My patient’s son stood vigil outside her hospital room day and night. His eyebrows were frozen at an anxious angle. Although his mom was healing well from her injury, I could see that he was worried about next steps. He asked staff repeatedly about his mom’s pain management, and reviewed every therapy session she attended.
His mom, on the other hand, was deceptively charming. She was a thin, well-groomed elderly woman who knew how to exact empathy from others. When I looked into her room from a distance she appeared comfortable, lying in her hospital bed covered in a quilt that her son had brought her from home. When I entered the room to check on her, she would grab my hand and wince, telling me that the pain was severe but that she didn’t want any medication. She was quite invested in convincing me that she was unable to go home and care for herself, and that she needed to be discharged to her son’s home. She would not accept others help at home, nor would she go to a skilled nursing facility.
She was doing well in therapy, limited mostly by her macular degeneration (poor eyesight). Again, I watched her from outside her field of vision. I saw her stand without assistance, push her walker across the room, and navigate a couple of stairs. I heard her speak to her son in angry and dismissive tones. When she saw me approach her knees buckled and she crumpled to a padded bench. “I am not safe to go home, doctor.” She said. And her eyes filled with tears – “I am going to fall and no one will know.”
I took her son to a private room to discuss the predicament. I carefully raised the subject of how his mom was doing well physically, and could discharge home safely with home health services, but was angling for a discharge to his house. I asked him some open ended questions and learned that he was her only son, that his mom had been guilting him about quitting his job to care for her full time.
He became tearful – “I have only a few more years to go before I can collect my pension. Mom knows this but wants me to quit right now and move back home. If I do that I won’t have enough money to survive my own retirement. She has no friends and dad died several years ago. She says she doesn’t want any hired help at her house, and she cries when we discuss nursing homes. She says if I love her I will let her live with me. But I don’t have time to help her during the day. What am I supposed to do? She has been doing this to me all my life – getting me to do what she wants!”
I decided to tell him the unvarnished truth.
“I can see that your mom can be quite manipulative, and this has been an ongoing struggle. You need to take care of yourself. The fact that she wants to be with you 24/7 does not prove her love — a loving mom would not ask her son to jeopardize his financial future so that she wouldn’t have the ‘discomfort’ of caregivers in her home. Do not feel guilty about continuing to work. Her insurance will cover the care she needs. It’s ok to say no to her. That’s my professional opinion.”
The son let out an audible sigh. He thanked me profusely for telling him the truth. I told him that it was entirely possible that his mom would fall down on purpose once out of the hospital, to try to get him to change his mind. I warned him not to let her consume his life. She likely had a personality disorder that made her capable of squeezing the very life out of him.
My patient ended up discharging to a very nice skilled facility that her son had pre-screened for her. She was as happy as a wet cat on departure, but I believe it was the right decision for both of them. I just hope that she didn’t succeed in wrapping her emotional constrictor muscles around the neck of her poor son again. I tried my best to save him, but in the end I know that sometimes people have to save themselves.
Why is it easier to talk about quality of life with patients who are dying? Why don’t we factor these considerations into the decision-making for patients with conditions that aren’t fatal?
The presence of a terminal illness serves to focus everyone’s attentions. Widespread cancer metastases? Concerns about tight blood glucose control fade away. End-stage liver disease? Blood pressure control doesn’t matter so much any more. Bony pain from prostate cancer? Narcotic and sleeping pill addiction doesn’t even occur to anyone. I find it far more problematic to deal with patients with debilitating but non-fatal conditions when treatment options are perceived as limited because of co-existing diseases that produce so-called contraindications to certain medications.
I have a patient in his mid-70s with severe pain from osteoarthritis. Several fractures and a couple of unsuccessful joint replacement surgeries haven’t helped matters. Several years ago he found that a little drug called Vioxx worked extremely well for him, reducing his pain considerably and allowing him to do pretty much watever he wanted. As we all know, however, that drug was pulled from the market because of an unacceptable increased risk of heart attacks and other untoward cardiovascular events. Interestingly, Read more »
*This blog post was originally published at Musings of a Dinosaur*
A sure-to-be controversial article appears in the Chicago Tribune earlier this asking the sensitive question of ‘Health care at any age, any cost?:’
“If you want to save all lives, you’re in trouble,” said Callahan, co-founder of The Hastings Center, a bioethics research institute in New York, and a faculty member at Harvard Medical School, in an interview. “And if you want to save all lives at any cost, you’re really in trouble.”
Callahan and co-author Nuland, a retired professor of surgery at Yale School of Medicine who wrote the best-selling “How We Die,” were both 80 when the article was published.
“We need to stop thinking of medicine as an all-out war against death, because death always wins,” said Callahan.
The article goes on the make some bold demands of doctors: Read more »
*This blog post was originally published at Dr. Wes*
Some medications are well known for being risky, especially for older people. Certain antihistamines, barbiturates, muscle relaxants—take too much of them, or take them with certain other medications, and you can wind up in serious trouble (and possibly in the back of ambulance).
But researchers from the federal Centers for Disease Control and Prevention (CDC) and Emory University reported in this week’s New England Journal of Medicine that those high-risk medications are not the ones that most commonly put older Americans (ages 65 and older) in the hospital.
Warfarin is #1
Instead, they found that warfarin is the most common culprit. Warfarin (the brand-name version is called Coumadin) reduces the blood’s tendency to clot. Many older people take it to lower their risk of getting a stroke.
After warfarin, different Read more »
*This blog post was originally published at Harvard Health Blog*
Getting a flu vaccine is on many “to do” lists in the fall, but for those who still haven’t checked it off their list, it’s not too late to get vaccinated. Many people don’t realize that flu activity usually peaks in the United States in January or February, and flu viruses can circulate as late as May. As long as there’s flu around, it isn’t too late to get vaccinated.
Getting a yearly flu vaccine is the first and most important step in protecting against the flu, and CDC recommends influenza vaccination for everyone age 6 months and older. We urge you and all health care professionals to get vaccinated yourselves and offer flu vaccine at every opportunity to every patient—except infants younger than 6 months and the very few people for whom flu vaccination is contraindicated.
Studies show that your recommendation makes the difference in your patients’ decision to get a flu vaccine. You should continue to emphasize the importance of flu vaccination for your patients. And, if you don’t already do so, consider offering flu vaccines to patients in your own practice, even if yours is a sub-specialty practice and you don’t see yourself as a vaccine provider. Even if you don’t offer flu vaccines, you can still recommend and emphasize the importance of flu vaccination as a way to keep your patients—and their families—protected throughout the season.
As promising as it is sounds that flu vaccination rates are increasing among children and healthcare personnel, Read more »
*This blog post was originally published at Safe Healthcare*