Locked-in, drugs & the 60’s

Here is a question…

What do you do when someone you are caring for, refuses your attention?

When you, the ‘carer’ – doctor, nurse, therapist, father or son are unable to find a position or a stance that makes sense to the other person, to the extent that you are viewed as a burden, an obstacle, or a threat?

I encounter this most days at work.

Many of my patients do not understand where they are, or if they do, why they are not allowed to leave or to go home.

In most instances, people, after a little explanation, discussion and sometimes distraction, settle and accept their situation; they slot-into the life of the ward, the routines – washing and dressing, mealtimes, activities, medicines rounds, visitors, etc.

Some of my patients refuse to accept the status quo and send us, the carers, into an endless cycle of reassurance, discussion and distraction, where there is rarely a point of acceptance, or if there is, it is when the patient has become so exhausted from pacing, struggling, seeking a way-out that they eventually fall asleep, only for the cycle to recommence when they wake.

It is very hard on the staff, working in this environment, in this context, where they are perceived by the patients as occupying roles more akin to jailors than nurses or healthcare assistants.

Staff sometimes try to overlay a medical model, or the sick-role to help their position – one that by and large, we try to minimize, usually however, this doesn’t work.

To the doctor in me, there is an instinctual pull to revert to my training, to my professional origins – to investigate, diagnose and treat; very often, within healthcare circles, and in particular doctors, this means to find a pill. Something that we can use to fix the behaviour we find difficult.

Yet, for people who are vulnerable, those who have lost capacity and insight into their situation, adding more drugs to their chart is not necessarily the right or appropriate thing. We have drugs to treat pain and infection, fever and inflammation; do we have drugs to treat disorientation and a desire to be at home – whatever the concept of home is?

Often, at the root of the patient’s need to leave, to escape, to get home, to catch the bus or attend the meeting, is anxiety, and we do have some medicines to help with this. Lorazepam is our most commonly used pharmaceutical agent which we resort to when all other tactics have failed. The drug, a benzodiazepine, which in the 60’s was seen as a panacea for anxiety and shortly after found to cause significant addiction, is the mainstay of our treatments, biding us time to allow the delirium to lift, for the dementia to progress or whatever turmoil is stirring within to settle.

This drug, like any has side effects which can at times, cause greater problems than those we initially intend to treat – whether falls, increased confusion, disorientation or over-sedation; finding the right balance can be difficult.

Again, balancing the right model of care – medical, holistic, psychiatric, integrative, is complicated, equally, doing anything has consequences.

What we know, is that no matter what we do, the numbers of people in positions of fear and anxiety, trapped in hospital or other institutional settings is likely to increase as our population ages and we need to come together to find the most appropriate, the most sensitive and balanced approach available.