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Physician, heal thyself!

Janet Webb
BSc(Hons) RGN
DiPN(Lond)
Practice Nurse
Lindum Medical Practice
Lincolnshire

For almost 20 years Janet Webb has been trying to encourage Len and Betty to take more exercise and eat a healthy balanced diet, but they just grow bigger and more breathless with every passing year. However, a recent experience with another of her patients forced her to question her methods ...

It could have been the dark morning, or maybe it was the van I was following as I inched through the early morning traffic. Emblazoned on the van were the words, "Mobile Dog Wash" and beneath that was a cartoon picture of a dog in a shower cap, surrounded by bubbles. At that point, I realised I had made the wrong career choice, and that for the last 30-odd years I could have been washing happy-looking dogs wearing shower caps.

Either way, I was in low spirits for my first appointment when Len and Betty puffed and panted their way into my room. Len had come for his six-month chronic obstructive pulmonary disease (COPD) review and Betty had tagged along for her flu jab. Both Len and Betty are short in stature, but severely obese. Len always tells me he's stopped smoking, but there is always a lingering odour of cigarettes about him. Sitting himself down, he slapped his three inhalers on the desk, declaring, as usual, that they don't work. He takes tiotropium, Symbicort and Salbutamol, and tends to suffer from two or three exacerbations a year, when he takes oral prednisolone with antibiotics. His FEV1 is 41% of predicted and his oxygen saturation 96%.

He tells me he and Betty had a week away at the coast, where Betty decided to hire a wheelchair.Len had found it very difficult to push her along the seafront in a strong headwind, and had to stop several times (variously in the cafes and pubs along the promenade) to catch his breath. He had not taken his diuretic, so his ankles had swollen. He had not tied the laces on his shoes because of the swelling, and this had made the walking even more difficult. For all of these reasons he declared his treatment useless.

As usual, I told him he needed to lose some weight and, as usual, he told me he was only this weight because of all the steroids I kept giving him, and his weight had been normal until he had stopped smoking. I tried once more to explain that his obese abdomen was restricting lung expansion, and the extra weight and breathing difficulty was putting strain on his heart so that fluid was being dumped in the soft tissue of his ankles. Losing weight would relieve the strain, allow more lung expansion and provide him with more energy. Betty said she didn't want him to have more energy; he was bad enough as he was. They both screamed with laughter.

I said that Betty was also obese, meaning that he had to push harder when she resorted to a wheelchair, and suggested she might not need to hire a wheelchair at all if she too lost some weight - they could help each other. I suggested a free, local weight-loss initiative they both might join, which they found uproariously funny. I could feel my enthusiasm waning, and knew I was failing, as usual, to motivate either of them. For almost 20 years I've been trying to encourage them both to take more exercise and eat a healthy balanced diet, but they just grow bigger and more breathless with every passing year. Len worked in a crisp factory when I first met him, and his story then was that he absorbed the atmospheric fat from the fryers through his skin.

I faced reality. I obviously lacked any skill whatsoever at health promotion, and my career had been a waste of time and government funding. Len and Betty left in good spirits, saying they were treating themselves to mobility scooters at Christmas, and they'd see me next summer.

Later that morning I saw Glenys for her fortnightly antimanic injection. She has a history of schizophrenia, which started at university. She no longer gets symptoms and is managed by the community mental health team. Since losing the destructive voices in her head, Glenys has rediscovered her faith and joined an evangelical church, from which she gained enormous support when her mother died last year; but it troubles her that she cannot convince her father that he should also be "saved".

Her father still works, and seems to be managing the loss of his wife, though I don't know him well; he is an infrequent visitor to the surgery. Glenys visits him several times each week, and they argue over her strong commitment to her faith. She's upset that she cannot convince him of what she sees is the "right path". We often talk about this, but today she tells me he has told her to stay away if she can't talk about anything but religion as he has no intention of being saved.
Possibly what hurt even more was that he told Glenys her
mother was dead, not waiting anywhere or watching over anybody but dead, and that she was deluding herself with ideas of an afterlife where everything was lovely.

Glenys's pain was tangible and I wanted to comfort her. She felt she now had to choose between her father and her religion. We went over the conversation she had had with her father. I suggested that perhaps he was as committed to his atheism as she was to her Christianity, and that faith was intensely personal, the same religion didn't work for everyone. He had, after all, only asked her to stay away if she only wanted to talk about religion; perhaps they would both benefit from distancing themselves from it, taking some breathing space, then a change of subject.

Maybe, having given him enough information to make an informed choice, she could allow him to raise the subject if he wanted to, but to respect his individuality and his freedom to choose. We talked about the processes involved in change, the individual perception of whether change would be possible, necessary or beneficial, and the frustration felt from trying to enforce unwelcome change. He wasn't rejecting Glenys herself, just her pressure to commit to religion when he didn't feel the need. Glenys said our conversation had helped.

Later, on reflection, I realised how cathartic it had been. Glenys' frustration and sense of rejection had been like mine with Len and Betty, only it had taken me nearly 20 years to realise they weren't ready to change. If I were to superimpose the ethical code, I would respect their right to individuality and freedom to choose, and do the least harm and most good by being ready with lifestyle advice if and when they felt ready.1,2
I would act fairly by accepting that individuals make different choices, and continue to provide the healthcare they need, and are entitled to, in the meantime.

I bet you can't get the dogs to keep the shower caps on anyway.

References
1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Oxford University Press; 1995.
2. Prochaska J, DiClemente C. The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Daw-Jones Irwin; 1984.

Your comments (terms and conditions apply):

"Yes it's a hard lesson to learn that no matter how much we encourage, support or cajole, patients are adults (mainly) and will continue to make their own minds up regarding what they want to do with their own lives. And so it should be, I always say to reluctant to change patients that as long as they know the consequences of their actions and how can they not it is at the end of the day their own choice. Another thought is why do we continue to feel as nurses we have to save the world? Let people get on with their lives we can no longer afford to keep on pouring good money after bad trying to change attitudes" - Name and address supplied