Nan Sperber was admitted to our medical/surgical unit with severe abdominal pain. "Do you have a mirror?" she asked softly the first time I entered her room. A petite woman with light brown hair, she carried herself with dignity. As I flipped up the mirror on her bedside table, she asked hesitantly, "Does my wig look straight?"

Learning her history

When I asked Mrs. Sperber if I could take her patient history and perform an assessment, she told me to call her Nan. I learned that she'd been diagnosed with breast cancer 5 years earlier, at age 53. After undergoing a mastectomy and completing a course of chemotherapy, she was given a promising prognosis and had enjoyed relatively good health until a few months ago.

When she developed a gnawing ache in her abdomen, testing showed that cancer had metastasized to her liver and pancreas. She underwent chemotherapy again, but her condition deteriorated. Now she was very thin and too weak to walk.

I'd finished assessing Nan and was starting to orient her to the unit when she said abruptly, "Could you come back later? I'd like to be alone. Please shut the door behind you."

Respecting her wishes, I placed the call light where she could reach it and encouraged her to use it if she needed anything.

Refusing to open up

When diagnostic tests confirmed widespread cancer, Nan changed her code status to do-not-resuscitate. Clearly she needed physical and emotional support, and I tried to give her both. As I medicated her for pain, helped her with personal hygiene, kept her linens clean, and moved her to the commode, I gave her many opportunities to talk, but she wouldn't open up. Her only request, besides keeping the door closed, was to make sure her wig was on straight.

Each time before I left her room, I made sure her wig looked all right and encouraged her again to use the call light. She never did. Nor did she discuss her grief with her husband, her family, a counselor, or me.

After 5 days, Nan told the oncologist she'd feel more comfortable at home. As we reviewed her pain management regimen together before her discharge, I felt I'd fallen short of meeting her emotional needs. She'd never called me by name, never once used her call light. As she sat in a wheelchair waiting to leave, I reached out and gently squeezed her hand. She didn't squeeze back.

Change of heart

About a week later, the ambulance brought in Nan, accompanied by her husband Joe. I hardly recognized her, she was so emaciated. Her jaundiced eyes had sunk into her bald head. The ambulance crew and I carefully transferred her to the bed.

One of the first orders I carried out was to start a continuous morphine sulfate infusion. Nan was groggy but responded to verbal stimulation. When she opened her eyes and saw me, she whispered "Hello," and added weakly, "Where's my wig?"

Joe handed me a crinkly bag. I removed the wig and placed the long, brown hair on Nan's head. "There," I said. "Your wig looks straight." Before leaving, I encouraged her, as I'd done so often, to press the call light if she needed anything, although I doubted she had the strength. Joe stayed with Nan and she rested comfortably.

When my shift was almost over, the call light for Nan's room lit up-the first time ever. Thinking Joe was ringing to tell me she'd died, I scurried in. Nan was alert and alone in the room.

As I approached, she looked up and mouthed the word "Thanks." I hugged her and took her hand. A few minutes later, Joe returned with a cup of coffee and I placed Nan's hand in his.

As Nan slowly drew in her last breaths, I realized that she pressed her call light when it mattered most-when she needed to say good-bye.