A person rolls into an outpatient clinic. A pleasant bleach smell emanates from freshly scrubbed chairs. Happy chatter about people’s lives, and this week’s health issues are dimmed by the local radio station playing in the background.

The person who just rolled in for the first time has a confoundingly complicating diagnosis. It’s not the first sized holes in their body under their urine-soaked shorts they initially refuse to take off. Or being able to feel bones within these holes. It’s not their uncontrolled diabetes. This person suffers from mental illness.

Two nurses are required to coax the shorts off in trade of blankets. The cause of this person’s holes becomes apparent. It’s not neglect, and it is neglect. It’s not the facility they live in, and it is the facility they live in. This person still has the right to refuse care. The right literally permeates to the bones in their body. Every layer of defeated granulosum (healthy tissue) leading to the extraordinary holes in their body is a victory for self-directed health care. Every overlay of slough and eschar (dead tissue) is a defeat of conservatorship.

The facility this person qualifies to live in isn’t equipped for dealing with mental health issues this profound. Reports show suspected illicit drug use by the person in the facility. The facility wrote their reports, they confiscated the materials, but the person persists in producing holes in their body. The person allows urine and pressure to erode their mortality because we cannot stop them.

There are facilities that can stop them from doing this to themselves. The process to get into one can take years. Conservatorship proceedings, court orders, lawyers, mountains of documentation to ensure we aren’t infringing on rights to independence. If the judge in these proceedings were standing next to me now, watching me spend 15 minutes coaxing urine-soaked shorts off this person would the process improve?

Let’s find out. I’m required to report anyway, let’s get some government into the situation. I file my mandated report to the government; it only takes about 15 minutes at the end of clinic hours.

The physician sees the person. Concerns of osteomyelitis (bone infection usually necessitating surgery and/or prolonged antibiotic therapy) down the road are high. This person’s mental state severely limits treatment options for his wounds. “He wouldn’t tolerate a wound vac.” “He refuses to offload in bed and limit chair time.” “He has been able to obtain illicit drugs and will likely continue.” Issues with incontinence management and refusal of care will likely lead this person to death.

The wounds are dressed, reports are filed. The person’s mother is called. The mother is tired; I can feel it through the phone. Her defeated voice already knows why I’m calling. She’s been working with a lawyer for months. She has no control over her adult person’s care. She’s trying. I’m trying. The facility is trying. The government tries. I never see the person again.

Some weeks or months later, I arrive home with my sweet toddler. He screams and runs for the garage door, babbling and jumping. We go inside and make a snack; he hugs me. “Oh, you got a stinky butt!” I exclaim. I change his diaper and put some Vaseline on his bottom. If he’s ever struck by mental illness, I hope I can at least do this for him if he needs it at any age. Sorting the mail together, or more realistically put, chasing down envelopes my son throws enthusiastically across the room, I realize there’s one from the government. I open it and read the short missive. The investigation is complete, no neglect found. They’re not wrong; we all filed our reports as issues arose and tried to address them as best as we could.

I hope someone out there found a way to fill the holes in the person’s body. From where my purview ends, we all tried, and we all failed.

Matt Dayer is a nurse and can be reached on Twitter @DayerRn.

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