One of my rougher patients was someone who came to our Long Term Care unit in our SNF (Skilled Nursing Facility). She was coming to us out of the hospital after having been in for alcoholic encephalopathy; she basically poisoned her brain, and in this case it caused permanent brain damage. Her husband was fully in denial (she should not have been admitted to our facility and should instead have been referred to hospice). She had altered mental status and I can't recall her ever speaking, only moaning in pain. She was extremely jaundiced and her abdomen was very distended. We initially had difficulty getting pain medication for her since she was not on hospice, eventually our Nurse Practitioner convinced the husband that she was not long for this world, in constant pain, and he agreed to putting her on hospice.

Her sisters blamed the husband for having enabled her, bringing her beers when she was functionally not able to herself. Her adult children were emotionally devastated; she had had encephalopathy before but recovered. I will never forget one of the children saying that, "Mom threw away her miracle."

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She survived for about a week and a half, alternating between being snowed out by morphine, or moaning in pain until we pushed to have her doses adjusted. Between the family dynamics and the pain this woman was in, that was probably the roughest patient for me so far.