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That Magic Time of Night

Posted Jun 09 2009 10:22pm
I first noticed it while talking to one of my mentors, a retired psych nurse. When she was the most comfortable, I was not consciously aware of the fact that she's disabled.
I have the privilege of working the 3-11 shift, and I'm lucky enough to be present for their transition into sleep, a critical factor in maintaining health and speeding recovery.

When someone is really comfortable, the fact that the person has an illness or disability just melts away in my mind. When the lights are low, the features of the face soften and you see them the way they might remember themselves. The brave warrior and the epic princess are still the brave warrior and the epic princess... but how many people can see them?

What you do to the infant, you do to the old man. What you do to the old man, you do to the infant.

The life span isn't some sequence of events. It's a life. Sometimes this is hi lighted dramatically when persons with dementia begin to step backwards through all of the developmental stages, more or less in order. At a variable rate. Until they're infants again, back to basic trust vs. mistrust, requiring what we like to call "total care".

This particular disease process is illustrative in that some particularly tricky areas to enforce arise which I'll call "dignity".

Say someone has mentally regressed back to their toddler stage of development. They may still recall war stories and be able to tell jokes and stuff but if you start contradicting them and yelling at them, you can expect some people to act more childish. This is well understood in pediatric nursing, where they have to deal with kids dropping a developmental level or two because of the psychological adaptation to hospitalization.

There's a hard and fast rule in pediatric nursing that I picked up in school, one that I haven't always seen enforced. Basically, "don't do invasive procedures while the kid's in the bed, take them to the treatment room and do the procedure so it doesn't screw up their association with their bed and sleep/rest".

This seems obvious, but the connection between all of this I think is that this is an area of improvement for adults in skilled nursing facilities. If we should strive to preserve the sacred space of the bed for children in health care facilities, why not for adults? Especially adults with cognitive decline?

No matter what bed it is, there's a chance it's the last bed you'll ever lay in. This is more obvious at some times than others.

Customer Service is an inadequate term for what I'm describing, despite it's popularity in the corporate world.

The only thing required is to be here. Now. The 8-year old ballerina is still there, see? The daring captain of industry is still at sea, see?

When people's caregivers start TREATING them like children, however, you head down a slippery slope that tends to end in behavior tracking and routine antipsychotics. When you treat people kindly and be there for them and listen to them, they'll still have their good days and bad days, but they'll present less problems for you in the course of provisioning them with care. Always. When the work of their care increases, it doesn't even seem like work.

It's your dear friend. The princess. The emperor. The fool. The hanged man. Any other series of archetypes you want to throw at it. This is what all of those symbols were tasked with describing. Some people do this, some people do that. They all get taken care of, because they're all here to be taken care of.

Whatever difficulties or concerns or hallucinations that arise are perfectly acceptable and to be expected. If a caregiver reacts to one of these difficult times with hostility, a tragic and avoidable spiral of behaviors increase our workload by 10.

Care requires a negative amount of effort. It actually makes the work at hand easier, because you're actually interested in what's going on. I first applied this oft-written about trick while I was in nursing school, and really found my instructors fascinating and wise people for 20 or so hours a week, even if I didn't like them at first. I learned more from them when I really listened to them. No notetaking, just paying attention. I eventually became fond of all of them, of course.

It's impossible to learn something from someone without becoming fond of them, I've almost always said.

A sleep doctor once told me that the bed should only be used for sleep and sex to prevent associations that interfere with sleep.

Still, once in a while, it's nice to have a conversation while lying in bed.
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