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

[catlvr]

Hospice would be terrific; staff would be happy with palliative care...but the family is adament: NO. NO. NO. Nothing but a full code for fear that we will just "let him die". Every type of professional (MD, daily care RN, daily care LPN, hospice RN) has talked with them. Honestly, it breaks my heart; this gent was up and walking about six months ago, incontinent of b&b, but he could feed himself his puree meal. Now, he is total care, and unable to speak or do anything for himself.

e

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

[catlvr]

Thanks, Suesquatch. It sounds like we're doing everything except the "no ship" protocol. I check his temp at the start of my shift and again before bed, and give a breathing treatment after dinner if he needs it. He's still opening his mouth for food/drink everytime someone comes near, so I feel that we cannot *not* feed him (esp since the daytime nurse refuses to feed him breakfast or lunch - but the time I roll in, he's very hungry).

Yes, Alz is terminal! A terrible, terrifying disease that is gonna kill you. All the more reason for all of us to have our advance directives in place, should this horror visit us.

e

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.

[SuesquatchRN, BSN, RN]

While AD is terminal since there is no specific "terminal event" associated with it it does not meet the criteria for a terminal illness. Ridiculous, I know.

Report the day people who are not feeding him. That is abuse and neglect, pure and simple.

These authors have done extensive research into this. If you have access to an electronic medical library I highly recommend them.

Sachs, G. A., Shega, J. W., & Cox-Hayley, D. (2004, October). Barriers to excellent end-of-life care for patients with dementia. JGIM: Journal of General Internal Medicine, 19(10), 1057-1063. doi: 10.1111/j.1525-1497.2004.30329.x

[PedsAtHeart, LPN]

My grandmother had Alzheimers dementia and was on hospice for the last few months of her life... No other diagnosis... I dont know how or anything, that was several years ago. I know it helped my mother out tremendously.

[SaltyNurse]

While AD is terminal since there is no specific "terminal event" associated with it it does not meet the criteria for a terminal illness. Ridiculous, I know.

Report the day people who are not feeding him. That is abuse and neglect, pure and simple.

These authors have done extensive research into this. If you have access to an electronic medical library I highly recommend them.

Sachs, G. A., Shega, J. W., & Cox-Hayley, D. (2004, October). Barriers to excellent end-of-life care for patients with dementia. JGIM: Journal of General Internal Medicine, 19(10), 1057-1063. doi: 10.1111/j.1525-1497.2004.30329.x

The problem with continuing to feed this patient is that he is aspirating and inevitably the resulting pneumonia is going to cause severe enough respiratory failure to require intubation (per the family's desire for full aggressive care) and very likely this patient will develop sepsis with multi-organ failure requiring additional aggressive interventions. I would refuse to feed this patient. I wouldn't want to try to defend feeding a patient that is known to be aspirating any more than I would want to defend pouring apple sauce into a patient's endotracheal tube. The net result is aspiration pneumonitis, sepsis, and death (and thanks to the family, not the kind, gentle death, but rather the long, drawn out ICU death) This family has some serious issues. CPR and intubation is cool and yet a feeding tube is not? ***** This family seriously needs some education, and I'm sure that multiple attempts have been made. It's a really sad, horrible situation.

[SuesquatchRN, BSN, RN]

The peg-tube folks we have suffer as much aspiration as do those eating PO. The choice is to starve a hungry man a/e/b his opening his mouth and avidly eating because you don't want to risk him aspirating or putting in a tube with which he will also aspirate.

[debRN0417]

Feed him he dies- do not feed him he dies...hummmm...If it were me, please feed me so I would at least die with a full belly...

seriously- I would talk again with the family and have them sign a form that releases the facility of the liability associated with feeding him, and then feed him. If people are afraid to feed him then he is going to die of malnutrition...that sounds like a bigger problem than aspiration to me.

[Nascar nurse, ASN, RN]

Sounds like you're in a no win situation.

Have you had speech therapy involved? chin tucks, double swallows after each drink/bite, etc.

[Nascar nurse, ASN, RN]

Feed him he dies- do not feed him he dies...hummmm...If it were me, please feed me so I would at least die with a full belly...

seriously- I would talk again with the family and have them sign a form that releases the facility of the liability associated with feeding him, and then feed him. If people are afraid to feed him then he is going to die of malnutrition...that sounds like a bigger problem than aspiration to me.

:yeah:

Cover your tail and careplan every bit of the above & document ALL attempts to educate the family on the risks/benefits of eating/tube feeding.

[Ephemera]

Hospice in my area will admit an Alzheimer's patient with a diagnosis of "failure to thrive secondary to Alzheimer's dementia."

[catlvr]

Yes, speech is involved and they just shake their heads. Unfortunately he is not responsive enough to chin tuck or double swallow. *sigh* I'm grateful for the ideas and the empathy, and will discuss getting something for the family to sign; maybe that will help them see just how serious it is.

e

Sounds like you're in a no win situation.

Have you had speech therapy involved? chin tucks, double swallows after each drink/bite, etc.

[CapeCodMermaid, RN]

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?

Hospitalized how many times in the last 6 months? Plus dementia...that's enough for an admission to Hospice.