Being consistent and reliable.
Such as regularly scheduled visits
by the same nurses whenever possible.

If the system works right, you will hear about them when they are discharged from hospital. How much effort will you make? After all, at this point, having just been discharged, they are in pretty good shape. Why would they even want your attention? Ordinary people wouldn't.

These are not ordinary people. Their perceptions of value and ethics are not yours and mine. Regardless what you think, if you do nothing you will be seen as "all the others" who have given up on them and gone away. That's how this population sees it. The rest of the clients, the more stable population, see it as "I don't need the nurse any longer, great." But the folk we are talking about here see their relationship with you differently. They see it as permanent. Or at least they want the relationship to be permanent.
If you want to avoid being caught in one ethical dilemma after another, you must understand how you are seen.

  • First, you are not treated with indifference.
  • Almost everything you say and do has an exaggerated impact on the patient's response.
  • It is easy to see this as some sort of friendship - the kind you might have with your neighbors or coworkers. It's not.
Think of yourself as a car. Or a computer. Think about how you feel about your car. You depend on it, you need to know it will be there when situations demand it. Of course, it's most clearly valuable to you when you really, really need it.
Now consider how you would feel about your car if it were only around in emergencies. The rest of the time, it just disappears. And it doesn't reappear until you are in crisis. I suspect you'd be looking for a new car. Or computer, or TV, refrigerator - you get the idea.

That's what we are: an appliance. A very useful, often clever... appliance. And like any good appliance, you're always around. Not just when disaster hits, but in ordinary times too. So that they can see you. That you will be there when they need you. When they decide they need you.
Otherwise, you will arrive too late. They want an appliance that will keep them out of a mess in the first place, something that will dish out the right 'ounce of prevention' so that they don't get once again pounded by the cure. Care delivery by crisis almost guarantees the second situation will be worse than the first, the third worse than the second. The patient will degenerate into 'noncompliant', 'uncommunicative', 'erratic', even 'hostile'. What went wrong?

Let us tell you about one of our favorite patients.
She was doing so well! It was hard to remember how close to the edge she really was. And is. She was doing so well that we kinda let her slide. We told ourselves we had other priorities and she could take care of herself. At least mentally, we closed her chart.
When she hit a rough spot with her boyfriend, we weren't there. She did call us but we took too long to get back to her. Let me say right away that we're not talking here about guilt. We got back to her reasonably quick, just not quick enough. In the three days it took us to reconnect, she had fallen off the wagon and started to use drugs again after two years of being clean. Additionally, she had moved us into the 'unreliable-like-everybody-else' category - was in fact referring to us as "those two bitches".
She is now struggling to get her addictions back under control and it's problematic whether she can get even back to where she was. Our communication with her is at best strained, just barely ticking along. Years wiped out in three days.
She is lost. At least for now, she is lost. We feel this often on a daily basis. There are many degrees of 'being there' for someone. You could spend all day searching someone's haunts for them and not visit the rest of your Clients. However, these other patients must be seen also. We are unable to be all things to all people.

This will be hard on you. You know her expectations were unrealistic. You know you gave her all that you could. That it wasn't enough for a moment - just a moment but a critical moment - that it wasn't enough is not something you should feel bad about. But you're human. You're a nurse. You're a professional. You want to do it right every time. It's your job to help them heal, to keep them alive and fighting against the chains of their disease, their dependencies, their mental turmoil.

So you feel bad. You tear at yourself, search for a way to turn back the clock for her, for yourself. Well, it ain't gonna happen. At least for the moment, she's lost.

And here's the thing: you keep her chart going. Yeah, she's not sick in the sense that there's a bandage to change or medication to deliver. But the disease, the big disease called DTES has its claws into her deep and it's only a matter of time before you see her on the hospital discharge list. Or the morgue.
So, you can try to help her now. Or help bury her later. And if you do help, she may reject your effort. And if she does let you back in, she may - the odds are good - crash and burn again. And again. And again.