It’s All Relative

I started my morning attending on the inpatient service, discussing end-of-life goals of care with the family of a patient with a large intracerebral hemorrhage. In the afternoon, I was scheduled for the outpatient clinic, and was thrilled to see Mrs. K on my schedule. Mrs. K was a 75-year-old woman with a history of hypertension and borderline diabetes, who came into the emergency department six weeks prior with a right hemiparesis. Her weakness was severe and she was bed bound and unable to walk. I had been the stroke attending on service, and because her husband had brought her in immediately, she was a candidate for IV tPA, the clot buster used to break up clots and treat acute strokes. She responded beautifully to treatment, demonstrated some improvement quickly, and left the hospital for rehab after only a couple of days.

When I walked into her room, she stood up to greet me and shook my hand. “You look terrific!” I exclaimed, so happy for her and entirely pleased with myself.

She burst into tears. “Would you want to look like this?” she asked.

She told me that while she could now walk, the last couple of weeks had been incredibly frustrating. She was tired all the time and her hand didn’t work well. This made things difficult, as she and her husband enjoyed going out to lunch with their friends and she was embarrassed to use a knife and fork at a restaurant. Instead, she had spent the entire time at home alone, isolated and miserable.

“Feeling like an insensitive jerk,” doesn’t quite encompass my reaction to her words, yet it’s a fairly accurate description. Her reaction illustrated an important point that I’ll never forget. Everything is relative.

Since my experience with Mrs. K, I’ve seen this pattern with my stroke patients time and time again. Stroke recovery is a process, much like Dr. Kubler Ross’ five stages of grief. Stroke recovery often begins with a patient’s joy that they’re alive and may recover. This typically extends past the hospitalization and through rehabilitation. But then things begin to change. As patients work to transition home and find things that were once easy, like getting dressed, are now exhausting, it soon becomes “not ok.” They’re convinced that they won’t get better, that there’s no end in sight. Sometimes there’s considerable guilt that they feel this way when they “should” be happy with how they’re doing.

Over the first few months at home, patients continue to improve, and by six months many are thrilled with progress they’ve made, though not entirely satisfied. They’re optimistic, but have lingering questions as to what their prognosis truly is. By one year post-stroke, there’s typically at least some form of acceptance, and for most patients, they’re ok with their level of recovery. While this path is common, each patient’s journey is unique, and each step requires a different attitude from their clinician.

I realized that my visit with Mrs. K that day was shaped by my prior experiences as much as it was shaped by hers. What if I hadn’t had the end-of-life conversation earlier that day? What if instead I had treated a patient with severe stroke symptoms who had immediately recovered completely? Would I have thought that Mrs. K’s improvement was so remarkable? Would I have been so quick to jump to conclusions before listening to her perception of her recovery?

We have to be mindful of the way that we approach patients, trying our best to determine if they need a cheerleader, tough love, or a sympathetic ear. We must remember how our own daily experiences influence our interactions and use that knowledge to strengthen our connection with patients.