Perspective
A Return to Hope
By Julia Leahy, R.N., M.A.T.
A home care nurse believes one patient's greatest need is help rediscovering life's meaning.
Chong was referred to me by his health insurance company’s case manager. He is a 65-year-old Hmong man who has been living in the United States for almost two years. He suffers from severe back pain and depression and needs skilled nursing care in his home. My role as his home care nurse is to assess his medical needs, teach him and his family how to improve his health, connect him with a primary care doctor and a psychologist, and coordinate treatment for both his physical and emotional pain.
I visit Chong in the townhome he shares with his wife, children, and grandchild. We sit in his sparsely furnished living room. His wife and grandchild are present. The air is humid, and the smell of boiling chicken, greens, and rice hangs in the air. Even though the room is warm, Chong is dressed in a heavy coat with a hat and scarf covering his face. He wears multiple white strings around his right wrist, an indication that he has had a string-tying ceremony to strengthen him spiritually and physically.
I look around and notice items in the room that indicate Chong and his family are traditional Hmong. On the wall is a large altar, a sign that someone living in the house is a shaman or healer who serves as an intermediary between the physical and spiritual worlds. The Hmong believe the two worlds coexist; therefore, illness can be a manifestation of natural, supernatural, social, or personal causes. Chong tells me he is the shaman.
Being in patients’ homes gives me a perspective I might not have if I saw them in the clinic. I am granted the privilege of witnessing what happens day to day—how they live, who provides them with care and support, what is important to them. It’s like stepping back from a painting and seeing the entire picture, not just the scar on the face of one of the subjects. Being in Chong’s home allows me the opportunity to ask questions about his religious practices, his beliefs regarding his health, and how those beliefs affect his health.
I notice he has many medication bottles. Some are new and full, others are old and partially empty. Some of the medications are duplicates, prescribed by different physicians and filled at different pharmacies.
“I see you have many medications, but you say you are not taking any of them,” I say.
He answers softly through an interpreter: “No, I am not. I do not know what they are for.”
“That’s why I am here,” I tell him. “To help you understand what your medications are and how to improve your health.”
“Let me tell you something,” he says. “I have injuries from the war, and they still hurt.” He shows me his scars. “I have pain every day. I am very sad. I have been here almost two years, and I have taken English classes, but I cannot speak English. I do not know anything. I am lost here.”
Chong starts to cry.
“Two years is not very long, and there is a lot to learn,” I explain. “I can imagine living in Minnesota is very different from Laos. It would be hard to get used to.”
“I am afraid I will never learn English,” he tells me. “My children will learn English, and I will not be able to talk to them. At home, I could do things and care for my children. Here, I am nothing. I am useless to them.”
“You are very important to them,” I tell him. “You and your wife hold in your memory the Hmong history. They will not have that unless you tell them about Laos and Hmong traditions.”
“I just don’t know how to learn here,” he says through his tears. “I cannot seem to learn.”
I try to reassure him: “You are in pain, and your body is not healthy right now. You are sad. You have a lot on your mind. This makes learning very difficult. I think it will be easier to work on one thing at a time.”
I know from this conversation his depression and, most likely, post traumatic stress disorder (PTSD)—a result of his experience in the CIA’s secret war in Laos—will be the primary focus of his treatment, with pain management being secondary.
I suggest making an appointment with his doctor.
During my next visit later that week, Chong tells me more about his pain, reminding me that it is the result of war injuries. He again points to his scars. “Do you know I jump when a chair falls? I thought America would take care of me as I was promised,” he tells me.
We talk more about the war and the United States’ involvement and his incredible journey through the jungle, sometimes carrying his injured wife on his back, across the Mekong River to Thailand, and then on to Minnesota. I give him instructions about his medications for pain and depression and review his doctor’s instructions from his last appointment. Chong will be seeing a psychologist who has experience with PTSD and the Hmong culture, a chiropractor for his back pain, and an occupational therapist for alternative pain management treatments.
Although I am concerned about Chong’s physical issues, I find I am more concerned about the lack of meaning he feels—his hopelessness and his sense of loss. In the past, Chong must have had great hopes—as a boy playing and working the rice fields, as a young husband caring for his wife and children, as a soldier fighting in the Vietnam war, as an exile trying to protect his family and make a new home in a distant land. Chong has since lost his homeland, sense of culture, independence, and status as a male elder whose wisdom and counsel are sought. He cannot fully live as an American or as a Hmong. He is, instead, living in the margins. I feel that until his loss of hope and feelings of inadequacy are addressed, Chong will not be able to focus on his health.
More frustrating is the fact that I feel limited in my role as his nurse. I am to guide him through the web of medical appointments and improve his physical and mental health by means of medications. I take time to listen to his story. But with four more patients to see in a day, I cannot stay with him for long.
The process of recovering self and seeking meaning takes time. The sad part about our health care system is that payers do not want recovery to take time. Chong’s insurance company requires me to instruct him on his medications, coordinate his care with other providers, and keep him out of the hospital by making sure he follows his doctors’ orders to take certain medications. The more time I spend with clients in their homes, the more I think their chronic illnesses are perpetuated by their dissatisfaction with life and their unresolved emotions. If these issues are not addressed, from both a medical and spiritual perspective, patients will not have the energy to focus on what they need to do to stay healthy.
The need to find meaning and have hope in life is universal and essential to improving one’s health. To begin to regain hope, Chong will need to incorporate his past into the present, to develop a new sense of identity and self-worth. Healing may take place with the help of someone to encourage and guide him through his memories and listen to his life stories, to help him recognize his strength, and to encourage him during difficult days. I explain to Chong that this person can be a shaman, doctor, psychologist, family member, or home care nurse.
Although I was initially supposed to see Chong twice a week for a month, I ended up seeing him weekly for eight months. Together, we did everything Western medicine would suggest for relieving his pain and depression. He and his family now are more knowledgeable and able to navigate the medical system. They understand his medications and how to contact the doctor. At this point, he has not seen a shaman or been involved in soul-
calling to bring his soul back to him. Such ceremonies cost money. And although I can get his doctor to write a prescription for a shaman to perform a healing ceremony, I can’t get an insurance company to pay for one. I am being paid to medically manage, not minister to the soul. I may see value in both, but Chong’s insurer sees value in only one.
Cultivating hope in Chong, who has experienced so much loss and hardship, will require compassion and patience. Although I cannot take away his emotional pain, I have learned from him how healing it is to be present—to witness the suffering, to listen to the story, to give light in the darkness of despair. MM
Julia Leahy has been a home care nurse with HealthEast for more than 15 years and has focused on Hmong patient care for the last five years. She also has a master’s degree in theology.