Narrative Inquiry in Bioethics

In medical school, I had the opportunity to train in several rural Family Medicine clinics. During one such rotation, I took part in the care of an elderly woman who for the sake of privacy, I’ll call Fran. Fran was well known in the community as a lovely [End Page 97] elderly woman who enjoyed socializing. Though she was homebound, friends frequently stopped by to bring her groceries, take her on a drive, or just chat.

One day, after several unsuccessful calls, a hospital nurse decided to stop by Fran’s house on her way to work. The door was locked, but she saw Fran through the window, lying on the living room floor. Paramedics brought her to the local emergency department where I was working. Fran was disheveled, dehydrated, and on the brink of death.

We diagnosed her with diabetic ketoacidosis (DKA), a very serious condition brought on by inadequate insulin dosing in type II diabetes mellitus. Her body was in starvation mode, and severely dehydrated.

Fran recovered in the days that followed. I remember sitting in the nursing station every morning, listening to the hospital staff tell their own stories of Fran’s friendship. I learned that she had once loved to garden, that the neighbor always shoveled for her, that she lived alone with no family in town.

Over the lunch hours, my attending and I would walk from the clinic back to the hospital to visit Fran. A homemade quilt lay across her lap, made by my attending’s wife. This, more than anything, was a sign of humanity only seen in a small-town hospital.

We presumed that Fran’s nearly fatal DKA was due to a brief episode of diarrhea. She became dehydrated and confused, which we believed led her to improperly dose her insulin. Because she lived alone, this went on for several days, allowing her blood sugar and acid levels to climb.

After a week in the hospital, it became clear that Fran needed to go somewhere. She couldn’t go home unassisted; her elderly age and acute confusion made it difficult for her to take insulin correctly. She made it clear that she didn’t want to go to a nursing home in a different town. Fran remained admitted on swing-bed, which allows the hospital staff to provide skilled-nursing facility level care, while we worked to find her a safe home.

We had a placement problem on our hands. No nursing home in a 50-mile radius had an open bed. No family lived in the area to offer assistance in helping Fran transition home. And perhaps worst of all, home health refused to qualify Fran due to her periodic excursions with friends.

Rural medicine has a way of highlighting the struggle between humanity and modern medicine. On one hand, it is essential to respect Fran’s desire to keep her home and ability to retain her social life. On the other, modern medicine dictates that we must “do what is best for the patient” (read: do what is best for her illness, for our numbers). I saw the healthcare team in this small town struggle with this dichotomy. The nurses discussed sharing unofficial home health duties. Could they get enough volunteers to visit Fran frequently? Would the physician and the neighbors pitch in? Or would they say goodbye and ship her to the next open nursing home bed 1.5 hours away?

Small-town values had saved Fran’s life. In a large city with isolationist and individualistic values, Fran likely would’ve died in her home before she was found. Would those same values find an acceptable placement solution for Fran?

My rotation ended before we solved Fran’s problem. I never heard what happened to Fran; one of the ironies of medical education is that we often do not follow patients through the course of their care. I learned that rural healthcare can be difficult at the best of times. Supplies and personnel are always at a premium. Access, or in this case, qualification for services is complicated by geographical and bureaucratic obstacles. For Fran, this meant that she...