Category Archives: combative residents

Selling lemons and changing briefs

Sunflower May

 

This is crazy.

It’s one of those times when nothing I do works. This woman is not going to let me change her brief.
I’ve already left the room and come back three times: the re-approach technique isn’t working. She may not remember who she is or where she is, but when it comes to how many times I’ve been in her room…good Lord, but this woman has a fantastic memory!
I place her hand on the opposite bed-rail and try to roll her over again.
“No! No! No!” she screams, letting go of the bed-rail and pushing against me with all of her frail but frightened might. “Oh, stop, please stop! Mother!”
And now she’s crying again.
My feet hurt. My head hurts. It’s been a long day: this shift just will not end and this woman just will not be changed.
“Please, Mrs. E,” I beg her again, “just roll to the right–just a little bit! One roll. One roll, that’s all I need! I can get this brief out from underneath of you and put the new one in just one roll. And, um, maybe the sheets too. Possibly. Please?”
Mrs. E just buries her face in her hands and cries harder. There’s a certain smell when a brief has been left on too long, when it is soaked beyond capacity to absorb anymore: I catch that scent now, wafting up at me every time she moves. There’s a brown ring on the pad too, further evidence of her refusal to let anybody change her all shift.
I’ve stood here for fifteen minutes, alternately pleading, begging, reasoning, ordering and bribing: nothing is working. She’s not my resident. I could just walk away, tell my newbie coworker that “Yep, she’s refusing care all right, can’t do anything with her”.
Or I could go get help and we could change her in spite of her refusals. This is one of the blurry lines between right to refuse and being mentally incompetent.
I groan and lean against the bed rail. I’m too tired for ethical quandaries right now. I’ve been working for fifteen hours now and I’m dead tired. I swear I can feel my patience wearing thin, like the belt in a car about to snap and bring the whole engine to a crashing halt. In this case, my ability to be a caregiver is what’s in danger…I want to scream, cry, run away and make this woman let me take care of her.
Instead of doing any of those wonderfully tempting things, I move the bed-rail closest to me and, taking care to land on the clean sheets, collapse beside her on the bed.
It feels good to sit down, to not be on my feet. I feel like all my bones have turned to liquid within me and all my muscles have turned to jello.
Mrs. E jumps slightly and hiccups, my sudden movement startling her out of her tears. I stare back at her, blinking away my own tears. The silence holds for a long, long moment.
“You see this thing,” she says suddenly, catching ahold of the call-light and swing it around in a lazy little arc that brings it close to my face. “I told my father, I said, I don’t know what you want me to do with this…thing. It’s just stupid, is all and I said, well, I said I’m not doing it. And he said, well, what am I supposed to do with it? What am I supposed to do with thing, huh? What’s it for?” She holds it out for me.
On a sudden inspiration, I lean forward. “Hello?” I say into it, pitching my voice as though it were being filtered through a microphone.
For the space of three heartbeats, Mrs. E just stares at me. Then she throws her back and laughs, great big chuckles that shake the whole bed. “You’re a nut!” she gasps out, shaking her head.
“That’s me,” I agree, “the biggest nut you’ve ever seen. A cracked nut, too.”
“A cracked nut,” she repeats. “You’re silly.” But she’s smiling now and not crying.
“I am so silly that I want to get this pad out from underneath you,” I continue. “Do you think you could roll for me so I can get it out?”
“No,” she says firmly. “I’m not doing that.”
Damn.
“Why?”
“Because I’m not. My father said, now he said, we’ve got to sell these lemons and I said, now who wants to buy lemons? That’s just stupid. But he, he wanted to sell them and I thought, he’s nuts. He’s crazy.”
“He sounds crazy,” I say, wondering how the hell we got to selling lemons. “Hey, how many lemons do we have to sell?”
“Lots and lots.”
“Tell you what, I think I can sell your lemons for you–there’s a baker who wants to trade me lemons for cookies…she’s, um, making lemon meringue pie or something. But I need your help with something, ok? My wallet fell under your sheets and I need to get it out or my father is going to be very upset with me.”
“We can’t have that,” Mrs. E says, shaking her head in solidarity with me over unreasonable fathers who expect us to sell lemons and not lose wallets in other people’s sheets. Then, without warning, she grips the bed-rail tightly in her left hand, braces her right hand on my thigh and lifts her bottom off the bed.
There are times to provide meticulous peri-care and times to hurry it the hell up. This most certainly falls into the latter category. Her bottom is hardly in the air for twenty seconds, but I somehow manage to whisk out the old brief and pad and replace them with a clean set. It’s hardly the best brief placement I’ve ever done, but at least it’s not saturated with six hours of urine.
“Did you say cookies?” Mrs. E asks as her bottom thumps back on the bed.
“Sure did,” I smile at her, “but first, can you give me a hug?”
“Oh, honey,” she laughs, but she rolls towards me and crushes me against her. “You’re so silly,” she tells me.
“Guilty as charged,” I gasp, using my free hand to wiggle the brief into a better position.

It’s serious work we do, as CNAs, but sometimes serious just doesn’t get the job done.
We cannot always bring our confused residents back into what we call the “real world” so must be willing to lay aside our pride and look silly for a good cause. I have often found that a person’s sense of humor is the very last thing to go.

Who’s the One with Dementia?

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Minstrel

For those who might not have seen the ‘goddess’ of dementia care (imho) Teepa Snow in action yet:  Teepa has a wonderful skit she performs in her training programs.  At these programs the audience members are generally caregivers.  Teepa will play the role of the caregiver while an audience member takes the role of the person with dementia.  (Every caregiver becomes an expert in this role!)

Caregiver, smiling:  “OK, Jeannie, time for bed.  Let’s go to your room.”

Person with Dementia: “No.”

Caregiver: “C’mon, time for bed.”

PwD: “No.”

Caregiver, now frowning:  “Now Jeannie, it’s time for bed.  You know you’re tired.”

PwD: “No, I’m not.”

Caregiver, in a louder voice: “Jeannie, it’s time for bed.  Come with me.  You need to go to bed.”

PwD:  “No!  I’m not going.”

Caregiver, louder still:  “Yes, you are!  It’s bedtime and I have to get you ready for bed!!”

PwD, now pushing and screaming:  “There’s a stranger after me!  He wants to rip my clothes off!  Stop it!  Somebody HELP me!!  I want my Mother, where’s my Mother!!  I want to go home!!”

Caregiver, louder than ever and totally exasperated: “You come with me right this minute!  You are COMING WITH ME NOW!!

As Teepa asks at the end of her role-play: Which person seems to be the one with the cognitive problem?  The one who seems to know what she wants (not to be put to bed yet), or the one who is hell-bent on getting the dementia-impaired resident to change her mind.  The resident probably can’t change her mind at this point, especially not in response to a caregiver who repeatedly sends, in an ever louder and more frustrated voice, the same message: DESPITE YOUR WISHES, I’M GOING TO PUT YOU TO BED NOW.  If anything, the caregiver’s rising frustration triggers the resident’s fight-or-flight instincts.

For CNAs, this is the question of the hour: What do I do when a resident won’t cooperate?  Do I become more and more insistent, and in the process arouse further defiance in the resident?  Maybe I worry “I need to rush.  If I don’t get everyone ready for bed by the end of the shift, the unit manager will be furious with me.”  (PS: Remind her of that person-centered care she’s trying to sell to families—and which the brand new CMS regulations confirm.)  Do I gripe to my co-workers?  Or do I try something new.  We CNAs develop great ‘tricks of the trade.’  My secret weapon is music.  Others try chocolate.   Sometimes a short walk will help.  Or we might initiate discussion of a favorite family photo.  Trial-and-error is the name of the game.  Creative redirection.  The point, as Teepa Snow and Naomi Feil teach us, is to connect with the person.  To empathize with the underlying emotion being expressed and validate that emotion.  To engage the person in an experience they might enjoy before moving back to the ADL.

All this takes time.  But taking time to engage a resident isn’t a frill.  It’s an essential part — the best part, of being a CNA.

As Long As You Know

Sunflower

May
I must have the worst sense of timing in the universe…or the universe has the worst sense of timing around me. One of the two. Either way, I seem to be the common denominator. Perhaps this is a touch self-centered, but I am inclined to be in a melodramatic mood at the moment. My patience is leaving me, escaping with every sigh I’m trying to repress. Somewhere along the way in my years as a CNA, I’ve developed the habit of rubbing my temples when I’m trying not to show my exasperation. It’s a useful little gesture as it almost completely obscures my eyes…my eyes which have never learned how to lie. My eyes which show everything I am feeling.
Including my current desire to throw myself down and show Mrs. S that she’s not the only one who can pitch a world-class tantrum. I feel a sudden swell of sympathy with Mrs. S’s long-gone parents: she must have been a hellion of a toddler and my goodness can she ever yell. All that’s missing is a little leg-thrashing and pillow punching.
Her entire vocabulary has boiled down to a single proper word–no–and those meaningless syllables that kids use to mimic and taunt each other. In this particular instance, I seem to be the other kid. At least, in her head. I’m fairly certain I did not toss my head from side to side screaming “wah-wah-wah” in a high-pitched, shriek-y tone.
If that’s what I really sound like, I think tiredly, I’m taking a vow of silence right here and right now. Well, that’s something. I might not have any patience left, but my sarcasm has not yet deserted me. Good old sarcasm: it’s seen me through many of crisis. I need to think of some way to handle this, but I’m just too tired to think. Instead I sink down to the floor, rest my back against the wall and bury my face in my hands.
The jeering stops after a minute. I peek through my fingers to see Mrs. S peering at me. Silence–and then:
“Would you like me to kick you in the face?” she asks, quite calmly.
“Um,” I reply, “no. Not really, thanks.”
We just sit there, her on the bed, me on the floor, and stare at each other. I’m in rumpled scrubs, looking, I imagine, quite harassed; she’s in filthy clothes nobody’s been able to get her out of for two days, looking quite put-upon. The silence stretches on again as we continue to regard the other with exasperation.
“I’m not a child,” she says suddenly, fiercely, coherently.
“No,” I respond, “you’re not. You are, however, being rather mean to me.”
Her foot swings out towards me, I jump back on reflex–but she’s not trying to kick me. She’s giving me access to the shoe that needs to come off so I can change her clothes. “Well,” she says, for all the world like she hadn’t two minutes ago been reduced to words to one syllable, “just so long as you know I’m not a child.”
And just like that, I appear to have won the argument. She allows me to change her clothes and, for good measure, her brief. I’m stunned but still possessed of enough sense not to comment.

It’s not until later, after I’ve left the facility, that I’m able to think back to the start of the incident and realize what triggered it. I had tried to soften the explanation of why I had to change her clothes; I had tried to sugar-coat it, sweet-talk her. In short, she felt like I had been babying her and had responded in kind. It’s hard, when my instinct is to protect them, handle them gently…it’s hard to realize that sometimes brutal honesty is the appropriate approach.
I drive home, feeling a touch amused (I mean, what did she expect me to say: “yes please, kick me in the face”) and a touch sad for her. I decide to stick with amused. I don’t think Mrs. S would appreciate my pity.

Validation for the Cognitively Intact

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Minstrel

I work on the dementia-care side of things.  One day an aide I was working with tried repeatedly to debate one of our dementia-unit residents about why she should just go and sit down and finish her lunch.  The resident left the table, the aide went after her.  The resident got up from the table again, again the aide brought her back, all the while scolding her.  This happened a number of times in the space of a few minutes.  I finally said to the aide, “Mary doesn’t want to sit at the table.  And we aren’t supposed to insist on keeping her there if she wants to leave.”  The resident was unhappy; her aide was unhappy.  Now I was unhappy with that aide.  And that aide was unhappy with me.  

I thought to myself, “I wouldn’t snap at a resident that way; why would I snap at the aide?”  I recalled something from my dementia training program.  One day the trainer asked, “Has anyone been able to use anything we’re learning, in your workplace?”  I thought of something that had happened that week on the train.  In front of me there was a little boy, three or four years old.  He was delighting in everything: in all he saw out his window, and in those of us sitting nearby.  Then his mother focused on this adorable, giggly little boy.  “Georgie, get over here.  Georgie, be quiet!  Georgie, sit still!”  In reality, little Georgie was actually pretty quiet and well behaved.  The only thing he was doing was enjoying his train ride!  But Mom kept on and on at Georgie for every little innocent move he made.  

Brimming with new knowledge, I was tempted to say, “Ma’am, scolding Georgie won’t work.  Repeating the scoldings won’t work.  Scolding him in a louder voice won’t work.  Georgie needs to be validated!”  [A common practice in dementia care.]  “Smile at Georgie.  Engage him; ask him what’s making him feel so happy.  Maybe give him a hug and tell him how glad you are that he’s so happy!  And soon Georgie may very well be focused on you instead of stretching backward to see all of us.”   

This was a Eureka moment for me: dementia-care training offers great lessons for relating to a child, to everyone, not just those with dementia.  This might sound condescending.  But dementia-care training is about how to transform resistance, stubbornness, and defensiveness in those who feel demeaned or threatened by us or confused by our demands — into cooperation.  We stay calm and positive.  We validate how the other is feeling.  We try to understand what the person is really trying to tell us when he rejects our attempts to get him to obey our wishes.  Instead of perpetuating the conflict, we try to discover—or create!—common interests.  Those who work among persons with dementia—and in any LTC setting that is most of us—become creative communicators.   Validating communication helps with dementia residents, and it might help us communicate more effectively with our families, our friends, our co-workers, even our supervisors.  (Now that would be sweet irony!)

 

The two Mrs. Gs

May

I hear shouting down the hall and I know: Mr. G is having a rough day. And I know why: it’s because Mrs. G is also having a rough day. She’s been in a foul mood all day and she’s the one yelling. It’s not something I want to hear again, even though I know I will. That is the ugly truth of Alzheimer’s.
I’m on my way to the room, to do what, I’m not sure. But Mr. G is quicker and he’s already out in the hallway, staring back sadly at his wife.

Mrs. G is a resident and though her husband is not, I still feel protective of him, like he’s one of my people. I see him almost everyday when he comes to visit his wife. Now that’s being faithful: coming to visit, day in and day out. No matter what.
I respect Mr. G…and I feel sorry for him. It’s got to be hard to hear your wife screaming out that she doesn’t know who you are.
“You okay?” I ask softly. It’s a stupid question I already know the answer to–but I feel like I need to ask anyway, if only so he knows I care.
“Ah, May,” he replies, resting his hand on my shoulder. “Sometimes I can’t help but feel like…that’s not my wife. She is already gone. My wife, the woman I have known since I was 15…she’s gone.”
There’s nothing I can say. It’s true in a way. Mrs. G is not the same as she used to be and so her husband mourns the loss of his wife, even as he visits her every single day.

But it’s different for me. I never knew his wife, the woman who could bake cakes and but hated chocolate. I never knew the mother who scraped pennies so her children could wear nice clothes to school. I never knew the laughing girl he fell in love with, or the strong woman he stayed in love with.
The only Mrs. G I’ve ever known is right here, with a wrinkled face and a hair-trigger temper. The woman who throws her water-pitcher at me and calls me names when she’s in a bad mood. The woman who pats my hand and smiles when she’s in a good mood. This is the only Mrs. G I’ve ever known and this is the woman I care about.
Even though she replaced this man’s wife.
Mr. G sighs. “Can you calm her down?” He asks. “I think I’d better go.”
He’s off before I can answer, hobbling down the hall towards the exit, surprising quick for someone in his shape. I guess he really needs out of here.
I turn back to the room and square my shoulders. Inside, Mrs. G is still fuming and I’ve got to calm her down before dinner. This might require chocolate…
And my Mrs. G, she loves chocolate.

Meet Them Where They Are

Alice

Alice

 

Alice

Unreasonable, misplaced anger, unrelenting fear, heartbreak from deeply felt emotional wounds, a lack of trust both of others and of their own capabilities, powerlessness, despair, frustration, feelings of abandonment, and utter lack of control over their own surroundings are only some of the negative emotions that those living in Long Term Care facilities face on a daily basis.  My residents who struggle the most with the above mentioned feelings are usually the ones who are the least capable of clearly articulating it.
So what happens? They act out. They become verbally and on occasion, physically abusive. They often yell or become obstinate over seemingly innocent little tasks. They manipulate situations in a way that they feel best benefits their needs. They are the residents labeled “difficult”, “trouble makers”, “problems”, not just by those of us on the floor but also by those in the office.
God knows, I’m guilty of it; inwardly sighing, as I make my way to a resident who is furious at me for something over which I have no control. Or a resident who is vengeful because I’ve had to set a boundary that she doesn’t like. Some days, I wonder if all of my uphill battle folks had a meeting and decided that they would join forces in order to make a shift impossible just for their own entertainment. Those are the days that I leave work questioning both my sanity and my capabilities; the days when I think I suck at this gig and wonder why I am so determined to stick with it.
The thing is, though, when I step away for a minute, I realize that I have a level of awareness that is desperately needed in this field. I really do know that these “difficult” residents are not behaving in such a manner simply because they’re “mean”. The powers that be may know that, but in all honesty they don’t care. They can’t possibly care because their only solution appears to be medication, a problem that I will be discussing in a future post. A facilities treatment of their caregivers directly corresponds to their level of interest in their residents’ quality of care. They are not invested in us, then they are not invested in them.
SOMEONE has to be, though. Someone HAS to see beyond the behavior, which is nothing more than a symptom to the greater underlying illness. That responsibility lies on the floor. We are the witnesses and the carriers of their emotional wounds. While we are unlikely to heal them, we can step outside of ourselves and use their behaviors to learn how to better care for them, much like the pain from touching a hot stove teaches us to not touch it again.

Unreasonable, misplaced anger, unrelenting fear, heartbreak from deeply felt emotional wounds, a lack of trust both of others and of their own capabilities, powerlessness, despair, frustration, feelings of abandonment, and utter lack of control over their own surroundings…that’s a lot for any human being to have to live with. Sometimes adding “fit into my concept of acceptable behavior” on top of all that is just too much to ask of them and they can’t meet US where WE are. That’s when our empathy and understanding needs to stretch in order to better meet THEM where THEY are.

The Art of Knowing

Alice

Alice

“I think I want to stay in bed today. I don’t feel like eating breakfast.” Ms. ___ declared with a sigh.   “Ohhhh. Well ok then. I guess you’re tired of coffee. And of course you’re going to miss the latest gossip from Ms.___. And Mr. ___ is going to be a little bummed out. You know he has a bit of a crush on you…”

I chattered on nonchalantly, as I moved about her room. Wait for it, Alice..3…2…1…  “You know what? I’ve changed my mind. I’m actually a little hungry. Is my purple shirt clean?”

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“Alice!!!!”. Uh oh. I saw my partner on the hall racing out of Mr.__’s room towards me. This was not good. She is relatively new to the facility, and though she seems both confident and competent with her skills, she undervalues the importance of getting to know the residents in her care. It’s a rookie mistake.

“He…he said…it was awful!’, she stammered. I sighed and headed to his room. Mr.__ is not morning person. If you want to start out your shift with a battle of epic proportions, by all means go in there, turn on the light and announce that you’re getting him up for breakfast. No. The way to help him is to go in, put on his TED hose, get him dressed and moving with as little chitchat as possible. Before ten AM, he is more action, less talk.

Mr.__ is the opposite. He is legally blind. He does best when he clearly hears step by step the actions that are taken as we assist him. Otherwise, he gets confused, scared, and obstinate.

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“She’s very upset because she is short on her colostomy supplies. She was actually crying”, I was informed when I came on the floor. As frustrating as that can be for Mrs.___, it’s nothing she hasn’t dealt with before and I knew it wasn’t a shortage of her personal supplies that had her in tears. I’d been waiting for it.

Mrs.___ lost her husband earlier in the year to a long illness. At the time, it didn’t seem to have a deep impact on her. While he was sick, she had a friend who helped alleviate some of her pain, much to the shock of the other residents. It was quite the scandal on the floor, as everyone, workers and residents alike, were very fond of Mr.__.

Regardless of how it looked, I knew that she never really allowed herself to grieve. She is relatively young and I felt she just wasn’t equipped to face the pain on her own.

Sadly, her friend recently passed. Again, she appeared to take it in stride, handling the loss even better than some of the workers did. None of us saw his death coming and it was a shock. Because I’ve known Mrs.___ for years, I knew it was only a matter of time until the emotional reaction from the loss of both people for whom she cared deeply would hit her.

After breakfast, when the pace on the floor slows from 100 MPH to 75, I quietly slipped into her room. I told her that it’s going to be ok, reminded her that she is not alone and is very loved. I said that I was here if she ever needed someone to listen. She didn’t say anything; didn’t remove the blanket that covered her head, but her hand found mine and squeezed it as she cried softly into her pillow. It was a beginning.

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The true art in what we do as caregivers does not lie in the ability to make an occupied bed or do perfect hospital corners. It’s not our ability to take blood pressure or put a shirt on someone with an affected arm. It’s not even in thorough and clear documentation. Those are all important skills, but they can be taught. The ability to see, notice, observe and be present is the gift. The art of knowing is at the very heart of what we do. The idea that we are there, walking hand in hand with those for whom we care is what really matters most; that they can trust us and know that no matter what, they are not alone.