Tag Archives: geriatrics

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Elder Care: Goals

I really enjoy elder care in Family Medicine. Mostly. Even some of the very difficult or very complicated people.

One thing I would try to figure out is what is the person’s goal? This can be quite funny at times.

“Can we talk about what you would want if you got really sick? If you were too sick to talk to us?”

“I don’t want to talk about death.” Ok, this person is in their 90s.

“That is fine, but if we don’t talk about it, your daughter and I have to guess what you want. And we tend to do more when we don’t know.”

That person glares at me. “Oh, all right.”

Sometimes a person says, “I don’t want to die of cancer.”

It turns out that this is an opening. “Ok, what DO you want to die of?”

“I don’t want to die!”

“Well, me either, but I can’t fix that. There are at least three “ideal” deaths that the Veterans Administration talks to people about. Maybe we could go over them. You could put your request in with your higher power.” I have written about the three here: https://drkottaway.com/2023/10/06/an-ideal-death/. The “Hallmark” or hospice death, sudden death and fight it all the way.

But, other than not dying, what is the goal? To stay in one’s home? To move to a retirement organization that has a nursing home and care until death? Home care insurance to stay home? I do have people imply that they will go into the woods or crash their car or something if they get very sick, but not very often. They are usually aware that I have to respond to any suicide threat. How much care do they want? People often say, “I wouldn’t want to be disabled,” but it turns out that life is often worth living even when very challenging. Most people want to be treated for cancer, for heart disease, for congestive heart failure, to go on.

Sometimes death comes from a cumulative load of chronic problems. We had a gentleman in his 80s in the hospital ICU many years ago. He had pneumonia, congestive heart failure and bad kidneys as well as a host of other problems. I sat down with him. “We are treating you, but when we give you enough medicine to help you breathe, your kidneys are getting worse. This is a small rural hospital. I could transfer you to the Seattle hospital, 2 hours away. You would have a cardiologist, a kidney doctor, a lung doctor. Here you just have me and the nurses. Either way, I do not know if you will live through this. What do you want to do?”

He chose to stay. “My family can visit me here.” His family was visiting daily. “I do not want a breathing tube. I do not want dialysis. If my kidneys go, let me go.” We discussed this with the family.

Four days later it was clear that without dialysis, he was dying. Dialysis might have slowed it, but he may still have died. He was no longer waking up. We withdrew the antibiotics and removed most of the monitoring and switched him to hospice. His family continued to visit and he died a few days later.

He did die in the hospital, and yes, we used some machines up until care was withdrawn, but this still seems like he got to make choices and his family understood. It can be much harder with memory loss when the person really can’t make choices any more.

He was complicated. To keep him breathing well without a machine, we had to give him diuretics, that were eventually too much for his kidneys. A bad heart, lungs with emphysema and pneumonia, and bad kidneys. Sometimes the liver is not working either, and then what is there left to work with? Nearly all drugs are broken down by either the liver or kidneys. Simethicone is not absorbed, so that’s the exception.

Sometimes people get along until too many things accumulate and then they end up in the hospital and on multiple new medicines. It can be very confusing. Regular maintenance is a good idea.

Sometimes the family wants something different from the patient. Or there is an elder parent and three adult children, who all disagree. My job is advocate for the patient. But this is Family Medicine, so I have a responsibility to the patient but also to the family. The person, the family, the community, how is it all fitting together? Sometimes functional, sometimes not.

I had one person who called me when he had been flown to a Seattle hospital. “I have to get home.” he says, “Can you release me? I have to take care of my wife!” I panicked for a moment. “Is your wife bedridden? Where is she? Why are you in the hospital?” She was not bedridden and she was fine. He was being more and more behaviorally squirrelly. He could no longer drive, but drove anyhow. His wife disabled the car, because he would disappear. I sent him to a neurologist for memory testing. The neurologist said, “Hmmm.” and sent him for neuropsych testing. The neuropsych report said dryly that his memory was fine, but he had certain long standing behaviors related to past heavy alcohol use. Oh. He was quite proud of not drinking and going to AA, but he also triangulated with his family and me. I sat him down and said, “Ok, I am not going to talk to a different one of your five children every time you see me in the clinic, because you’ve said, “Don’t tell mom I called you.” Pick ONE person for me to talk to and now you have to have a family member with you when you come to clinic.” He grinned and chose his wife. He had certainly fooled me about his memory, because he blamed his behavior on his memory. The neurologist was not quite fooled. The family calmed down and he did not drive any more, thank goodness. He was not an easy patient, but he was entertaining and educational too. And I felt that I had helped both him and the family.

Sometimes families fight. Sometimes a dysfunctional family will get way worse when someone is sick or dies. Sometimes families go on fighting. Other families are so kind and so good to each other and their elders. Every family is different.

For the Ragtag Daily Prompt: concentration.

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Age-defying

I get lots of quasi and fringe medical emails. I subscribe to some so that I know what they are “pushing”. The current trend is online “classes” where you sign up and then they have hours of talk and interviews and stuff. The talks can be three hours or more for a week. I am offered a bargain daily to sign up to be able to access the talks over and over. Hmmm, not today, thanks. I have very low tolerance for videos and television.

Currently I’m getting notes from an “age-defying” one.

I am skeptical about “age-defying” as they are describing it. However, there is a study that I think is very convincing about how to stay healthy as you get older. It was done in England. They looked at five habits: excess alcohol (averaging more than two drinks a day), inactivity (couch potato), addictive drugs, obesity and tobacco.

They had people who had none of the five, people who had all of them and people who had one or two or more. The conclusion was that for each one added, the average lifespan dropped by about four years. That is, the people who did all five tended to die 20 years sooner on average than the ones with none of the bad habits.

Recently in the US, the news said “Gosh, it turns out that any alcohol is bad for us.” I thought, how silly, when various studies made that clear over a decade ago. There was a very nice study from Finland, with 79,000 people where they looked at alcohol and atrial fibrillation. Atrial fibrillation increases the risk of strokes. They concluded that lifetime dose of alcohol was directly related to atrial fibrillation. That is, the more you drink, the sooner your heart gets really grumpy and starts fibrillating. Alcohol is toxic to the heart, the liver, the brain. Tobacco is toxic to the lungs, the heart, the brain and everything else. The addictive drugs: well, you get the picture.

So the anti-aging prescription is pretty simple to recommend. It just is not always simple to do. That is why we still have doctors. For chronic bad habits I am part mom/cheerleader/bearleader/nag/kind helper. Here is the prescription. Feel free to send me money instead of buying that seven day set of twenty one hours of lectures:

  1. Minimal or no alcohol.
  2. No addictive drugs (that includes marijuana and THC and we have almost no studies indicating that CBD is not addictive.Remember that THC and CBD and the other 300+ cannabinoids produced by the marijuana plant were not studied because it is illegal at the federal level.)
  3. No tobacco.
  4. Exercise every day: a walk is fine.
  5. Maintain your weight, which means as you get older you either have to exercise more or eat less or both. Muscle mass decreases with age.

The last anti-aging piece is some luck. Born into a war zone? Caught in a disaster, flood, fire, tsunami? Born into a family with trauma and addiction and few resources? Huge stress in your life? Discrimination or abuse? If you have had none of these, help someone else, because you have the luck. Pass it on.

The header photograph is all family members: two are my aunts and one is a cousin of my father’s and they all play church organ! Music sustains that side of the family. I took that in 2017 in Baltimore, Maryland. We had the uncles along too!

This is my grandmother on my mother’s side. I took this in the early 1980s at Lake Matinenda.

I will try to dig up the links to the two studies.

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Admitting diagnosis: Old guy, don’t know

During my three months temp job in 2010 at a nearby Army Hospital, I was asked to help the Family Medicine Inpatient Team (FMIT) whenever a faculty member was sick or out, which turned out to be fairly often. I enjoyed this because I wanted to work with residents, Family Practice doctors in training. It was very interesting to be at a training program, watch the other faculty and work at a 400 bed hospital instead of my usual 25 bed one.

Two patients needed to be admitted at the same time on our call day, so the second year resident took one and I took the other. The report on mine was an 82 year old male veteran, coughing for three weeks, emergency room diagnosis was pneumonia.

The resident soon caught up with me because her person was too sick and got diverted to the ICU. Mr. T, our gentleman, was a vague historian. He said that he always coughed since he quit smoking 15 years ago and he couldn’t really describe the problem. He’d gotten up at 4:30 to walk around the assisted living; that was normal for him because he used to do the maintenence. He had either felt bad then or after going back to sleep in a chair and waking at 10. “I didn’t feel good. I knew I shouldn’t drive.”

He’d had a heart attack in the past and heart bypass surgery. Records were vague. The radiologist read the chest xrays essentially as, “Looks just like the one 3 months ago but we can’t guarentee that there isn’t a pneumonia or something in there.” He had a slightly elevated white blood cell count, no fever, and by then I did a Mini-mental status exam. He scored 22 out of 30. That could mean right on the edge of moderate dementia, or it could be delerium. I got his permission to call his wife.

“Oh, his memory has been bad since he spent a year in a chair telling them not to amputate his toes. And he was on antibiotics the whole time. He wasn’t the same after that. He just said he didn’t feel right and that he shouldn’t drive.” So his wife called an ambulance.

The third year chief resident came by and wanted to know the admitting diagnosis. “Old guy, don’t know.” was my reply. “Either pneumonia or a urinary tract infection or a heart attack maybe with delerium or dementia or both.”

The second year was helping me put in the computer orders, because I was terrible at it still. She could put them in upside down and asleep. “Why are we admitting him, anyhow? We can’t really find anything wrong, why not just send him home?”

“We can’t send him home because he can’t tell us what’s wrong. He might have an infection but he might not, and he has a really bad heart. If we send him home and he has a heart attack tonight, we would feel really bad. And he might die.”

I was getting a cold. I had planned to ask to work a half day but half the team was out sick so I just worked. But by morning I had no voice and felt awful. I called in sick.

At noon the phone rang. It was the second year. “You know Mr. T, who we admitted last night?”

“Yes,” I said.

“He had that heart attack during the night. Got taken to the cath lab. You made me look really good.” We had worked on the assumption that it could be early in a heart attack though the first labs and the ECG were negative. I had insisted on cardiac monitoring and repeating the enzymes. The resident had finished the note after I left and the night team had gotten the second and abnormal set of enzymes.

82 year olds are tricky. With some memory loss he couldn’t tell us much except that “I don’t feel right.” He was right not to drive and we were right to keep him in the hospital. And if it had all been normal in the morning, I still would not have felt bad about it. The residents are looking for a definitive diagnosis, but sometimes it’s “Old guy, don’t know,” until you do know.

 

Previously posted on everything2.com in April 2010. I am not sure if this branch was dead or not, but the moss grows on it here in the wet winter anyhow.

I took the photograph in the woods last weekend.