July 7, 2010
by Fran Harmeyer
Occupational Therapist Fran Harmeyer offers insight this month on creative use of physical care to meet even deeper needs for relationship for both patient and caregiver in a challenging case. Thank you Fran.
Case scenario: 92 y.o. female, end-stage dementia, multiple contractures. Helen gets out of bed for about 3 hours a day in a custom wheel chair. She is blind, moderately hard of hearing and dependent in all her activities. She is verbal but her language is word salad for the most part. She knows when someone is touching her, but it is hard to tell if she knows what is happening. She is used to“care”, but she usually doesn’t like it and “holds” against efforts to range her limbs during washing and dressing. The aides are having a hard time, now, because of her habitual posture of crossing her legs in her wheelchair and in bed. The OT referral reads “Nursing unable to open legs for care”. After consulting the charge nurse, I find that the family doesn’t want any splinting or bracing. The nurse tells me the resident has been on prednisone for so long her skin tears “if you look at it “. I say “OK…” and I’m thinking “oh boy, this will be an easy one!”
I go to see Helen at her bedside. She looks at me with unseeing eyes and when I touch her shoulder to let her know I’m there, she smiles a small toothless grin and says “What is it Dearie? Is the criketh smalltic sogme? Well, I told them tiljaw mopple hhuridge.”
I lean down to speak close to her ear, hoping she will hear the calm in my voice. “Good morning, I’m Fran and I’m here to make your legs feel better” I say hopefully. She smiles again and I’m not at all sure she understands, but I feel like there is good will between us. There are pictures of various family members above her bed and as I hold her leg gently I take a snapshot inventory of her life. Apparently there was music, apparently there were children, grandchildren and maybe great grandchildren, I’m not sure. There was a husband confirmed through several decades of pictures. She was a snappy dresser. The 1930’s pearls and round -necked sweater portrait and the ‘mod’ jump suit of the 70’s proves that. She would have been a friend of mine, I’m sure. Maybe someone my mom would have known. Well, back to work.
So I begin. I rock and hold, rock and hold and she begins to release the habitual knee crossover. Occasionally, we chat, she in her language and I in mine. There is a definite give and take, energetic more than anything else. That’s the thing about people like Helen. The nature of relating is always different from ordinary interchanges. If you’re open to different languages, like the shifts in a person’s energy, your patient will respond to your energy and bam! You have a connection.
Helen inspires me to sing a little. I choose “You are my Sunshine”, a favorite from my own childhood, and I know it’s an oldie. I doubt she can hear me. She says “What dear?” and then sighs “oh” and I feel her leg relax again. It took a few sessions to get her right hip to neutral. Of course, it didn’t last. I never did get her left hip rotated at all. Her overall passive range of motion was improving remarkably in spite of those limitations. We were finally able to comfortably place a small soft wedge in between her legs so her left knee was no longer in danger of punching a hole in her right thigh. The Aides reported a much easier time doing her care, so I showed them what they could do in a few minutes during their care to help maintain the range I had achieved during our sessions. I discharged Helen from skilled services.
I had fallen in love during my work with Helen. Our relationship had deepened with every “conversation” and every touch. At our last session, I squeezed her shoulder reassuring and she returned the gesture with a toothless little smile. This case wasn’t easy, but you never know how you will experience your most significant treatment.
Frances Harmeyer OT writes little stories about the people she meets in the world of inpatient rehabilitation at skilled nursing facilities. She is currently completing a Master’s Degree in Geriatric Health and Wellness. As a rule and on a daily basis, she is amazed by the variety of human experience at the end of life and is a strong advocate for choice at any stage of life.
