The admission paperwork was complete and authorization for a prolonged admission was approved. A serious bacterial infection, multiple fractures of the lumbar spine, deep contusions, and a hematoma over the right kidney from being kicked with a shod foot. These were just the tip of the iceberg. The first few days were touch and go. Temperature spikes, intense pain, and ongoing workup to find the source of the elevated white blood cell (WBC) count and fever. Fortunately, the patient's condition began to improve. There was no damage to the kidney, nor there were rib fractures. There was a rather sizable abscess discovered. Treatment became more focused; the abscess began to shrink in size, and the WBC count came down. The patient's mother came in regularly despite her full-time job, which required overtime hours, placing additional stress upon her. She was, quite literally, the patient's last ally.

The hospital stay was turning into a constant battle. Swearing at the hospital staff when pain medication did not arrive started a cycle of worsening relationships. There was little compassion shown to the patient by any staff member. Weeks passed, and as the discharge date approached, the patient's mother talked about next steps, such as where would he go once discharged. She suggested asking the staff about getting into a program. He said that the staff "hated" him. Can you imagine a hospital where the staff made a patient feel hated?

It was not too hard to imagine the staff was not embracing him in light of the fact that there was an increasingly frequent stream of foul language or silence depending on the patient's frame of mind. All of his pent-up frustration and fear resulted in him yelling at his mother, accusing her of abandonment and not caring about him. She reminded him of her earlier suggestions, but he accepted no responsibility. In his mind, his mother was the reason he was going back to the street. Over the 6 weeks, he took no responsibility for looking into programs or sober houses to which he could be discharged. Instead, he aimed his anger at his mother, the one person who stood by him and either visited or spoke to him regularly over the entire stay.

Normally, a patient would start receiving visitors after the critical period passed, especially in light of the weeks of intravenous antibiotic treatment. Normally, the nursing staff would be compassionate toward someone who was facing a prolonged hospitalization. Normally, the parents would receive calls or supportive greeting cards from concerned relatives and friends. The phone would ring with inquiries about their child's condition, an offer of a visit to drop off a casserole, or perhaps to take them out to lunch or dinner. Unfortunately, there were no visitors aside from his mother; there was not a single call, nor card received by patient or parent. Brothers, sisters, aunts, and uncles had given up a long time ago ... but not his mother. She refused to give up on her youngest child because of the disease of addiction.

She was wracked with guilt, a victim of an intense weight of shame, a load difficult for all addicts' loved ones. In today's patient-centered care approach where both the patient and the caregiver are members of the care team, what happens to the caregiver when a patient is difficult? Sadly, there was no discussion between a care team member and the caregiver. Although at a minimum, support groups should have been offered, none were recommended.

This is the epitome of a difficult client. The patient is 31 years old and a homeless, hostile heroin addict. Each and every patient and caregiver deserve our best effort despite how difficult the situation may be. The patient presented multiple challenges to care coordination, but where is it written that every client will be easy and straightforward? Professional case managers don't give up on a client, especially one with so many red flags. Short of an outright refusal of case management services, we must put forth our effort toward addressing the needs of each individual and his or her family caregiver. In this situation, the caregiver clearly needed additional support resources, but nothing was offered.

At times I wonder why some health care services seem to come with a revolving door. This chain of events is a reminder of what sets up the next admission or emergency department visit. The worst case scenario is that this may have been the last opportunity to engage this patient in his own care. Sadly, he may not have a "next time" to do a better job of care coordination. He may go straight to the morgue instead ... and his mother will continue to suffer in silence, alone in her grief.