Crossing boundaries

I missed her funeral. Teresa was 41 years old when I met her during my first week on the job as a nurse practitioner. She had been living in mental institutions since she was 14, when she had discovered her five brothers and sisters and her mother dead, shot by her father before he killed himself. That day, Teresa started screaming and continued to do so for 27 years as she made her way through the mental-health system on various psychiatric medications - medications that made her fat, broke down her body, and numbed her soul.

Teresa owned no underclothing, and her pendulous breasts drooped, further dehumanizing her. Joe, her favorite therapist, bought her some underclothing with his own money, and we were told we had crossed boundaries - those ethical lines that separate professionals from their patients, protecting us from getting too involved, or too personal. Professionals who cross these sacred boundaries are looked at with dismay and are viewed as filling their own needs, rather than their patients'. As with most professionals, I adhered to this philosophy. That is, until I met Teresa and it became clear that boundary lines had to be widened.

"We watched Teresa gingerly limp toward a cross that Joe had made and placed on the burial site. She had flowers in one hand, a cigarette in the other, to fortify her against the horrible images that must have appeared in her mind."

On Memorial Day, Joe, Teresa, and I went to her family plot at the cemetery. We watched Teresa gingerly limp toward a cross that Joe had made and placed on the burial site. She had flowers in one hand, a cigarette in the other, to fortify her against the horrible images that must have appeared in her mind. I realized just how significant this was - her first visit to the cemetery, her first physical confrontation with the tragedy of the past that would forever spin her out of reality. She lay the flowers down at the grave as if it were an act of forgiveness and a release of some of the emotional burden she had carried throughout her life. Yes, we crossed a boundary in accompanying her as friends, as family really, but by doing so, we helped bring about a result that is very acceptable in our profession: closure.

Teresa's body was wearing out, but I noticed a metamorphosis - she seemed happy at times. Sadly, my friend and colleague Joe died unexpectedly. I had difficulty dealing with the loss, but Teresa handled it well. She told me she "really missed Joe," but she knew she would see him again in heaven someday. Again, we went to the cemetery, this time to see Joe. Teresa brought flowers and placed them on his grave, bolstering me, allowing me my own closure.

I realized that day that I was no longer just a nurse practitioner and Teresa no longer just a patient. She too had crossed a boundary, and in doing so, provided me a great deal of comfort. She sensed the shift, and in trying to articulate it, said I was "like a sister to her."

"No Teresa," I said, "not a sister, a girlfriend."

"Yeah that's it," she said, "girlfriends."

"I realized that day that I was no longer just a nurse practitioner and Teresa no longer just a patient."

Teresa survived many additional medical traumas over the next two years, but her dialysis fistula kept failing; her veins were gone, there were no more sites. Teresa had to make a decision: whether to go on with the pain and invasive treatment, or stop all treatment. She and her guardian signed out of the hospital, went to the home of a friend, and talked. There, she decided that if fate deprived her of dignity during her life, she would not let it deprive her of dignity in her death. She made plans. There would be a farewell party with all her "friends" at the hospital. She wanted a church funeral, a casket with a purple velvet lining.

At her farewell party, she greeted each guest graciously, appearing bright, animated, and free. Her last phone message to me was, "Peggy, it's your girlfriend Teresa, saying goodbye and thank you." Seven days later, Teresa died. We realized that the boundaries we crossed were from medical care to loving care. In spite of her tragic beginning, Teresa had a peaceful ending. She was laid to rest one day in June.

Yes, I missed her funeral. But I did not miss her courageous and meaningful life.

Margaret Ackerman is a nurse practitioner in the PACE program at East Boston Neighborhood Health Center. She has 25 years experience working with disenfranchised, urban populations.