Sunday, October 30, 2011

Adrift with a Diaper Rash

Gert was beside herself with worry. She felt alone and adrift, unsure of what would happen next. A frail woman in her late eighties, Gert had been diagnosed with multiple sclerosis over 60 years before I met her. Her MS hadn't gotten in her way too much, with long periods of remission punctuated by occasional episodes of spasticity. Four years and two husbands later, she finally lost the ability to walk. At her childrens' urging, she'd moved from her home in another state to an assisted living facility the next town over.

For a few years, Gert was the queen of assisted living. "If anybody needs to know the answer to anything, they just say, 'Ask Gert,'" she proudly told me when we met in her hospital room. Gert had organized the card games and the bingo tournaments. She was a leader in her community, grounded and secure. But a few months ago, things began to go south. Her old doctor retired, and she got a new one with a different practice style. He hospitalized her several times for reasons she still doesn't understand. She developed urinary infections that required repeated courses of antibiotics. She lost interest in eating and in life itself.

One of her sons, who lives where I practice, convinced Gert to move a few weeks before she was admitted once again to our hospital. Now she was in a new facility where she was not the queen. In fact, she didn't know anyone there. She'd had more urinary tract infections requiring hospitalization and then -- in a cruel irony that's all too common these days -- the antibiotic for the UTI allowed a nasty germ called Clostridium difficile ("C diff") to flourish in her colon. So she had intractable diarrhea and was admitted for a different antibiotic to treat that new infection. "Can you do something to help my lady be more comfortable?" the hospitalist asked when he called me.  "She's so miserable." She'd been in the hospital five days.

I introduced myself to Gert and explained that one of the jobs of palliative care was to help people relieve pain and other symptoms. Gert was straightforward about her physical discomfort. The diarrhea was letting up, but she had a diaper rash. "My bottom is so sore," she told me. (And it certainly was when I examined her -- beet-red, in fact.) She talked about the difficulty of waiting to be changed, the brusqueness that some hospital staff exhibited, and her feelings of isolation. She wondered alound whether she'd ever see anything of the state where she now resided. "I just don't know what to do," she said several times. When I asked her about her sources of strength, she mentioned her faith. "I'm a very religious person, but I don't belong to a church here."

I said I thought I could help her feel a little better. I would work on the rash and ask a hospital chaplain to come. She thanked me effusively for taking the time to listen to her. I went out to the computer and learned that they hadn't been treating her rash; they were just using a so-called barrier cream to cover it up and, theoretically, not let it get worse. I made one small change, adding a prescription-strength cream that's only slightly different from what you could buy over the counter. Gert's internist and I agreed that she had had her emotional legs kicked out from under her by the illnesses and the relocation. She seemed to have lost all meaning in her life.

When I made rounds the next morning, Gert was a different person. The chaplain hadn't been there yet, but her bottom had started feeling better within hours. She'd passed a solid stool and was anticipating discharge that very day. She was animated and optimistic that things would work out in her new home. I took her hand and said, "Don't take this personally, but I hope I never see you again." We laughed and said good-bye.

In palliative care we are all about relieving suffering at any level. We talk a lot about interdisciplinary teams, advance care planning, and care coordination across multiple settings. For some patients and their families, all of that is needed in large doses. But sometimes, all it takes to relieve suffering is to treat a diaper rash.

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