In the majority of cases, the death of the patient is the issue to be expected, however much it may have been delayed or postponed—a result saddening and discouraging to those whose previous training has been to preserve life. What nurses are not trained to see, and what many of them have neither imagination nor faith enough to see, is the number of lives that are probably saved through the safeguarding of a dying individual. It has been said that the world would be infinitely better off if every consumptive in it could die to-day, since by this loss the people of to-morrow would be saved. The nurse must cease to reckon in terms of hundreds of patients—she must reckon in terms of the thousands who come in contact with these patients. The amount that can be done to protect these thousands is the standard by which the work must be judged a failure or a success. If she bears this constantly in mind, she will not become so easily discouraged.
Therefore, to sum up once more: upon entering the home, the nurse’s first care is the family, and her second is the patient himself. But it is by working through the latter that the former may be reached. The patient himself is the point of attack, and if in the ensuing pages he becomes so prominent as to delude one into thinking that his welfare alone is the final goal, he is only made prominent in order that we may reach our goal more quickly.
Sources through Which Calls are Received. The nurse goes to the patient’s home, in the first instance, at the request of some one who has sent her. This may be a physician, a dispensary, a neighbour, or she may even go on her own shrewd suspicion that some one is ill. When the door is opened to her knock, she must be careful how she explains her coming. If a municipal nurse, she should never say that she has come from the Health Department, for this conveys a suggestion of authority which is often most alarming. Since the patient has been referred to the Health Department from one of the sources just mentioned, it would be more tactful to name the agency through which the call was received.
When calls are anonymous, such as by letter or telephone message, or when the sender gives his name but asks that it be withheld from the patient, the task of gaining an entrance is often one of considerable difficulty, and requires much strategy. Calls of this sort should never be refused, since in this way many advanced cases are brought to light. It is also a wholesome indication that the community is learning to take an intelligent interest in an infectious disease, whose presence is recognized as a menace. These cases can best be managed if the nurse assumes the responsibility herself, saying that in a roundabout way she has heard that there is illness in the house, and so has called to offer her services. As a rule, her offer will be readily accepted, for a case reported in this manner is usually advanced, and, as we have said before, when the neighbours diagnose tuberculosis, they are frequently right.
Entering the Home. As a rule, when a nurse presents herself at a house and explains her errand, the door is opened wide and she is cordially asked in. In some instances, it is held half-shut, in a dubious manner, and she is admitted with reluctance. Sometimes it is banged in her face. It is a great satisfaction to gain an entrance into homes of the latter class; to win the confidence of such patients is a victory worth having. The surest formula for entering all homes is a broad smile; to stand on the doorsteps and grin like a Cheshire cat disarms suspicion, and once across the threshold, the victory is won.
Taking the Patient’s History. The facts concerning the patient must be gathered in his home, and they are of two kinds, those concerning his physical and those concerning his social condition. The first thing to be done is to establish a feeling of trust between the patient and the nurse. As a rule, all patients are communicative, and a few adroit questions will open a flood-gate of confidence from which can be gathered full details concerning their personal and family affairs. This gives the nurse much of the information which she needs not only for her charts and records, but also in order to deal intelligently with each case. For unless she understands the patient, and knows something of his social and economic condition, she will not be able to give helpful advice. But the nurse must also bear in mind that tuberculous persons are frequently shy and sensitive, and it may be difficult to obtain their true histories. They may be more ready to describe their physical symptoms than their social condition, and facts about their employment, hours, wages, life insurance, and so forth are not always forthcoming. It is inadvisable to make notes in the presence of the patient, for among the poorer classes there is a fear that their words, when noted in a book, may in some mysterious manner be used against them. Occasionally, in a matter of some importance, distrust may be quieted by asking, “May I just write that down? The doctor will be interested in that and I want to get it right,” but it is well to remember that suspicions once aroused are difficult to quiet, and that for the welfare of the community it is better to teach them to use their sputum cups, than to antagonize them by too many questions. The nurse should get all the facts the chart calls for, but with certain patients this may take considerable time. At each succeeding visit she can ask another question and a more intimate one, until she collects, little by little, all the data she requires. But it is a mistake to keep on asking questions—collecting statistics—at the expense of confidence and good-will.
It is true that when a patient goes to a dispensary, he is prepared to answer many questions, but there is this difference—it is he who seeks the dispensary. When the tables are reversed, when he is not the seeker but the one sought, he must be handled carefully. There are of course many patients to whom this does not apply, and who willingly volunteer every detail of their lives, but these are not the majority. The others, the more sensitive ones, make up three quarters of the visiting list. The antagonizing of a patient by tactless questioning is an unfavourable commentary on the method of handling him.
Telling the Truth to the Patient. The most difficult of the nurse’s duties, and the saddest, is to tell the patient the nature of his disease. Yet this must be done, for unless he knows from the very beginning, it is impossible to exact from him that intelligent co-operation upon which rests his sole hope. Only on the rarest occasions is there any justification for withholding this knowledge. If a patient has but a few more days to live, or if a hopeless case is surrounded by scrupulous care and attention, this information may, if it seems best, be withheld. But these are exceptional instances. To hide the truth from an early or moderately advanced case would be criminal. Apart from the first shock, people are never really injured by being told the truth, and we all know of hundreds of cases in which lives have been ruthlessly sacrificed through the policy of silence.
The truth need not necessarily be brutal—it can be made full of hope, interest, and encouragement. In her efforts to encourage the patient, however, the nurse must be exceedingly careful never to use the word “cure.” Tuberculosis is never cured in the sense that typhoid fever is cured, for example. At best, it is only arrested—that is, brought to a standstill, to a point where the destruction of the lung tissue goes no farther. Thus, if a person loses one or two fingers from a hand, a cure would imply that these lost fingers could be made to grow again. The lung tissue destroyed by tuberculosis can not be replaced or renewed any more than lost fingers can be renewed. Yet a lung, in spite of this loss, is still able to serve its owner well and enable him to lead a useful and happy life, just as a hand which has lost a finger or two may still be a fairly useful hand, and serve its owner well. This distinction between arrest and cure must be made perfectly clear to the patient, and he must also be taught that whether the arrest of the disease is temporary or permanent depends in large measure upon himself. His improvement depends upon his thorough understanding of his illness, and upon his ability or willingness to co-operate as to treatment. According to Dr. Minor,[[3]] it is not so much what a patient has in his lungs, as what he has in his head; namely, common-sense, which determines his recovery. Therefore to keep a patient in the dark concerning his condition, and yet expect him, without knowing the reason, to do over and over again the tiresome routine things necessary to improvement, is to expect the impossible.
[3]. Dr. Charles L. Minor, Asheville, North Carolina.