David was in his late 50s and had been diagnosed with Parkinson's disease several years previously. Following a lengthy hospitalization, David's wife agreed to a placement on the subacute/rehab unit in the facility where I was the instructor for nursing students during their older adult clinical rotation. She hoped therapy sessions would help David improve his strength so that he could return home.
Although ravaged by the disease, David seemed to like having students provide his nursing care. He was unable to speak, but could nod "yes" or "no" in response to short questions or grunt in approval. His room contained photo albums of his hunting and fishing trips, and he enjoyed looking at them with the students. A consummate sports fan (as evidenced by his T-shirts and the pennants on display), his eyes would sparkle when favorite teams were discussed. We suspected that he was more cognitively intact than people realized.
One of his favorite activities was sitting by his room window, which overlooked the facility gardens and a play area for the preschool next door. For several weeks, I discovered a nursing student and David sitting by the window watching the outdoor activities in companionable silence. Students worried they weren't providing nursing care, but I assured them that being present with someone can be just as therapeutic as a task-oriented intervention.
Diagnosed with pneumonia, David was transferred to a medical facility. When he returned two weeks later, he was admitted to a room on the long-term care unit. Because his wife had realized home care was no longer an option, he couldn't return to his previous room on the unit for residents who would eventually be discharged home.
David's new room overlooked a parking lot. The day after his return, students noted that he seemed apathetic in response to their attempts to reconnect. Later that day, some of the students asked if they could take David for a wheelchair ride. During the ride, which was approved by unit staff, they entered the rehab unit. Soon David began to grunt, pulling away from the students and propelling himself to his old room. He entered the room, oblivious to the fact that it had a new occupant. The woman in the room had mild dementia-her screams that a man was attacking her got everyone's attention.
I hurried into the room, with students close behind. David wasn't trying to touch the woman, but he was angrily grunting at her while attempting to knock her things off a tray table. I instructed a student to comfort the frightened woman, and we maneuvered David into the hallway as he shrieked and clawed at us. The sounds of children in the play area wafting in through the open windows seemed to spur his determination to return to his former room. The students stood in shock at David's uncharacteristic outburst-he'd always seemed calm and easygoing.
Then I saw the tears rolling down his face, and I understood that David wanted to be in his old room-the room where he could look at the gardens and watch the children play, the room that gave him hope he was going to return home. He was grieving yet another loss. So I reached out and held him. His tears turned into sobs, and he rested his head on my shoulder.
After a time, David quietly allowed me to take him back to his new room. He pointed to his bed, so a student and I helped him into it. After a few minutes, he was asleep.
When I discussed the situation with staff, I discovered that there had been no plan in place to prepare David for admission to a different unit and room. No one seemed to know if any information had been communicated to David before his return to the facility. In addition, some of the staff didn't believe he was cognitively intact enough to realize what was going on.
Later, the students and I discussed the importance of preparing people for change, the lack of communication among the caregivers on the two units, the importance of individualized care, and the RN's role as a patient advocate. Some students wept for David's losses as they began to understand that grief isn't limited to situations of death or dying. Many later wrote movingly about the incident in their clinical journals.
David died unexpectedly before our next scheduled clinical day. It's hard not to wonder if he died of a broken heart, a grief too great to bear. But whatever the reality, I do know this: he'd taught nursing students about loss in a way they'd never forget.