Alert and Oriented (Again and Again)

Hospice ADLs:  My Adventures of Daily Learning.92

Who-are-you800x420_thumbIs the patient alert and oriented?

That was the first official “hospice type” question I learned when I was a hospice chaplain.

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, and very essential questions, to help discern 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 5:30 in the morning (or it’s an early Thursday morning if you’d prefer me to be general). 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 Liam (#4) thunder down the hallway, likely headed toward the back of the house to bother my 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 three mornings ago? Often, in movies or television shows, in a starkly furnished interview room, a tough cop will press the squirrely ex-con about his whereabouts two months ago on the night of June 31:

  • 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 is at the top of the list. Hospice wants a patient to participate in his or her care. The question behind nearly every question 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 off a to-do list, but because the evolving here and now 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.

But please, don’t ask me what I had for breakfast yesterday. Spare me that embarrassment!

(Hospice vigorously protects a patient’s privacy. I’ll take care with how I share my experiences. Any names used are fictitious. Events are combined and/or summarized.)

Picture is from here.

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