"It is the highest folly to judge of the sick, as is often done, when you see them merely in a period of excitement. People have very often died of that which, it has been proclaimed at the time, has 'done them no harm.'

As an old experienced nurse I do most earnestly deprecate all such careless words. I have known patients delirious all night, after seeing a visitor who called them 'better,' thought they 'only wanted a little amusement' and who came again, saying, 'I hope you were not the worse for my visit,' neither waiting for the answer, nor even looking at the case. No real patient will ever say, 'Yes, but I was a great deal the worse.'

It is not, however either death or delirium of which, in these cases, there is most danger to the patient. Unperceived consequences are far more likely to ensue. You will have impunity-the poor patient will not. That is, the patient will suffer, although neither he nor the inflictor of the injury will attribute it to its real cause. It will not be directly traceable, except by a very careful observant nurse. The patient will often not even mention what has done him most harm." Florence Nightingale1

In her often quoted book Notes on Nursing: What It Is and What It Is Not, Nightingale's observations of the effect of visitors and healthcare personnel's interactions with the sick are exquisitely sensitive and astute. Sadly, visitors and practitioners at times interfere with patients' welfare through careless remarks and free-flowing unguarded conversations-"conversations" which, if dissected, might reveal problematic subjects and themes more in the interest of the visitor or provider than of the patient. For example, family members visit out of a sense of duty; family members visit together and talk among themselves, ignoring the patient; healthcare providers and family members talk about the patient within his/her hearing; visitors joke with one another, leaving the patient out of the interaction; visitors objectify the patient by giving advise and telling stories about other people that have "the same malady." And surprisingly, you might hear these very same visitors say that they had a good visit with their loved one. Nightingale suggests that the nurse "come back and look at your patient an hour after he has had an animated conversation with you. It is the best test of his real state we know."

I would suggest that one of the reasons that we witness these types of conversations is because of the visitor's anxiety and fear, not the patient's. It may be ignorance on the visitor's part of the most truly caring and compassionate way to visit and care for another, or it may be the visitor's lack of awareness of his or her effect on the vulnerable. It is also simply a fact that visitors may be worried about their loved one's condition and fearful that they will not know what to do or how to help.

Nowhere is this phenomenon more apparent at times than in long-term care. Loving relatives come to visit, but their visit is rarely fulfilling for them or the resident. I believe this is largely because of visitors' fear of their own mortality, of which they are reminded as they prepare to visit their loved one and then find their fear and dread heightened as they enter the long-term care facility. If their loved one is in distress, the visitor's dismay and sense of helplessness are palpable. And it is this fear that impedes their most sought after human connection with their loved one. One hears comments expressed with great sadness, "We haven't had a meaningful conversation in a long time." This seems surprising because those who have found a way to overcome this dread do have meaningful conversations regularly with residents. The lack of connection might simply be that the patient is no longer interested in what was once meaningful to both but now has other interests. The patient has moved on, but the visitor is stuck in the past.

What would we observe if we went back to the resident after just such a visit? Sadness? Loneliness? Bewilderment? Anxiety? Anger? Agitation? Confusion?

How will each of us, as visitors, overcome our fears and anxieties and past conflicts to be present to those we love?

Reference