Nursing is a field where caring is expected, where the character of the persons participating in it is expected to be nurturing. This can be expressed in many different ways, in a gentle washcloth on the mouth or some harsh but honest truths or reexplaining how to perform an action for the umpteenth time or any number of things: the core is that the expression may not be "nice," but it should be kind.
And that takes a degree of emotional energy, to use both the training and that base compassion into a combined demonstration of "kind." It makes complete sense that we have emotional connections to some situations, where we are frustrated on the patient's behalf. Yes, sometimes because of the patient's decisions, too, but that is not the focus today.
We have social workers on our team: truly, I cannot fathom what we would do without our case managers and social workers. They submit all the right paperwork, follow-up with facilities, arrange home healthcare, talk to families about their options, and wear so many hats. There are so many needs that they are working to meet, with literal hours on the phone. They manage the next steps so we can focus on the current ones. And still there are places where their hands are tied.
I cannot tell you how many times I hear discussion about insurance in my workday. We talk about placement in nursing homes, home health care, new medications, in terms of waiting for insurance and/or Medicare to respond back. I cannot fathom how many extra days of hospitalization happen in a year because the patient's case is pending with insurance in one hospital let alone the country. It affects their care. It affects their options. This waiting adds to collective suffering. The worry over the burden of cost is its own suffering, especially when you factor in the remaining cost even after insurance has been calculated. And if the patient is covered by the VA, that's a whole other regulatory body and then we get into some fun specifics about what hospice elements are and are not covered by Medicare. And then we have a patient that needs a locked dementia unit wandering around our floor for a month or so because there is no place for them to go that will accept them (this has happened multiple times) or the family has decided against the place that would for one reason or another. There are persons who are denied may have no other resources to pull from--sometimes, we have to send people home. And if they have no home, sometimes there is a shelter and sometimes there is not.
The cost is measured in time. The cost is measured in hospital resources (including staff and space) that cannot then be spent elsewhere. The cost is measured in pain. The cost is measured in stress. And, yes, the cost is also measured in money.
There are many, many needs that are being met; there are also many needs that fall through the cracks because the system is not built to support them. There are more gaps to fill. Make no mistake: if we did not have to contend with insurance--or, more specifically, the bloated prices of the American Healthcare System--what a different world healthcare would be. I won't claim that this is the ONLY problem, but it does seem to be the loudest. There are other countries with better healthcare outcomes that do not cost nearly as much as we pay here. We do not have to imagine what the alternatives look like: they already exist.
There are many, many people in this country that are one bad day away from complete bankruptcy, just one accident or one diagnosis, even if they've done everything "right." No one seems to understand these costs until they are faced with that first terrible bill, the one that opens a chasm where their stomach used to be and swallows them whole in a deep, impossible dread. It is hard not to despair in these places. I know these places. I have been one of the lucky ones, one of the persistent ones that has been able to argue successfully with insurance and plan ahead in other spaces--this is purely luck, that we had the right series of compatible insurance coverage, where the egregious totals somehow whittled down to just a few thousand dollars. I have seen patients where that has not been the case or a surprise thousand dollars was not something that could be found.
If their routine doctor's office visits had been covered, they could have avoided the entire hospitalization. If they were able to afford their medication, their condition would not have exacerbated to this degree. If their hours had not been cut in COVID, they still would have been able to afford all of their medication instead of only some. If their dental insurance covered anything outside of a single cleaning a year, they would have been able to get the dental work necessary to avoid endocarditis. If they had a job that allowed them actual sick leave, they would not be leaving the hospital AMA. There are so many "ifs," and they are measured in suffering.
How can I not carry righteous indignation when I see how others are suffering in this way? It is the antithesis of "kind" to watch people simply slip through these holes. I have many thoughts about the system as it stands, how I would wish it fixed. I reject the idea that it is unfixable--better is still better, and there will be a degree of discomfort as we adjust to changes. So sometimes the best I can do is swallow the indignation until it's ready to be used, vote, recognize that I cannot fix everything in the twelve hours I have the patient that day, express the needs that they make me aware of, and otherwise take specific gratitude in the places I see our case management and social work teams find solutions.
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