Can enyone shed light on this for me?

[Lindasfriend]

Thanks to anyone in advance, who takes time to respond. I am not a nurse, but currently persuading my oldest daughter to become one.

My question: When does a medical facility say 'enough is enough' and discharge a terminally ill patient--or lock her up and force meds on her!

I have a friend that has been diagnosed with Non-Hodgkins Lymphoma with a tumor in the brain. Diagnosis was 3 months ago and she was told it was inoperable. She was also told that radiation wasn't an option because it was so deep in the tissue.

She was given radical chemotherapy treatments immediately (two rounds) using Methatrexate.

Here is the problem... she is also on Decadron, and it is making her nuts. Three different times now, she has gone ballistic claiming everyone is out to get her. She screams/cusses/yells at the nurses and doctors. I have witnessed this myself, and I do not understand why she is not placed in a psych ward.

She is now coming off another 'episode'... she refused any and all meds, her radiation treatment (they can't give her chemo anymore), and refused her 'surgery' to remove her port. She will not talk to anyone on the medical staff... thinks everyone (including her husband)is involved in some conspiracy to keep her locked in the hospital.

Sorry so long... but this woman is going nuts in a hospital where she has been treated for 3 months with no insurance. WHY WON'T SOMEONE force meds on her??? Her husband has POA, but was told that it means nothing, as long as she is 'competent'.

My 3 yr old neice could tell you SHE IS NOT COMPETENT right now.

[kids]

Originally posted by Lindasfriend

She does not qualify for SS or Medicare, because the clerk at the agency told her 'she was 3 quarters shy(of work) of ever receiving benefits'

But she gets SSI, because she has Scleraderma (KREST) & Lupus, so how can she qualify for one and not the other?...

Was she denied SINCE her terminal diagnosis?

If not "she" needs to reapply for SSD, if she was denied WITH the terminal diagnosis it needs to be appealed. If she didn't have enough income they can base disability off of her husbands wages.

[elkpark]

Maybe I can help make things a little clearer -- dealing with this sort of situation used to be my job, when I was doing psych consultation-liaison in a major teaching hospital a few years ago. The reason your friend is not being admitted to a psychiatric unit is because her delirium is a _medical_ problem, not a _psychiatric_ problem. Whether it is a result of the underlying brain pathology or a reaction (not uncommon!) to the steroids, she is not an appropriate candidate for a psych unit, which would have little to offer her.

There are a couple different routes to treating people against their will. Psychiatrists do not declare people incompetent -- only a judge can declare someone incompetent and appoint a guardian. However, an evaluation and recommendation by a psychiatrist is a necessary step in that process. In the medical center where I was practicing, the first thing the treating physicians did in situations similar to this one was to request an eval by our team to pursue guardianship.

You mentioned that the husband is "POA." If what he actually has is a "durable power of attorney for healthcare," as opposed to just being her husband/next of kin, that makes life much easier. That would be an actual piece of paper that has been signed by your friend, witnessed, and notarized (and it doesn't actually have to be drawn up by an attorney; I have seen handwritten POAs on a piece of notebook paper that were considered valid and legally binding), authorizing her husband to make medical choices for her in the event she is not able to make them herself.

The beauty of the healthcare POA is that, in that case, the decision as to whether the patient is able to make her own decisions becomes a MEDICAL decision rather than a LEGAL one. She could be perfectly competent legally, but (for example) unable to communicate for the time being because she's on a vent and in a full body cast, inc. her arms -- -- ok, that's a pretty weird example, but you get my drift ... As long as her treating physicians find that she's not able to make decisions for herself or to make her wishes known for _any_ reason, the POA would take effect, until whenever she is able to communicate her wishes again. Of course, that needs to be a reasonable decision on the part of the physicians, and not some clever plot to swipe her inheritance or do her in .... But, under the circumstances you describe, it certainly sounds like she is, at least temporarily, unable to make decisions for herself.

I don't know why anyone would have told the husband that the POA means nothing, if that's really what he has. However, lots of people use the terms "POA" and "guardian" when what they really mean is that they are the next of kin, or have been helping the person manage his or her financial affairs, or whatever, without any actual legal status.

I agree with the recommendations that the social work department at the hospital, if there is no psych consultation-liaison service available, should be able to offer some guidance and assistance. What a difficult situation for you all to be trying to live through! Best wishes --

[SchlNrsKrn]

If she has lupus, the decardon could be causing lupus cerebritis-in which case she doesn't belong in a psych place-her lupus needs to be managed. One of my close friend's spouse suffers from lupus and has twice suffered psycotic episodes after large doses of steroids. First time he was put in a psych facility and not medically managed at all, second episode he was on a medical floor and managed well. Sounds like she's got a lot going on and needs someone to take all her dx's into account.

[caroladybelle, BSN, RN]

Agree with much of the above.

And as I have had several patients get volatile on decadron, yes it can be difficult. It can also be related to the chemo side effects, mets, and associated inflammation/infection. Another matter is the patient is very stressed and facing great emotional trials that we cannot comprehend but that we should empathize with.

My question is why does the port need to come out - is it infected???? As a general rule, ports can stay in for years.

The other issue is how would you "force treatment" and why would you do so on someone that has a terminal diagnosis? What purpose would it serve???? While you may get her committed, I can tell you from experience, that even with some paralysis, most patients can seriously impair our ability to care for them. I have had patients that have ripped out central lines with their teeth, refused to eat, pulled out feeding tubes, contaminated their own IVs, causing infection, kicked and scratched staff to necessitate stitches/IV ABX for the staffer. All of this despite being in restraints. Verbal is unfortunately pretty minor in comparison.

We have schizophrenic criminals on the streets that we cannot force meds on....and you think that we can do it for a patient that is not crazy.

As far as psych is concerned, she probably is not "medically" stable. And most will refuse as her problem is probably not considered purely psych in origin (cancer, steroids, stress, etc.)

I am an Onco nurse...please feel free to PM me.

[Lindasfriend]

Thank you all SO much, you have no idea how valuable all of your insights have been. I appreciate you taking time to respond!

I just want to say that I do not want to force treatment on her, I did hope they could sneak a shot of morphine in on her so that she could calm down again... and be able to think straight. If she wants to go home, I am all for it.

She has no insurance, thousands of dollars in medical bills piling up for over a year (aneurysm included), and no way to ever pay for any of it. I know she is horrified, and it is horrifying to watch.

I was just frustrated that she couldn't be given something to calm her down again...

Yes, her first port got infected... they said it was very bad... they put another port in on the opposite side (of course), and then needed to take it out because the last round of chemo almost killed her, so the doctor doesn't want to give her any more chemo. He has now switched to radiation (which he said would not work at all in the beginning)

Thank you all again so much...