Studies: Some Nursing Home Elderly Get Futile Care

During my clinicals I met a patient very much over the age of 80 who had lived alone and independent up until one day when she didn't feel well and her daughter brought her to the ER. She had bradycardia. The doctor said she needed a pacemaker. The patient didn't want a pacemaker. She said she was old and she just wanted to go home. Her daughter insisted she get the pacemaker. After a couple of days of resisting the operation, the old lady gave in. If her daughter wanted her to have a pacemaker, that's what she would get. During the procedure the lady had a stroke. She was unable to walk and could barely talk. All she wanted to do was go home. She had a foley. She had C-diff. When I went back the next week, I found she had died.

It would have been so much nicer for her just to fall asleep, at home, and not wake up.

I guess I can only say.... Duh!

Had a 60 something year old daughter insisting that 90 something year old Momma needed the H1N1 flu shot "BEFORE ANYONE ELSE" because Momma might get it. You just can't convince some families of much of anything they don't want to hear.

That's regulation, not the facility.

Yeah, it's ridiculous. I have a 100 year old woman, faculties intact, on Fosamax. She already has a fractured femur that it is ackowledged will not heal.

Sometimes, no. Sometimes the refusal to eat is due to the process of dying, but sometimes it's a matter of residents not getting the kind of food they like, being on an improper diet that they physically can't eat, or being unable to feed themselves. Although the nurses might be aware that someone is refusing food because he/she is slowly dying, how can state tell unless it's all documented? Then it all needs to be care planned, and, let's be honest here, there are often some pretty sloppy care plans in LTC. Some nurses don't care but others simply don't have enough time to care plan everything that should be.

And so we keep on doing what doesn't work and trying to shove food down the throats of people who don't want it. You are right; it does seem to be counterproductive and, if I were the resident, I would not be very happy with someone trying to feed me lukewarm pureed glop that I didn't particularly like. (I have heard of LTC facilities that got deficiencies on their state surveys because they served something different from what was on the menu to residents who needed pureed food. So that meant, if they were serving bratwurst and sauerkraut to the residents on regular diets, they had to puree bratwurst and sauerkraut for those on mechanical soft or pureed diets. I'm sorry but that just sounds nasty to me.)

On the other hand, I have heard of LTC staff trying half-heartedly to feed someone pureed mush and, after a couple of difficult bites, they turn away because the resident "isn't hungry" or "refuses to eat". Or someone will set up a resident's tray and not make sure the resident can feed him/herself and then takes away the tray because he/she didn't eat.

I think LTC staff is between a rock and a hard spot on this issue. I can see facilities getting dinged and staff written up for not trying to feed people and yet, is it really the right thing to do when someone is dying and does not want to eat? And then we have families coming in, accusing the facilities of trying to starve Grandma.

You are absolutely right about improper pain management in LTC. I don't know what is wrong with physicians (or PAs or NPs) who are reluctant to give an elderly person adequate pain medication. Yes, try non-medication measures to ease the pain. And no, we don't want to constipate everyone or give so many narcotics that people are snowed. But it's frustrating to hear docs say they don't want to give pain medication because they don't want a 97-year-old with dementia to become addicted. Or when they do prescribe pain meds, they prescribe huge oxycodone tabs that could choke a horse---to someone who has difficulty swallowing.

What I really don't get about LTC is how many docs continue to prescribe medications that are not going to significantly increase the quality of life. Sue's example of the 100-year-old woman receiving Fosamax is a good example. Why prescribe Fosamax for someone that old, especially for someone who cannot sit for at least half an hour after receiving it? And why prescribe calcium or multivits---also huge pills to swallow---to someone who's refusing to eat or cannot swallow something that big? If a resident has dementia and is refusing meds or becomes combative when the nurse tries to administer meds, aren't we just irritating them---maybe making their aggression worse---when we try to give them meds that are not going to do a whole lot in the long run?

Good post, LMC! I think you have a lot of common sense, which, unfortunately, is not very common these days. BTW, I like your screen name. I'm owned by a couple of felines, too.

We are a society that has learned to expect miracles in every thing that has to do with medicine. In the United States people do not accept death as a natural process of life. I work in a hospital where we have a multicultural patient population. The Asian community tend to take the elderly loved ones home to care for them in their last days. Very few ever go to a nursing home. Most people just don't want to or don't have time to take care of their elderly family member so they place them in a nursing home, still expecting a miracle to occur. They cannot seem to understand the natural processes that occur as people grow older. On the med surg floor where I work I spend a lot of my time trying to explain this to people. Somehow they think that we can cure their dementia and make them walk when they have not walked in months and then get angry when we can't do it.

I have one patient, who is my favorite patient, who is 99 years old. I love him and his family and have gotten very close to them over the 4 years that I have known them. He told me he wants to make it to 100 which will be December and then he will be ready to go. His wife I know will go right after him. They celebrated their 76 th wedding anniversary in the hospital last year. We gave them a party. She is 96 and has an amputated leg. She takes care of him at home by herself with someone who comes in three times a week to give him a bath. You just don't see this type of love and dedication any more. But he is fully awake and oriented, just weak. I finally discussed with them the facts about what is going to happen if we code him and they finally made him a DNR. His wife is an amazing woman.

The amount of ridiculousness that goes on in geriatrics and LTC is infinite. Families need to get a grip and learn about and face the reality of getting old.

And anything the government gets its paws on goes to hell in a handbasket.

I've seen some extreme cases in this area because when the elder can no longer voice desires, some family member will take over and suddenly decide that 97-year-old grandad who's in renal failure w/ severe dementia, really needs to be "saved" and allows intubation and tube feedings for the poor fellow whose last wish was to have his DNR honored.

It's really all about the money, folks. The elders who pass on are not going to be the ones trying to sue for our license and livelihood; the relatives will. So caregivers are forced into providing extreme and unrealistic measures instead of Hospice care.

Having worked in the acute care setting, home care, and hospice I would say that pain control in the elderly is no where near optimal. Too many elderly both in their private homes and in LTC and assisted living facilities are living with daily pain that seriously impacts their quality of life. Some of these people are not able to adequately communicate their levels of discomfort. Many, however, are simply poorly managed by their medical team. I find this fact horrifying, sad, and all too common.
Surprisingly, I find that many of the persons actually providing the care to elderly residents of LTC have little knowledge about the health issues most prevalent in the geriatric population. Looking at this "futile care" from that perspective then makes a bit more sense...they really DON'T know what kinds of things to look for, what signs and symptoms to anticipate, what strategies might improve quality of life or health outcomes. Don't get me wrong...there are lots of excellent geriatric health professionals out there...there just needs to be many, many more. And the education needs to get all the way to the person wiping poop off of wrinkled butts.
In terms of advanced directives and health planning for the elderly...most of these families simply need a rational, compassionate, well informed health professional who will provide honest information for them. We (as a medical community) need to stop fearing death and focus more on quality of life and the wishes of the person. Our traditional medical system remains very much in the business of advocating for "one more" pill, or procedure, or treatment; even when the bulk of the data suggests that such options will be unlikely to increase the life span and may well actually decrease the overall quality of life in some fashion. The "risk vs benefit" value of some of these options is not even discussed in some cases with the family or patient! Take for instance, the 80 something person who is diagnosed with a cancer of some sort...and the MD recommends a course of chemo and radiation even though they are well aware that the success rate may be below 50% for an increased life span. Some docs will not even discuss, honestly, with the patient and family the negative effect the treatments will have on the quality of life that patient will experience. The SE of the chemo, the hours spent in chemo, in radiation, in appointments, the multiple blood draws...etc, etc, etc. Given the ACTUAL options, a reasonable percentage of those elderly may opt to enjoy their lives and forego the treatment. It is fine if people want to go out with guns blazing...however, there are many people who are really at peace with their lives, with their mortality, and with the concept of death. Perhaps the mistake that some families make is in assuming that if their elderly loved one is resident in a LTC that they are receiving good oversight of their medical care and needs. The families often do not realize that THEY must be the ones to advocate for timely, appropriate medical care. Take for example a case I dealt with just yesterday...the bedside aids had reported to their superiors last week that an elderly dementia patient had a foul smelling vaginal discharge, the superiors did NOTHING with that info, they didn't even bother to advise the family. When they told me, I assessed it, notified the family and the doctor, and got an RX for the most likely cause of the discharge. No reason the demented woman must suffer through a vaginal infection simply because she cannot complain of the itch or discomfort. In this case there was no professional advocating for this patient although the family sort of expected there was.

It's a smart nurse who listens to the aides.