Aspiration: Help request

[catlvr]

Hi, I work in LTC, and we have a gent with advanced dementia (full code, *sigh*) who we suspect has been aspirating on his puree food and honey thick liquids. He coughs when eating, but remains afebrile. Lung sounds are rhonchi in the upper lobes, and they usually clear with a duoneb treatment. The CNAs refuse to feed him; I feed him dinner. The day nurse said that they feed him until he coughs - a few bits and sips - and then they stop. He opens his mouth continually for food when you are feeding him or even address him, so I suspect that he is hungry; I feed him the entire meal, since I figure that I'm damned either way: we give him far too little intake, or he aspirates.

His family does not want a feeding tube (thank goodness!), but refuses to make him a DRN. They said that if we do so, we will let him die. We've sent him to the hospital three times in the last six months with aspiration pneumonia.

Any tips that might help to keep this gent as safe as possible? We feed small amounts at a time, slowly, keeping him upright for at least 30 minutes post meal.

TIA,

e

[GRUNGE]

if he is having that much trouble he really needs a PEG tube. if the family refuses the tube there is not much we can do. he would more than likel do well with bolus feedings. it would be a lot of work but it would be better and cheaper than having to constantly treat for pneumonia.

[shiccy]

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[millhouse]

Sounds like the MD needs to discuss quality of life with the family and explain what a DNR actually does (not kill him). Unfortunately they need a vivid understanding of what happens should he need to be coded... and do they want their loved one going through that. I do agree that it sounds as if he needs a PEG. If they are adamant about keeping him alive, then he should be given the best possible care including his nutrition. I work in hospice and our docs are great about giving the family a vivid idea of what is to be expected and still give them the option to choose. They typically choose what is best for their family member.. and not what's best for themselves. Good luck!

[missdeevah, NP]

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huh???

[SuesquatchRN, BSN, RN]

He does not need a PEG tube. They are awful in instances such as this. They do not reduce aspiration nor do they extend life in this cohort.

Someone needs to explain to the family the difference between DNR and "do not treat."

[catlvr]

Yes, much better people than I have done so! The wife is adamant that the problem is that we feed him too large of mouthfuls of food; that may be partly because a few weeks ago, her daughter fed him and he aspirated. Our facility's medical director has explained all of this, the DON, ADON, unit manager, floor nurses, and hospital staff. She insists that since he has health insurance that we just keep plugging along until he dies. They adamantly refuse a feeding tube, and are equally adamant about the DRN status. Some staff suspects that there may be financial reasons for this inhumane treatment.

So we're left to do the best that we can with an impossible situation: how the *heck* do we keep him as safe as possible?

Thanks, e

He does not need a PEG tube. They are awful in instances such as this. They do not reduce aspiration nor do they extend life in this cohort.

Someone needs to explain to the family the difference between DNR and "do not treat."

[SuesquatchRN, BSN, RN]

Pureed, teeny bites, and we keep a lot of people going on Ensure and Mighty Shakes. Make sure he is sitting at almost 90 degrees with his head straight. Get the doc to write a protocol for suspected aspiration so every coughing spell doesn't get him shipped to the ED.

Until Alzheimer's is deemed terminal we are going to be stuck with this. The docs can't override family wishes with a "medical futility" decision, which is never made lightly - our med director has never made one. But the cessation of reflexes and the ability to swallow following a predictable course of decline - yeah, it's terminal.

[millhouse]

But the cessation of reflexes and the ability to swallow following a predictable course of decline - yeah, it's terminal.

Maybe a referral to Hospice. In hospice we admit advanced debility (dementia) patients with a prognosis of less than 6 months.

[SuesquatchRN, BSN, RN]

Maybe a referral to Hospice. In hospice we admit advanced debility (dementia) patients with a prognosis of less than 6 months.

See, though, there has to be another diagnosis making the predictability of death callable. That was my understanding, anyway. Can you admit someone with no morbidity other than dementia?

[millhouse]

See, though, there has to be another diagnosis making the predictability of death callable. That was my understanding, anyway. Can you admit someone with no morbidity other than dementia?

Yes... Debility with a prognosis of 6 months or less. I am not predicting this patient will die. That my friend, is imminent.

[SuesquatchRN, BSN, RN]

Gotcha. We can't do that in NYS for some reason.