pause to wonder when I had last gotten keyed up about the arrival of a patient. There was probably a time when I did get excited over the prospect of a challenging patient, but it's been quite a while. Am I jaded? Or am I just more comfortable with whatever gets slung my way? Maybe it's a little of both. Don't get me wrong, I spring into action when the need arises, but I don't find myself getting excited about it like I used to. I tell myself that it's because someone has to remain calm when things start happening on the unit...might as well be me.

Upon reading through this particular patient's chart, I felt my disdain for this person rising up in my throat like bile. This particular patient had been driving drunk and was involved in a one-car rollover. Luckily for this patient, no one else was involved. If there's one thing I have zero-tolerance for, it's drunk driving. I've known too many people in my personal and professional lives who have been affected in one way or another by a drunk driver. I try to understand, I try to be compassionate, I try to separate the person from the act that got them into my care, and most of the time, I can't. I can't forget that this person knowingly and purposefully got behind the wheel of their car while under the influence of alcohol. I can't forget that an innocent family was affected by a person's careless choice. I can't forget that in drunk driving accidents, the drunk driver frequently survives while the others involved are injured or killed. I can't separate it, no matter how hard I try. Believe me, I've tried. I know that no one aspires to become an alcoholic. No one sets out with the intention of killing someone else with their car while under the influence. I know that alcoholism is a disease and should be treated as such, but there is a level of intention with direct consequences towards others with alcoholism that you don't see with diseases like cancer or heart disease. An innocent bystander will infrequently be mortally affected by someone else's heart attack. For Pete's sake, if you're going to drink, do it at home. Call a cab. Call a friend. I feel like as a society, we have had the ramifications of drunk driving shoved down our throats for as long as I can remember...how can people still be doing it and act surprised when there is a negative outcome? So while my new nurse coworker was buzzing around attentively caring for and reassuring the patient, I assisted blank-faced and detached, too caught up in my personal bias to be as compassionate as she. Truth be told, I was more of a helpful presence to my coworker than I was to the patient.

When a patient arrives into my care having made these choices, I find that I'm cold and indifferent to them, but I still provide care that myself, my coworkers, and even the patient themselves will be satisfied with. I still take their vitals and make sure they are comfortable and safe and stable. I dress their wounds and I wash the blood off their face and hands. I make sure their broken limbs and battered bodies are receiving the attention they need to promote healing. And I do all of this without uttering barely a single word to them unless they address me specifically with a question, a complaint, or a request. If they want to talk, I listen, but rarely will I be the first one to speak about things outside of the care I'm providing. I fear that to engage in conversation with a drunk driver would be detrimental to my care, as I'm not sure I could hold back all the disdain and disgust I feel for people who make the decision to drink and drive. So I treat them in silence, because that's the kindest thing I can do for them. Is it compassionate? Probably not, but it's kind, and I guess that's similar enough, at least personally for me. I'm sure they must feel my emotions, assuming that they are aware enough to notice. They see it in my body language, my lack of eye contact, my clipped sentences and silent shuffling about.

I had the opportunity a while back to take care of drunk driver who had killed someone. This person veered into oncoming traffic and hit another car head-on, killing at least one occupant in the other car. Frequently when we receive accident victims, regardless of cause, we know little to nothing about who else was involved or how many were injured or killed. In this particular case, the patient had been interviewed by the police regarding the incident and mention of that had been made in the chart. The patient had been in the Intensive Care Unit for a few days prior to coming to my unit and being assigned to my care. This patient was a mess. Broken. Not only physically, but mentally and emotionally. The patient arrived on the unit in tears. When asked to rate his pain on a scale of 1-10, the patient instead responded with, "You mean how stupid do I feel on a scale of 1-10? 10. Fucking 10." He then withdrew into himself and didn't speak to me, or anyone else for that matter, for the next several hours. It was at that point that I felt my resolve crack. I had initially approached this patient with caution in regard to my personal bias as I knew that he had driven drunk and killed someone. I hadn't expected his remorse. It sounds weird to say that most drunk drivers that I've dealt with in the past have shown little to no remorse in their actions. The reasoning is sometimes multi-factorial...sometimes they are still drunk and can't comprehend what's being done to them outside of wanting their neck brace removed; sometimes their memory has been impaired from the accident and they don't remember anything; sometimes...I don't know, sometimes they just don't seem to care, which I think is where most of my disdain comes from. Even if you don't kill someone when drunk driving, the odds are so high that you might. To be flippant or indifferent about it makes my blood boil. In regards to the patient above, he knew he had killed someone, and it was tearing him up inside. Had it been possible for him to trade places with the person he had killed, I had no doubt in my mind that he would have. Without a second thought...at least at that moment in time. I don't know if he remembered the accident or not, as I didn't find it appropriate to ask and really didn't feel it would contribute positively to my care of him. I still think about him with a heavy heart. I wonder how he's doing. I know deep down that he was a good person with a supportive family, a good job, and for the most part, a good life. I couldn't help but think that he was a good person who'd had demons that were already causing him to drink, and now that he had killed someone while under the influence...what did that do to his psyche? I'll probably never know. Given the propensity for survivor's guilt in situations like this, perhaps I don't want to know.

Aside from the mental and emotional strain that caring for these patients presents, most of the physical abuse I've sustained in the hospital has been at the hands of alcoholics. Abuse isn't something that they told us about in nursing school, but it's amazing how often we are subjected to physical, verbal, psychological, and emotional abuse. It's a felony in most states (probably all states at this point) to assault a healthcare worker, but patients who assault healthcare workers are very infrequently ever prosecuted. I've never prosecuted a single patient that's hit, punched, pushed, bent my fingers back, grabbed, pinched, spit on, or attempted to bite me. Alcoholics, whether still drunk, going through withdrawls, or suffering permanent brain damage from drinking, are very unpredictable, and frequently become violent. A lot of the time, they don't even realize that they're doing it, and once sober or fully detoxed, have no recollection of their abusive behavior at all. How does a healthcare provider go about prosecuting someone who has no cognitive memory of their behavior? Perhaps had I been more injured, I would have pressed charges...but should the degree of injury and the mental state of the patient at the time of the incident really be factors? Shouldn't all assault be viewed equally regardless of the outcome? There has only been one incident when a patient got me good right square in the chest with a closed fist. I didn't press charges against her, mostly because I knew her time here on earth was severely limited due to her severe alcoholism and the irreversible organ failure that went along with it, and I felt that to be punishment enough for what she had done to me. It's safe to say that she was definitely not in her right mind at the time of the incident, and rather than understand that we were trying to help her, she responded with physical violence. All compassion I had for her went right out the window. I wasn't prepared for how angry I became when she punched me, and I was glad that I had another coworker in the room with me at the time of the incident to deflect the attention of the patient from me...and mine from her. Not that I would have responded in kind with physical violence, but I was extremely angry and it was all I could do to keep myself from punching her right back. Expletives were forced through my clenched teeth. I've never punched anyone in my life, but I've never been put in a position where I've wanted to so badly either. I called out the next night from work so I could mentally process what had happened. I learned not long afterwards that she had passed away during that same hospitalization, and the relief I felt was palpable...no longer would she hurt anyone else who was trying to help her. I didn't feel guilty about that, which was new for me. Typically I felt something when I learned a difficult patient had passed, but because she had hurt me, I felt nothing. I'm still not sure how I feel about that...the feeling of nothing...am I losing my humanity? Or am I just calling a spade a spade...a person like that was doomed to die from her addiction, and maybe she's better off...maybe we're all better off. Some people just can't be helped. Obviously, the situation has stuck with me...not to the point that it keeps me up at night and I assume that every alcoholic is going to punch me or deserves to die as a result of his or her addiction, but I give them a much wider berth mentally, physically, and emotionally, now than I used to.

I feel as though I've emphasized substance abuse thus far in this blog, and while those patients with addictions make up the majority of those patients whom I struggle with compassion, they aren't the only ones. There are patients in the hospital who are completely alert and oriented who are mean to hospital staff. Not just mean, but callous, uncaring, abusive, and disdainful. They are so disdained at the state of their own health and the lifestyle that landed them in the hospital that they take their anger out on nurses, doctors, and other healthcare workers. I've witnessed patients who were completely alert and oriented attack my coworkers verbally, physically, and emotionally. Patients are upset, they are angry, and are extremely disappointed that we can't fix 50 years of bad habits. I had a patient and his family verbally abuse me because they felt that his bed wasn't comfortable enough. As if I personally was responsible for the construction of the mattress. They surrounded me on all sides and were all yelling and aggressively posturing, which made me feel threatened and uncomfortable. I felt myself escalating, and had to remind myself that all of this anger, all of this aggression, had less to do with the bed and more to do with their unrealistic grasp of the patient's illness and debility. He threatened to leave the hospital on account of the bed. I gave him the paper to sign to indicate him willfully leaving the hospital against medical advice and showed him the door. Upon realizing that it mattered not one iota to me whether he stayed or went, he changed his tune and decided to stay. But the tone for the night had been set. I was determined not to waste what little compassion I had on this angry little man and his family members. I said as little to him as I had to while providing care appropriate for his diagnosis. At the same time, I spent a fair amount of time conversing and chatting with his roommate, who, if I recall correctly, was far more ill but far more pleasant. Compassion for days for those willing to receive it and in turn, give it back. The roommate, I might add, actually apologized to me for the mattress-hater's behavior. The patient himself never apologized, but made a few comments that revealed that he was embarrassed by his behavior and that of his family. At the end of the day, he was still too prideful to admit that he had treated me badly and had behaved inappropriately.

Over the years I've had patients who have touched my heart in ways that still give me the warm fuzzies today. The number of patients who are decent human beings far out-number the ones who feel entitled to abuse me and treat me poorly.  But I've come to the conclusion that it is possible to give adequate care without sacrificing my compassion on patients who have shown that they neither appreciate nor deserve it. It isn't in my job description to stroke egos and empathize with every single malady or behavior that a patient might present with. I view compassion as icing on the cake to care that will be appropriate no matter the patient's attitude or behavior. As I've gotten older and farther into my career, I've realized that I have a finite amount of compassion to give, and patients are not equally deserving nor are they entitled to it. I dole out compassion as I see fit, and I'm learning that that's okay.