Pureed Sweet & Sour Pork and other Reflections on LTC

[SuesquatchRN, BSN, RN]

This is going to be a very rambling thread, full of brain farts and possibly unrelated comments. Feel free to enter your own. And please try to refrain from judgment - I'm venting.

I remember the first time I fed someone a pureed diet. The dietitian asked me how she did, and I answered, "She ate all of the brown stuff, half of the green stuff, and none of the white stuff." She broke up.

That stuff looks horrible to me, but we just put an anorexic COPDer on pureed - an experienced coworker, LPN, had the brainstorm - and she's eating up a storm. Feeding herself, even. My, to be so weak that chewing is difficult!

And all they ever ask me for is salt. One day I just started laughing and answered the resident, "Honey, I know. And you're never going to get any." She smiled and kept eating.

I hate force-feeding people. I mean, not anti-suffragist feeding tube down the nose stuff, but really forcing people to eat. They and nature KNOW it's time to give it up, but read those regulations! God forbid that anyone die in an SNF.

I'm sick of taking care of other people's demented, dying relations, particularly when the denial factor runs rampant. I had someone say to me about her 94-year-old mom who has in the past suffered fractures pof both hips and both legs - the COPDer - "Should I get her up and walking? I'm just not ready to see her in a wheelchair yet." No? Honey, get ready to see her in a coffin, because that's the next stop. The mom sleeps EOD, when the CO2 overwhelms her, and sleep most of the days it doesn't. Let the poor thing go!

We have a married couple with galloping Alzheimers and they no longer recognize anyone, let alone one another. Their kids want to take them home for a celebration of their 60th wedding anniversary. For whom are they celebrating? Certainly not the parents. Let go of them!

Administration has all drunk the Kool-aid. They believe in the regulations forced down our throats. We should be fighting to get back the right to put a restraint around the waist of someone who falls asleep in her wheelchair and then falls ass over teakettle to (in one case) break her neck. We always have one horribly facially bruised resident who did that. But the facilty - no facility -= is not willing to get the belt care-planned for and risk having the state cite a "pattern of restraint." We should be fighting for the right to keep people safe. The pendulum has swung too far in the other direction.

And aside from demented wanderers, most people, singles aside, could care for relatives as was done in the old days. And if the relatives were at home they wouldn't live as ridiculously long with as little function or quality of life as they now do.

I have one woman who is horribly demented - mutiple strokes and infarcts - and always frightened. She actually recognizes me now, because I talk to her and treat her kindly - most others aren't mean to her, they just ignore her - and we have to justify her Seroquel to the state. Since when are lawyers and legislators physicians?

The state's due any minute, so we have someone painting the trim on all of the doors because gouges in the paint can get us cited! Good golly, Miss Molly! Can we say, stretchers and wheelchairs and med carts and geri chairs smashing into things, oh my? Of all the unimportant bulldinky.

I'm sure I'll have more to add later. Please, express yourselves.

[star2nite2000]

It's not about the resident's or the care anymore, it IS about the almighty dollar. And it just gripes me to death when I hear 'well the state says they have the right to fall'....ARGH!

One of our SNF residents really could benefit from hospice coming in. Our administrator says 'no way'...why? money received from being on skilled is why.

Never ending cycle.

[VivaLasViejas, ASN, RN]

Sue~

I hear you! I've worked in geriatrics for most of my career, and all I can say is, please GOD don't let anyone do these things to me when it's my turn!! I just want to fade away into oblivion without being force-fed, turned, changed, made to get OOB when I'd rather sleep, hauled down the hall in a Hoyer lift, showered in a cold and unwelcoming room, and put to bed again...........only to do it all over again the next day, and the day after that, day in and day out.

We haven't made much headway yet, but I do believe the times will be a-changin' within the next 10-30 years as the huge Baby Boom generation goes kicking and screaming into old age. I'm a boomer myself, and I haven't talked to a single member of my generation who wants for themselves what our parents are having to endure. I don't know if there's just going to be huge numbers of suicides or what, but we have NO plans to waste away in nursing homes. I prefer to be optimistic in believing there will be improvements in geriatric care, including prevention and treatment of dementia and the other diseases of aging, because we will demand them; after all, we're the generation that refuses to grow old, and even if we cannot escape the ravages of time completely, we're not going down without a fight!!

Anyway, Sue, feel free to vent anytime...........there are many of us who feel exactly as you do about the 'care' given the frail elderly when they or their families refuse to let go and let God, so to speak. I've told my kids that the way NOT to love and honor me is to put me in a nursing home, stick a feeding tube in, and fill me full of medications just to keep me around a few more years. I don't believe in euthanasia..........but for mercy's sake, when I've lived my life and my mind and body no longer work, PLEEEEEEEEEEASE let me go home to God as He intended.

'nuff said.

[Penny8611]

Oh, boy, where to start. I'm not even in nursing school yet so I'm unqualified to remark on much of what you've written, but on the other hand...my 78 year old Mom is in a LTC facility. She had dementia coming on anyway, and then threw a clot after knee surgery. She can't walk, can't use her right side and is convinced on a weekly basis that her mother (who died in 1970) has been coming to see her. Over the past few months she's stopped recognizing me. After her stroke she was initially NPO.

I really do believe the facility she's in is a very good one. I grew up with a long string of relatives in nursing homes, and learned from a young age how to spot the hell-holes. The first question my RN cousin asked when I'd first checked out my Mom's facility was, "How does it smell?" Very perceptive. Very telling.

I was nodding in agreement to everything you stated, but then my mouth fell open at "justify their Seroquel." That's EXACTLY what they did to my Mom over this past spring; they put the woman through HELL in order to have it documented that she gets very combative and physically abusive when they back off on her dose. I was LIVID when I found out why they had really done it! They had couched it in terms of it being for her benefit. I'm trying to not hold it against them; I know any facility where she might be would do the same thing.

I love my Mom dearly, but (gotta pull out the pulpit for a second - bear with me) I have had many angry conversations with God about why He won't just LET HER GO. I believe as my Mom does, and I know in my heart of hearts that she'll be with Jesus when she goes, and it will be better and finer than her best day on earth ever was. So why is she being kept alive like this? The stroke rendered her NPO; she was cognizant enough to agree to the PEG. If things had tipped a little further into the "Oh, crap," end of the scale, her legal documents would have dictated that she be kept comfortable. Period.

My Mom was a very intelligent woman who tended to rule with a little too much of an iron fist. She was a control freak. She now controls NOTHING, and is aware enough of her surroundings to be utterly and completely MISERABLE on a near-constant basis. I'm glad God forgives me, because I'm madder than hell that this has happened. And yes, I've pondered long and hard that a few decades ago she would have not survived her stroke. And would have been off with the Heavenly Host over two years ago. And contrary to what modern medicine seems to believe, that would have been FANTASTIC compared to what she is dealing with now.

I am an animal fanatic; I have held and stroked many beloved family members as they been allowed to slip away from their pain and infirmities. As horrible a decision as it is to make, I'm honored to make it and honored to be there when they move on. I do NOT advocate euthanasia for people. But...going to the extremes we go in order to keep them "alive" is insane. Just because we CAN does not mean we SHOULD. And I imagine your frustration is compounded enormously by what I suspect: I would have to guess that many more family members are of the, "Keep her going, no matter what" school of thought than the one I belong to.

Thank you for your thoughts and for your service; I truly believe that my Mom's caretakers really do care about her. I'm thankful to know there are people like you working in places like this. God bless you. There are people like me who are more thankful than you might believe that you are doing the job that you do.

Penny

[SuesquatchRN, BSN, RN]

I was nodding in agreement to everything you stated, but then my mouth fell open at "justify their Seroquel." That's EXACTLY what they did to my Mom over this past spring; they put the woman through HELL in order to have it documented that she gets very combative and physically abusive when they back off on her dose. I was LIVID when I found out why they had really done it! They had couched it in terms of it being for her benefit. I'm trying to not hold it against them; I know any facility where she might be would do the same thing.

Penny, if it isn't documented we are cited for using "chemical restraints." Why they couldn't just tell you this I don't know - I hope Miranda or CapeCodMermaid can tell us.

Thanks, everyone, for venting with me. And hey, you don't need to be a nurse to belong to this forum and comment, Penny. Everyone's welcome.

I sorta believe in euthanasia for people. I mean, the last week of cancer-ridden hell seems like a good time for an intentional overdose, y'know? But yeah, then there's, "Who are we to make that choice?" yada yada yada.

Your poor mom, Peggy. I hope the Heaven in which you believe is real, and that she makes it there soon.

Miranda, my parents believe as I do, that there are justifiable times to commit suicide, when it isn't cowardice but strength. The trick is getting meds to do it. I can't get Claritin-D without the state getting my driver's license listed.

But boy, we boomers are gonna go kicking and screaming into that good night.

[rn/writer, RN]

Hey, Sue. What a sad but important thread.

Penny, if it isn't documented we are cited for using "chemical restraints." Why they couldn't just tell you this I don't know - I hope Miranda or CapeCodMermaid can tell us.

I think you're referring to Marla. She's the one who posted earlier.

Common sense has gone out the window to the point where LTC residents are subjected to things that would be considered torture in other settings. This whole business about "protecting" people from restraints to the point where they are falling and injuring themselves is sheer lunacy. "Least restrictive" ought to compare not only restrained vs. unrestrained, but restrained vs. imobilized d/t fractures or other injuries. The people making these rules have some airy-fairy fantasies about life in LTC. It's obvious they aren't consulting the folks who take care of the residents. Yes, restraints used to be over used and employed for the convenience of the caretakers. But as was said earlier, now we've gone to the other extreme and made a hash of long term care.

I don't believe in euthanasia either, but there's a ginormous difference between killing someone and letting them die. This business of sending people out for aggressive abx therapy when they're demented, decrepit, and miserable is just stupid. Pneumonia used to be called the old person's friend because it took them in a relatively painless fashion. Now it's "the enemy" and must be vanquished at all costs so we can keep the shriveled body going for another six months.

Incredibly sad and pointless.

Thank you, Sue, for starting this discussion. And, Marla, I hope you're right that we boomers will right some of these egregious wrongs before we have to endure them ourselves.

[SuesquatchRN, BSN, RN]

I think you're referring to Marla. She's the one who posted earlier.

Oh, sorry, you're right. Well, I think highly of you both.

As to pneumonia - yes, the old man's friend.

My brother's FIL died recently, 79. He went in his sleep. Let out a little sound and died of a heart attack. And given what I've been seeing I was able to honestly comfort my SIL that he had something in which I now believe - a good death.

[JarOfPennies]

Of all the unimportant bulldinky.

[Natkat, BSN, MSN, RN]

I work in dialysis and I have seen much sadness around end of life issues in our facility.

We had a patient who had breast cancer that metastasized to the brain. For a good long time things were fine. Then when she started going downhill the woman wanted to stop dialysis and die peacefully, but her family guilt-tripped her into continuing on. It really pained me that instead of spending her last moments on earth with her family in peace, they burdened her with their grief. I felt it was selfish of them to make her feel that she had to keep fighting for life for their sake.

Eventually her dementia grew worse, and this sweet, lovely woman became combative and abusive. She was cursing at us for hooking her up to dialysis yet again. By this time she was too out of it to make any of her own decisions and her daughter was DPOA. This same daughter would come with her to the clinic every day. I realize this woman was devastated by her mother's impending death, but I couldn't help feeling that she was getting her ego stroked by being the hero - the long-suffering daughter who was making so many sacrifices to care for her dying mother.

It was high drama every day they were there. She would actually fight with her poor, confused mother who was so wracked with pain she would scream whenever anyone moved her. She would insist on sitting with her mother during dialysis and pick at her for her demented ramblings and odd behavior. I would shoo her away, telling her "you look exhausted. Why don't you sit in the lobby or take a nap in your car. I'll come get you if she needs anything." The truth was the mother was agitated by her daughter's presence. She wasn't any help at all, but only made more work for us when she was around. When the daughter was gone the patient would calm down and even sleep a little.

The daughter would go on and on about how she wasn't eating or sleeping because of her mother; how she broke her wrist from trying to take her mother to the bathroom by herself, yet she refused to get home health or hire a sitter to be with her mother once in a while so she could sleep. No. She LOVED being the martyr. It turned my stomach to watch this go on. It would have been so easy and so merciful to just take Mom off dialysis and let her die peacefully.

[Penny8611]

Penny, if it isn't documented we are cited for using "chemical restraints." Why they couldn't just tell you this I don't know - I hope Miranda or CapeCodMermaid can tell us.

I don't know...I kind of filed it under, "Let's tell her about the more palatable reason." And really...even though what happened was horrible for my Mom (and me, since I got the brunt of her anger during this time) I do understand that they didn't do it just for the hell of it. I understand that they did it because they really had to.

I can't remember the dose of Seroquel she's on, but it's MASSIVE. Most people would be damn near catatonic on a fraction of what she's on, but...even after all she's been through, her iron will keeps coming to the surface. They needed to document that what they have her on really is necessary, should anyone ever question it. They didn't present it to me in so many words; they explained it from the angle of, "She's been here for over a year, so let's see if she can do without some of the meds she needed to make her adjustment to being here." Really, both reasons were valid.

I'm pleased that they came to feel they could tell me BOTH reasons behind what they did. I'm pleased that I'm apparently not perceived as one of "those" daughters. ;-) I can only IMAGINE what you deal with in terms of the families of the residents. ~~~~shudder~~~~ Yes, it would have been better if they had been upfront from the beginning, but I trust that they have good reasons for everything they do. I also hope that they trust that *I* won't freak out and start yelling anytime I have a concern about something.

This home has a big holiday dinner a couple of weeks before Christmas; I attend mostly because I don't want my Mom to feel like she's one of the very few residents without a family member present. I see her on a regular basis, and have become familiar with some of the other family members who show up weekly or so. The two of these holiday dinners I've attended produce scores of people I've never, ever seen before. It's so sad!

Penny

[SuesquatchRN, BSN, RN]

I'm pleased that they came to feel they could tell me BOTH reasons behind what they did. I'm pleased that I'm apparently not perceived as one of "those" daughters.

......

The two of these holiday dinners I've attended produce scores of people I've never, ever seen before. It's so sad!

Penny

I know just from your posts here that you aren't close to one of those daughters! And it's a relief to just be able to be honest with the critical family member - usually the eldest daughter. :)

Natkat, wouldn't it be wonderful to prosecute that twisted martyr for elder abuse?!

And those holiday scenes. My last facility had the brainstorm of having a huge Thanksgiving dinner. 90 residents, 94 guests excluding children! Can we say seizures and frightened, confused dementia patients and children insisting that Mom "celebrate" even though Mom's O2 sat was 70% on 4 L/min and Mom thought she was taking a trip to Bombay that evening anyway? And a frightened 7 year old who had never met incontinent, Parkinsonian GreatGramma and asked me in a furtive whisper, "What's wrong with her?" And of course, no extra staff.

[Ruby Vee, BSN]

we went to visit my mil at her nursing home last weekend. we don't get there very often because it's over 400 miles away and i've only recently been able to tolerate sitting long enough to travel after my back injury last year. mil was "rescued" from her home after she wandered away from an evacuation center in the aftermath of katrina. she was confused and combative -- the confused is a relatively new issue which started about a year before katrina but she's always been combative. last weekend was the first time i've ever seen her in the same room with even one of her children for more than 30 minutes without screaming insults and abuse at them. she's still on the same 10 minute conversation loop she was on when i last saw her in february of 2006: "is my house ok?" (no -- it was flooded and the parish wants to demolish it.) "how's fill-in-the-blank-with-names0of-her-five-children-and-12-siblings." (scattered to the four winds -- we don't even know where some of the aunts and cousins landed!) "how's the baby?" (fifteen and looking forward to her learner's permit.) "how's my house?" she's always been a vain woman, delighting in being the center of attention and posessing an extensive wardrobe and a lot of jewelry. the wardrobe and jewelry are gone, and i don't want to be the one to tell her that her oldest daughter ransacked the house immediately after the storm, removing anything of value to hide it from the rest of the family. she's not happy -- not that she has ever been happy -- and she doesn't want to take her meds. so why are we forcing her to take her meds? because if she doesn't she might die.

call me crazy, but i think she'd be much happier dying than trapped in this hell!