Hospitals for Advanced Cases—The Careful Consumptive—Chief Duty of the
Nurse—Responsibility of the Institution—Home Care of the Advanced
Case—Exceptions to Institutional Care—Compulsory Segregation.
=Hospitals for the Advanced Case.= The crux of the tuberculosis problem
lies in the segregation of the advanced case. Until the distributor is
removed from his family, and separated from the intimate circle
surrounding him, we can make but little progress in the fight against
this disease. No community can protect itself from the ravages of
tuberculosis until it provides a place to which these advanced cases may
be sent. Not only do we need large special hospitals for these patients,
but we need special wards for consumptives in connection with every
general hospital which receives either city or State appropriations.
These special wards would be of even greater benefit to the community
than large special hospitals situated in the environs of a city, since
it would be easier to persuade a patient to enter an institution just
“round the corner” than to go to one far distant from his home. A dying
man dreads being separated from his family, and his family is equally
reluctant to part from him; furthermore, if a hospital is remote from
the city, his family can afford neither time nor carfare for frequent
visits. These facts play an important part in influencing a patient’s
decision, and due consideration should be accorded them.
It would probably cost less to build and maintain special wards in
connection with hospitals already existing than to erect and support an
entirely new institution. The greatest objection to special wards is
that the coughing of the consumptives is disturbing to the other
patients, but if the ward is sufficiently isolated (a separate building,
if the hospital is planned on the cottage system) this objection would
not apply. Furthermore, these wards would offer good teaching centres,
where both doctors and nurses could learn more about pulmonary
tuberculosis than the average hospital teaches to-day.
In attempting to secure ground for the erection of a tuberculosis
hospital, there is usually great opposition from laymen. They are not
only afraid of tuberculosis, but they fear the depreciation of property
which may arise in the vicinity of such an institution. Considerable
education is required to calm them to a realization that the consumptive
sheltered and cared for is less dangerous than the consumptive at large
and unrecognized. When it comes to a special ward in connection with a
city hospital, we may again encounter great opposition, really from the
same reason, though the objections expressed are expense of such a ward,
the lack of nursing facilities, that the room is needed for acute
diseases, and so on. All of which is a grave commentary, from the people
who best understand it, upon the infectious nature of this disease. Yet
the medical profession tells us with apparent sincerity that “the
careful consumptive is not a menace.” If this be true, where can he be
more careful and less of a menace than in a place specially provided for
him?
The truth of the matter is, there is not, nor can there be, a _careful
enough_ consumptive. The very nature of the disease precludes such a
possibility, however much we educate him, or however earnestly he
himself may try to co-operate to that end. And for the vast majority of
patients, from whom we can obtain but little or only spasmodic
co-operation, there is even less to be said. There is one simple method
of determining whether or not a patient is careful—it consists in asking
the question: Under these circumstances, would I, myself, feel safe?
Would I be satisfied as to the safety of my nearest and dearest friend?
At the beginning of the year 1912, the nurses of the Tuberculosis
Division of Baltimore had on their visiting lists about 2800 patients.
Of these 2020 were positively diagnosed, and had been under supervision
for over three months. Undiagnosed cases, and positive ones who had been
under supervision less than three months were excluded. These 2020 cases
were then classified according to their willingness or ability to follow
instructions, the groups being: Fairly Careful, Careless, and Grossly
Careless. We purposely omitted a “Careful” class, since adequate
carefulness would imply a condition in which there was absolutely no
danger, a condition hardly possible with this disease. In Fairly Careful
we included all those patients who really tried to follow advice, doing
so to the best of their ability. Careless included those who tried
intermittently, or who were badly hampered by circumstances. Grossly
Careless speaks for itself.
The results of this analysis are here given:
Patients visited over three months 194
Fairly Careful 98, or 50.5%
Careless 75, or 38.65%
Grossly Careless 21, or 10.82%
Patients visited over six months 346
Fairly Careful 171, or 49.43%
Careless 151, or 43.64%
Grossly Careless 24, or 6.84%
Patients visited over one year 623
Fairly Careful 300, or 48.15%
Careless 267, or 42.85%
Grossly Careless 56, or 8.98%
Patients visited over two years 857
Fairly Careful 443, or 51.69%
Careless 339, or 39.55%
Grossly Careless 75, or 8.75%
Total Number of Patients 2020
Fairly Careful 1012, or
50.09%
Careless 832, or 41.13%
Grossly Careless 176, or 8%
It will be noticed that these percentages vary but slightly, or to a
negligible extent. Roughly speaking, about half the patients try to be
careful, and half do not try, or do not succeed if they attempt it.
Furthermore, it will be noticed that the time element has little to do
with making a patient careful. The natural supposition would be that a
patient visited for one or two years would show a marked increase of
carefulness over those who had been under supervision but a few months.
Yet there is virtually no difference between them, 50.5% of the
three-months class being careful, as against 51.69% of the two-years
class. These figures, we believe, show conclusively that long-continued
teaching does not necessarily lead to satisfactory results. They also
show that the patient left in his own home, even under constant
supervision, is unable to achieve a degree of technique which means
positive protection to those around him. There is but one conclusion to
be drawn from these facts—not that the nurse is useless, but that the
patient at large is dangerous. It proves the necessity for hospital
care.
The hospital for a patient to die in appeals less to public sympathy
than as a place in which he may get well. But it is better economy. Care
of the open case, during his last and most infectious stages, is care
which strikes at the very root of the evil. Until this fact is realized
and full provision made for these cases, it will be a waste of time and
money to spend them on superficial or half-way measures. If our goal is
the elimination of tuberculosis, we should concentrate our efforts upon
radical and fundamental methods.
At present, however, we can conceive of no community sufficiently
advanced or far-seeing to make adequate provision for these last-stage
cases. Therefore, the patients who make up the difference between the
number of those needing hospital care, and those receiving hospital
care, must be cared for in their homes by the nurse. Never for a moment
should home supervision be considered a satisfactory substitute for
hospital accommodation. The nurse’s efforts, no matter how thorough and
conscientious, can never entirely remove the danger. Her care often
lessens it to a marked degree, but never absolutely eliminates it. It is
at best a makeshift, a stopgap—better than nothing, often much better
than nothing, but never for a moment the proper alternative to removing
the patient from his home. No one knows better than the nurse herself
the inadequacy, the futility, of even the closest supervision.
=Chief Duty of the Nurse.= For this reason, the chief, the absolutely
most important duty of the nurse is to induce the infectious patient to
go from his home into an institution. To accomplish this end, she must
bring every effort to bear upon the patient and his family, and appeal
to them from every conceivable angle. This is her one great duty—the
paramount reason for her existence.
To accomplish this, is as difficult as it is important. A patient does
not willingly give up his home, however poor and humble it may be, while
his family often cling to him with an obstinacy open to no argument. As
a rule, the difficulty of removing him is in inverse ratio to his
intelligence, and to the danger to those surrounding him.
=Responsibility of the Institution.= In overcoming this prejudice, a
great deal depends upon the character of the institution itself. It is
not enough to establish hospitals:—they must be attractive and
comfortable to such a degree that they become highly desirable to
prospective patients. They must be well run, well managed, the food must
be good, and the patients well treated. To obtain segregation, we must
have hospitals which offer great advantages over the home.
=Home Care of the Advanced Case.= If there are no hospital facilities,
it then becomes the nurse’s duty to give nursing care to the bed-ridden
patient. This is also done when the hospital accommodations are limited,
and the patient must wait to be admitted. During this waiting period,
which may extend over weeks, he should be visited every day (or at least
as often as the work will permit), and given such care as he requires,
including bed-baths, care of the back, and so forth. The nurse must also
teach some older, responsible member of the family how to care for him
in the intervals between her visits. Sometimes, when a vacancy finally
occurs, the patient may be contented with home treatment and refuse to
enter the institution, or his family may refuse to let him go. The nurse
must do her utmost to persuade them. She must explain that in the
hospital he will receive constant, not intermittent care, and that her
work will only permit her to render nursing service to those who cannot
otherwise be provided for. Should he still refuse, she must continue her
visits of supervision, but must stop all nursing care. No premium
whatever should be placed on his remaining at home. This may seem like a
harsh and unfeeling policy, but it is the only course to pursue when we
take into consideration the fact that the institution is the proper
place for an infectious disease. If a patient has become accustomed to a
daily bath and other attentions, he will miss them; when he misses them
badly enough, he will consent to go where they may be had. This plan
does not mean that the nurse neglects the patient,—if he suffers, it is
through choice. An excellent alternative has been offered, and his
refusal to accept it should not entitle him to continue infecting his
family, assisted by the nurse to do it in comfort.
=Exceptions to Institutional Care.= A few exceptions may be made in
advising institutional care. For example, if a family is in good
circumstances, with excellent home conditions, and the patient is
surrounded with every care and attention, it would hardly be necessary
to counsel his removal. On the contrary, with our present lack of
hospital facilities, to urge such a patient to leave his home might mean
taking a hospital bed from another who needed it infinitely more. Again,
if a tuberculous child is being cared for by his mother, or some one
equally unlikely to contract the disease, it might not be worth while to
remove him. An exception might also be made in the case of a childless
couple, advanced in years. The nurse must use her judgment and
common-sense in such cases, where the chances of infection are slight,
or non-existent. On the other hand, if there is ample hospital
accommodation, and cases like the above ask for admission, they should
always be taken in.
The cases in which separation is imperative are those in which there is
great exposure, inability to control the home surroundings, extreme
poverty and neglect, or undue and prolonged strain upon other members of
the household.
=Compulsory Segregation.= Not until our hospital facilities are so large
that we can accept every case which applies for admission, can we
consider forcing people to enter these institutions against their will.
It is illogical to consider compulsory segregation, while we cannot
accommodate all those who voluntarily ask for it. The patient who
refuses to go to an institution is probably no more dangerous than he
who clamours in vain for a bed. The docile, well intentioned, kindly
consumptive is doubtless as much a menace as the selfish, vicious,
avowedly careless one; in fact, the former may be more harmful, since
his kindly nature surrounds him with friends, whereas the latter forces
people to avoid him.
As for the tramp, the homeless man who wanders from pillar to post,
sleeping in saloons and lodging-houses, he is far less of a menace than
people suppose. He comes into but casual relationship with his fellows,
and no one is in prolonged and intimate contact with him, as is the case
of the man in the home, the centre of the family circle. Until we can
accommodate the latter, we must let the former do as seems best to him.
If ten anxious people are clamouring for every hospital bed at our
disposal, why force it upon the reluctant one who refuses? When we can
handle the problem of voluntary segregation, it will be time to consider
compulsory measures.