100 year old stroke patient

Nurses General Nursing

Published

Specializes in Telemetry, IMCU, s/p Open Heart surgery.

so last weekend on my unit we received an ER admit: 100 year old female ruled IN for a hemorraghic stroke. SBP in the 200s, on a Cardene drip. Oh, she's a DNR. Throughout the night, the HR would dip down, then come right back up, BP was still ridiculous... we were getting ready to call the morgue!

Fast forward a week, I come back to work expecting for this patient to have moved on.... WRONG! This DNR patient had an NGT put in. She had been combative a few days before (her CT scan showed a GROWING intracranial bleed and developing hydrocephalus). I'm guessing she'd been dosed with Ativan before the CT result had been released. Well anyway, she slept for over a day and finally elicited a response when the NGT was put down and she was trying to swat it out of her nose. She'll do that every once in a while, meaning about twice a shift. Next day I took care of her the only response I was able to elicit was a moan about the Peri spray being cold. But other than that, nothing. She didn't even try to swat the NGT out of her nose. Here's the kicker.... she went in for a PEG tube placement today.

This is a patient I felt guilty about having to draw blood from... put a peripheral IV in... why are we invading her body with surgery??!! I feel like her children are committing crimes by putting her through an extended hospital stay, complete with needles, tubes and surgery.

Am I the only one who feels this way? My favorite PCA and I think the docs are trying to milk the insurance. lol.

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Specializes in Developmental Disabilites,.

Yes. I usually try to get a family meeting together with case mgmt, the mds, nursing staff and social work. This way the family can hear from the whole team. Sometimes ppl just have a hard time letting thier mom go.

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Specializes in Critical Care.

While it does sound like Comfort Care should be a consideration, none of the treatments you mention conflict with a DNR status. At 100, I would think she would have had some sort of advanced directives or a POLST that would help better clarify her wishes.

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Unbelievable.

This disgusts me. Whatever happened to letting people go in peace?!

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Specializes in neurotrauma ICU.

:mad: unfortunately, I see it all the time. It makes me sick.

nothing says "I love you mom" like filling her full of tubes, sticking her in a nursing home and letting her die of infected bed sores.

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Poor patient! She is 100 years old, I hope she has a DPOA or a living will that has made her wishes VERY clear.

Seems like she is not getting any better.

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Specializes in ER, ICU.

It's amazing the families are so ill prepared for the death of their 100 year old family members. Clearly she should be allowed to die rather than suffer the indignities of modern medical care. I would be frank but gentle with the family. Hopefully your hospital or the doctor will also be on board with comfort care. The family almost always needs a few days to absorb the change in Nana's condition so they can do the right thing.

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Specializes in Telemetry, IMCU, s/p Open Heart surgery.

Thanks for all the responses.

I tried speaking to her son, but it sounds to me like he's really in denial.... the whole family is afraid to let go. He was telling me that the healthcare staff (MDs, nurses, clinicians, etc) are giving them conflicting prognoses and advice. We referred them to hospice, which they turned down. Some "big-shot political Senator" friend of the family threatened the attending MD, which is where the NGT came into the situation and it just snowballed into a PEG tube.

I really think this family has unrealistic expectations about their mom. The home care aide told me the patient was totally with it prior to the stroke and they used to go to the mall, shopping, beauty parlor on Fridays. I have a hard time believing that when the MAR includes Namenda and Aricept. Actually the home care aide is the only one who kinda understands that granny is probably NOT gonna get better.

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

Well, as far as I'm concerned, this is little better than assault. I would be pulling the NM aside or someone from management higher up, and saying I don't feel comfortable 'treating' this poor lady.

Did anyone (a social worker say) ask the family what their mum's wishes were? I know in Aust if someone even says verbally to have no life saving measures done, their wishes must be followed.

I still blame all the TV shows and media, advertising drugs/new procedures saying we can extend your life, use this and that, do this exercise, Dr Oz writing his books saying you can extend the life of your telomeres by following these steps, your real age will be younger than your current age. I doubt anyone over the age of 40 would even know what a telomere was.

The exercise and vitamin industry is just as hysterical re making people younger.

However I digress. I would try to sit down with the family and say gently: 'Time to let go don't you think?' and answer any questions they may have patiently and with as much knowledge as I could. I'd also get the palliative care nurse to sit with them too.

My gf who is a very experienced hospice & community RN, stood up to all the doctors etc who wanted to do a battery of procedures & tests on a 90+ woman, who herself verbally refused any and all procedures. She was a terminal patient. My gf advocated for her patient, and I found out later the patient went home and died peacefully with her family around her.

I'd be seeing my NM today to discuss this situation and asking her to set up a meeting with palliative nurses and the family.

Seems death nowadays is just not acceptable to anyone, at any age. We are not raised in our society to accept death or any of it's consequences.

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Specializes in Telemetry, IMCU, s/p Open Heart surgery.
:mad: unfortunately, I see it all the time. It makes me sick.

nothing says "I love you mom" like filling her full of tubes, sticking her in a nursing home and letting her die of infected bed sores.

this woman's skin is surprisingly INTACT! she just has a few bruises that were present prior to admission d/t Plavix and ASA therapy. i have to give kudos to my fellow staff who has been doing a good job with turning and keeping her skin protected from being incontinent.

My mom is 52 and although we've had the "talk" before, seeing this injustice done right before my eye prompted me to sit down and have a really serious talk with her and my sister. My mom is a smarty... doesn't want any "life-extending" procedures or tubes. I don't think I could bear to see my mom with anything more than a PIV in her arm. I'm also happy that my 99 year old great grandma has jumped on the DNR, no tubes, no nonsense bandwagon.

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Specializes in Hospice.

I hope this post doesn't sound harsh ... it's intended with all respect.

Please consider the idea that if granny was as functional as described above, her illness has probably hit the family like a freight train.

Even given the presumed dementia, we have no info as to where she was in her disease trajectory ... if she was functional and enjoying life up until her stroke, it may be incredibly difficult for family to wrap their heads around a terminal diagnosis.

Grieving and letting go is a process and, IMHO, it's unrealistic for caregivers to assume we determine the proper timeline for that process to take place. Denial is a process that's hardwired into our psyches and it exists for a reason. It is not a failure of intelligence, education or concern for the loved one.

I think the advice given above to continue to be gentle but clear in explaining what's going on with the pt, as well as having a team conference is great advice. If there's a palliative care service at the hospital, you might suggest a consult to the doc. The hospital chaplain or the family's own pastor can help, too. If treatment is truly abusive and the pt appears to be suffering, a referral to the ethics committee might be helpful.

Above all, check your attitudes and meet the family where they are. Trust me, the attitudes come through and it's no help to the family. As I said, I don't mean to be harsh, but the contempt for pts/families that don't "get it" as fast as we professionals think they should, gets to me.

Besides, there is no info in the post as to what the family knows about the pt's own wishes for aggressive treatment. They could well be trying to respect her wishes, for all we know.

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Specializes in ICU, prior telemetry experience.

This is something we are always going to face as nurses, and its all too common. I personally feel the same way... but this is the families decision. This patient is on a DNR, not comfort care. The family has not decided to let go, and until the code status is changed to comfort placing a PEG tube is not unreasonable. We as nurses can support the family and the patient through this process, and not cast our judgements on them.

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