A few months ago, our unit had a 33 year old patient that was challenging at best. She had been admitted with a diagnosis of failure to thrive; weighing less than 60 pounds. She had frequent outburst- crying and screaming when her needs were not met to her expectations. She was accusatory ("You don't care, no one listens.") and at times manipulative. Her most frequent outbursts related to lack of inadequate pain control and wishing to die. She frequently voiced that she wanted to die in peace but her mother was preventing her from doing so.

After discussing this with her doctors, I was informed that the mother had stated that the patient was incompetent to make this decision. We were able to obtain a Psych consult to determine competency. Upon hearing that this evaluation was to be done, the mother became irate and demanded it to not be performed. The family dynamics were not healthy and the situation was tense. At a young age the patient had been diagnosed with a disorder that had a short life expectancy; she was told that she would probably not live to adulthood. In addition to this, she and her sister were the victims of sexual abuse at the hands of her father. She resorted to drugs and inappropriate behavior. Now her father was in prison and her mother was dictating her care. She felt hopeless, frustrated, and angry. Shortly after the competency evaluation was ordered, Nancy was assigned to this patient.

Little known to anyone, this was an answer to prayers. Nancy gave the patient a voice. She listened to her needs and concerns. She set a patient care conference to implement a plan of care WITH the patient. She verified her home pain regimen and was able to get it instituted. She fought with doctors, pharmacists, ancillary staff, and family. Within a short time, the patient's behavior began to change. She was more accepting of her care and willingly participated. She had a new lease on life. Her pain was more manageable and she felt she was no longer being ignored. She painted a picture to show Nancy her appreciation. Later, she was discharged home with hospice and subsequently died. Her family contacted Nancy to thank her for all she had done.

Nancy was able to help a patient's voice to be heard, repair a broken family, give a mother the peace to let her daughter make her own decisions (even if she did not agree), and show others that you cannot judge a book by its cover. Sometimes beneath the anger and manipulation is fear, pain, and a feeling of no control. Nancy is an example of a great patient advocate.