4 (Not So) Simple Questions

Is the patient alert and oriented?

That was the first official “hospice type” question I learned when I was a hospice chaplain way back in the late 90s. (Yup, last century!)

Are they alert and oriented times 1, times 2, times 3, or times 4?

Ah, it gets more complicated! Here, as I understand it, are the key questions for determining if a patient is alert and oriented:

  1. Who are you?
  2. Where are you?
  3. What time is it?
  4. What just happened?

These are very basic, universal, and essential health care questions—and not just meaningless jargon—to aid in discerning the current mental status of a patient. Ideally, we all “know” these four answers. I am Larry. I am in Fresno, California. It is about 5:00 in the morning (or it’s an early Tuesday morning if you’d prefer me to be general about when I wrote some of these words). And, finally, not all that much is happening in my (see #1) home (see #2) at this pre-dawn hour (see #3), other than I just heard our kitty Milo slink down the hallway, probably headed toward the back of the house to bother my slumbering wife.

In hospice, #4 is often less a concern. Many hospice patients won’t necessarily know what “just happened” because of medication or temporary disorientation from the recent and unsettling changes in their lives. Even in so-called normal circumstances, we are hard-pressed to recall what has happened earlier today or earlier in the week. What did you have for breakfast this morning? What about your lunch selections three days ago? Details can blur for everyone.

Often, in movies or television shows, in a starkly furnished interview room, a tough cop will press the weasel-like suspect about his whereabouts two months ago on the night of February 30:

Where were you between nine and midnight?

Were you with anyone?

Can you prove it?

How could anyone remember what she or he was doing back then!

Trust me, if you asked about yesterday’s breakfast menu, let alone what I was doing the day before, I’d hem and haw, mumble and mutter, and at most come out with a guess.

What is your name? Where are you? What time is it?

There are multiple reasons to ask these questions of a hospice patient, but—for me—two stand out.

How is the patient doing at this moment? One of the key goals in hospice is to manage pain. If patients have too much pain, they can’t give coherent answers to even simple questions. Patients may also exaggerate or downplay the severity of their pain. The “alert and oriented” questions will help a nurse determine the most likely here and now needs. There are other kinds of pain management. As old medications are discontinued and different medications added, the newer drugs often need to be adjusted. Some patients become drowsy, others agitated. The search for the best dose for a particular patient can take time, and may cause the “where are you” or “what time is it” questions to become a struggle . . . and a sign that more work needs to be done to achieve comfort.

The second reason for these questions probably tops any list. A good hospice team wants a patient to participate in his or her care. The question behind nearly everything a nurse, social worker, or chaplain asks is: can this person help make the decisions for their best care? Of course, some can’t. At some point, for some patients, a spouse, parent, or child assumes the responsibilities of decision-making. But what the patient wants, needs, hopes for, is afraid of, and so forth is best understood from their own mouth and mind.

And so, variations of the alert and oriented questions are asked. And asked again. They are not asked because a nurse is merely checking boxes on a medical to-do list, but because the evolving needs of a patient are paramount. When we know who we are, where we are, and what time it is, we can also share what we want and what matters most.

If a patient is no longer able to respond, then the questions will lead to the caregivers assuming more responsibilities. This is also the irony of the phrase. So many of the patient’s family, as they support their loved one—in the days, weeks, months, and more of the illness—increasingly feel less “alert” and less “oriented.” So much is so overwhelming.

Answered or unanswered, these are never “simple” questions. Patients and caregivers may tire of how often questions are repeated, but they are done because of how rapidly hospice patients can change.

But please, don’t ask me what I had for breakfast yesterday. (Was it a bagel, or was that two days ago?) Spare me that embarrassment!

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  1. One “truism” that is learned early in one’s role in hospice care is that a patient’s frame of mind and/or emotions rarely stays constant. In fact, it can change from one hour to the next – never mind one day to the next. The reasons for this are numerous.

    Our hospice medical staff is excellent at dealing with these issues.

    As a volunteer, I rely on my 9 years experience -the only training I have is volunteer training (and a lot of ongoing training) .

    Despite (or perhaps because of this), I find that I am able to bring a measure of comfort and peace to the patients and their families.

    I try always to apply this value (at hospice, and in life in general): “Always be kinder than necessary, you never know the burden that someone is carrying.”

    No matter what their cognitive , emotional or spiritual state, when people are approached with kindness and made to feel loved and to be seen as precious, it can have a positive impact.

    I love the quote, “People don’t care how much you know until they know how much you care.”

    I am from the 60s and I remember well the Beatles singing, “All you need is love.” Is the dream of this ideal foolish because it is so simple? Or is the world foolish for accepting the complexities of life as being insurmountable?

    Sorry for being a bit quixotic, but your thought-provoking posting today put me in a contemplative mood. That’s what good writers do. Thank you for being a good writer and causing us to think deeply on such important matters, Larry.

    – Michael

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