Aa
What is medically necessary and reasonable treatment?
My mother is 96 and lives with me. She had a major, major heart attack 10 - 15 years ago and has been fine. I think she is now having TIAs. She complains about her vision, drops (urinates herself when she does this), dizzy when standing and needs to hang on when walking, and is getting confused and forgetful (lost in her bedroom). She knows who everyone is. I do not know what to do. She has a DNR. She is 96. She has insurance. Do I bring her for tests? Put her on aspirin? Leave her alone. I don't want to neglect her medical needs, but I don't want to subject her to medical procedures that will only prolong the inevitable. I/she do/does not want her to end up in a nursing home, alone, waiting to die. What do I do?
First of all, keep in mind that I am unable to diagnose you because I am unable to examine you, this forum is for educational purposes.
The symptoms that you describe could be related to TIA (transient ischemic attacks), but could also be seizures or cardiac arrhythmias. The ethical question is difficult and I would advise you to discuss this with her and resolve what your think she would have wanted. It sounds like she was most interested in maintaining her independence as long as possible and wanted to comfortable (no invasive test, breathing machines etc). If this is the case (again have the discussion), then I would recommend a limited diagnostic workup that is non invasive and evaluates for things that could impact her comfort level. First I would obtain an MRI of the brain to evaluate for evidence of stroke. If there is stroke then being on medication (aspirin, plavix coumadin-depending on the circumstances) may allow her to remain independent longer by preventing a major stroke. Second I would recommend an EEG (brain wave test) to evaluate for signs of seizure. If this test is negative, she may still have seizures (just not caught on the EEG) and often the addition of an anti-epileptic medication that does not interfere with other medication or her liver such as Keppra, neurontin, lyrica, can be helpful (if it is seizure the antiepileptic drug can stop the spells). Third I would suggest a Holter monitor to evaluate for cardiac arrhythmias (a smal box that is worn home and mailed back after 24-48 hours).
I hope this has been helpful.
The symptoms that you describe could be related to TIA (transient ischemic attacks), but could also be seizures or cardiac arrhythmias. The ethical question is difficult and I would advise you to discuss this with her and resolve what your think she would have wanted. It sounds like she was most interested in maintaining her independence as long as possible and wanted to comfortable (no invasive test, breathing machines etc). If this is the case (again have the discussion), then I would recommend a limited diagnostic workup that is non invasive and evaluates for things that could impact her comfort level. First I would obtain an MRI of the brain to evaluate for evidence of stroke. If there is stroke then being on medication (aspirin, plavix coumadin-depending on the circumstances) may allow her to remain independent longer by preventing a major stroke. Second I would recommend an EEG (brain wave test) to evaluate for signs of seizure. If this test is negative, she may still have seizures (just not caught on the EEG) and often the addition of an anti-epileptic medication that does not interfere with other medication or her liver such as Keppra, neurontin, lyrica, can be helpful (if it is seizure the antiepileptic drug can stop the spells). Third I would suggest a Holter monitor to evaluate for cardiac arrhythmias (a smal box that is worn home and mailed back after 24-48 hours).
I hope this has been helpful.
You have given me food for thought. Thanks.
What is medically necessary and reasonable treatment???
I so not want to tell you what to do. Just give you some more food for thought.
Have you thought about Hospice for your mom??? You would need a physican's order but they would help you immensely in decisions such as this while keeping her at home.
In Hospice, pts. continued to take their regular medicines to maintain quality of life as much as possible. We treated such things as infections, anxiety, pain etc.. These were not to increase quanity of life but quality. They were sure to die but not of something that could be treated.
In reading your post my feeling are non-treatment could hassen your mom being bedbound with all of it's complications, which could be more difficult for you to handle on an in home basis. I know this sounds like it could be TIA's but there are many other ailments it could also be. By taking her to see a physican you would know what's wrong & that does not commit her to treatment.
How does your mom feel about this? Do you have medical power of attorney?? Are you from the USA?
God Bess, TJ
I so not want to tell you what to do. Just give you some more food for thought.
Have you thought about Hospice for your mom??? You would need a physican's order but they would help you immensely in decisions such as this while keeping her at home.
In Hospice, pts. continued to take their regular medicines to maintain quality of life as much as possible. We treated such things as infections, anxiety, pain etc.. These were not to increase quanity of life but quality. They were sure to die but not of something that could be treated.
In reading your post my feeling are non-treatment could hassen your mom being bedbound with all of it's complications, which could be more difficult for you to handle on an in home basis. I know this sounds like it could be TIA's but there are many other ailments it could also be. By taking her to see a physican you would know what's wrong & that does not commit her to treatment.
How does your mom feel about this? Do you have medical power of attorney?? Are you from the USA?
God Bess, TJ
It sounds like you are in a situation where you are between a rock and a hard place. I am not a Dr, but have worked with the elderly in a professional capacity in the past.
My own grandmother is 93 nearly 94 and in a supported living care situation. She has maintained her independence to an extent but is monitored in her own apartment. Truthfully, she improved markedly when she elected (with some family encouragement) to sell her home and move into a supported living environment. She is also losing some of her edge memory wise and her health is deteriorating when its looked at over time. She has chosen herself to be evaluated and have low level intensity medical intervention when its required, eg when she has an ulcer on her leg, needs some assistance with her chronic anemia etc. She will always be evaluated but not necessarily aggressively treated, if you know what I mean.
In your situation it sounds like your relative could do with a physical and an overall medical evaluation. At 96, with a DNR its hard to actively pursue hard core interventions but they does not preclude an evaluation and some interventions that can improve her quality of life, not necessarily focussing on her quantity of remaining life, does that make sense? You could try to have her admitted for a complete evaluation for a wk or two at an appropriate skilled nursing facility and see how she does and what the recommendations are, or alternatively seek some adult day care for her, these places can sometimes also offer evaluation of her medically and from an activity of daily living perspective, so she is more closely monitored and you have a clear picture of her health wise to be working with. If she is losing her way in her own bedroom, it is concerning but equally the fact she is urinating unexpectedly and is confused, can indicate something as simple as a urinary tract infection, which is a fairly easy thing to treat.
Its always a loaded question when you are faced with this type of situation, I wish you and your relative well and hope that things settle down soon and the path becomes clearer. BTW, my grandmothers sister was diagnosed with breast cancer at 90yo, chose to have surgery, did post surgical treatment and tamoxifen for 5 yrs and is still alive and kicking 7 nearly 8 yrs later.
Best wishes and I hope my comments have helped.
Fiona
My own grandmother is 93 nearly 94 and in a supported living care situation. She has maintained her independence to an extent but is monitored in her own apartment. Truthfully, she improved markedly when she elected (with some family encouragement) to sell her home and move into a supported living environment. She is also losing some of her edge memory wise and her health is deteriorating when its looked at over time. She has chosen herself to be evaluated and have low level intensity medical intervention when its required, eg when she has an ulcer on her leg, needs some assistance with her chronic anemia etc. She will always be evaluated but not necessarily aggressively treated, if you know what I mean.
In your situation it sounds like your relative could do with a physical and an overall medical evaluation. At 96, with a DNR its hard to actively pursue hard core interventions but they does not preclude an evaluation and some interventions that can improve her quality of life, not necessarily focussing on her quantity of remaining life, does that make sense? You could try to have her admitted for a complete evaluation for a wk or two at an appropriate skilled nursing facility and see how she does and what the recommendations are, or alternatively seek some adult day care for her, these places can sometimes also offer evaluation of her medically and from an activity of daily living perspective, so she is more closely monitored and you have a clear picture of her health wise to be working with. If she is losing her way in her own bedroom, it is concerning but equally the fact she is urinating unexpectedly and is confused, can indicate something as simple as a urinary tract infection, which is a fairly easy thing to treat.
Its always a loaded question when you are faced with this type of situation, I wish you and your relative well and hope that things settle down soon and the path becomes clearer. BTW, my grandmothers sister was diagnosed with breast cancer at 90yo, chose to have surgery, did post surgical treatment and tamoxifen for 5 yrs and is still alive and kicking 7 nearly 8 yrs later.
Best wishes and I hope my comments have helped.
Fiona
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