Suggesting DNR orders to an 80+ year old.

[Jo Dirt]

My father-in-law is getting on up there and this past summer has gotten into a deal where he will go to the ER every couple of weeks because he gets dizzy, has a fainting spell, his blood pressure gets low and his eyes roll back or he just doesn't feel well(he wants a lot of attention). Every time they find nothing immediately wrong with him and send him home.

(Right now, these visits are only costing him about $60 but does Medicare have a cap on how many ambulance rides and ER visits they will pay for? Because the bills actually come to a lot more than that, and it would be finanical suicide if we ever had to chip in to see those bills were paid.)

Anyway, regardless of the bills it is getting to a point where we think it is...I don't know, this revolving door is getting out of hand. My father-in-law has always boasted that he is going to live forever and he wants heart transplants and machines and whatever it takes to keep him alive. But my husband is his health care proxy and when he talks to the ER he tells them no heroics. The visits have become so frequent that the last couple of times the hospital did not call, my husband had to call them.

So, the husband and me decided it would not be cruel or unreasonable to suggest a DNR to his father (though we both know he won't sign it) but we at least need to bring some reality to the situation for him. The last time we went to pick him up from the ER my father-in-law was in the car saying he couldn't understand why the doctor wouldn't talk to him because there was sure something wrong, his other arm was starting to get tremors and today he fainted and fell to the floor. My husband (who isn't known for his tact) said, yea, there's something wrong, you're 83 yrs. old! Not 20 yrs. old, 83! These foray's to the emergency room several times a month are getting ridiculous, when you faint they need to put you in the bed and let whatever happens , happen. There's no cure for old age. You need to think about signing a do not resuscitate order.

So, FIL just gets real quiet and won't say anything like he always does when he doesn't agree with you or like what you're saying. I tried to tactfully explain that they don't even think it's generally a good idea to do CPR on people over 80 because first of all CPR is iffy even on healthy people and second when you beat on someone that old it puts the body through so much trauma that is as likely to finish them off as any time it could buy them, which in a lot of cases is only a few days.

Nothing but the sound of crickets from the backseat.

So, we had "the talk" with him. I don't know if it was the right thing to do but we did it. We know him so well we are certain that when we left the boarding home he started running his mouth a mile a minute and telling people we were full of $h*^ (that is his favorite expression).

But my question is...do you know of a tactful yet effective way to suggest a DNR to someone, especially one who is deteriorating? No, we don't want him to die, but we have to be frank about it, the time is coming and why put his body through unneccesary trauma to maybe buy him a few more days of misery?

Other than med reviews to rule out S/E and changes to try to make him more comfortable there is really nothing else that can be done. He has been diagnosed with Lewy Body Disease and fits the s/s like a textbook. My FIL either can't comprehend or refuses to accept the prognosis.

[TazziRN, RN]

Mama, if he's with it, why is your husband making the decisions about his status? The health care proxy thing is supposed to be if the pt is unable to make the decision because of declining mental faculties or illness/injury so severe the pt is unable to take part in the decision making. And if he's made it clear he wants everything done, then why do you want to talk him out of it? I agree that at that age, with his problems, DNR is the way to go, but it's not our choice, it's his!

Look at this from his point of view. He wants everything done should he code. His son and daughter in law are telling him that it's time to think about being let go. The message there is "My son wants me to die."

That would not be a very good feeling to have.

When I admit a new pt I have to ask about the DNR status. The way I bring it up is, "If you should drop right now and your heart stops, your breathing stops, do you want me to let you go, or do everything I can to try and save you?" If the pt is 98 years old and is on home O2 with lungs so bad he's whistling and tells me he wants to be saved, the discussion ends right there.

[Jo Dirt]

Mama, if he's with it, why is your husband making the decisions about his status? The health care proxy thing is supposed to be if the pt is unable to make the decision because of declining mental faculties or illness/injury so severe the pt is unable to take part in the decision making. And if he's made it clear he wants everything done, then why do you want to talk him out of it? I agree that at that age, with his problems, DNR is the way to go, but it's not our choice, it's his!

Look at this from his point of view. He wants everything done should he code. His son and daughter in law are telling him that it's time to think about being let go. The message there is "My son wants me to die."

That would not be a very good feeling to have.

When I admit a new pt I have to ask about the DNR status. The way I bring it up is, "If you should drop right now and your heart stops, your breathing stops, do you want me to let you go, or do everything I can to try and save you?" If the pt is 98 years old and is on home O2 with lungs so bad he's whistling and tells me he wants to be saved, the discussion ends right there.

Yea, we understand how health care proxy works, that is why my husband told the ER no heroics, in case my FIL became incapacitated. With Lewy Body Disease, some days the person is as sharp as they ever were, other days they are so confused they don't know where they are, they can even be psychotic. Even if the person is a DNR and they tell you to hook them up you have to do it.

I know it's his life and it isn't up to us to decide when someone else's life isn't worth living but as cold as people may think it sounds, when it comes down to it it really isn't all about him, anymore. He can't care for himself, we tried to bring him here and care for him and he made life living hell, we can't really do a whole lot more. We are in a bad situation, too.

[oMerMero]

Have you looked into assisted living facilities for him? Perhaps that would ease the burden on everyone. Your FIL would know there are people around to help him if he needs it, yet he can still remain independent.

I think you need to hold off on the DNR issue for now. You have already had the discussion with him, and you are on separate pages. Maybe when his status changes again you can bring it up, but until then, I would leave it alone. As hard as that is, bottom line is, you disagree with his decision, but he has the right to make the decision.

[Jo Dirt]

Have you looked into assisted living facilities for him? Perhaps that would ease the burden on everyone. Your FIL would know there are people around to help him if he needs it, yet he can still remain independent.

I think you need to hold off on the DNR issue for now. You have already had the discussion with him, and you are on separate pages. Maybe when his status changes again you can bring it up, but until then, I would leave it alone. As hard as that is, bottom line is, you disagree with his decision, but he has the right to make the decision.

The boarding home is basically assisted living. It isn't uncommon for him to have big-time personality conflicts with people and he has been in and out of several. We hope to God this place will work out for him until the end because I can't bear to think of bringing him back here.

[GregRN]

Yea, we understand how health care proxy works, that is why my husband told the ER no heroics, in case my FIL became incapacitated.

I must be missing something here. The whole point of proxy is to act on someones behalf when they are no longer able to make decisions for themselves. As a proxy, you ask the question, "What would this person want done for them" and you answer the question and carry out those wishes on their behalf. That your husband said "no heroics" is ABSOLUTELY CONTRARY to the very wishes of your FIL. That's not being a proxy at all.

It sounds to me like your family is tired and no longer has the energy to care for your FIL in the manner he needs. That's understandable. There are other ways to accomplish this than going against the will of your FIL. It may be time to find other resources to help care for your FIL (nursing home, home health care, etc.). Most importantly, in order to allow your FIL to be whole, even in the absence of his ability to make decisions for himself, you need to assign proxy to someone who isn't skewed by past events and can make clear decisions in accordance to your FIL's wishes.

[Jo Dirt]

I must be missing something here. The whole point of proxy is to act on someones behalf when they are no longer able to make decisions for themselves. As a proxy, you ask the question, "What would this person want done for them" and you answer the question and carry out those wishes on their behalf. That your husband said "no heroics" is ABSOLUTELY CONTRARY to the very wishes of your FIL. That's not being a proxy at all.

It sounds to me like your family is tired and no longer has the energy to care for your FIL in the manner he needs. That's understandable. There are other ways to accomplish this than going against the will of your FIL. It may be time to find other resources to help care for your FIL (nursing home, home health care, etc.). Most importantly, in order to allow your FIL to be whole, even in the absence of his ability to make decisions for himself, you need to assign proxy to someone who isn't skewed by past events and can make clear decisions in accordance to your FIL's wishes.

Well, I guess you're right about the proxy deal. I'm glad I refused to be a part of that proxy.

But a nursing home is out of the question because in this state WE are financially obligated to see that not only his resources have been exhausted before he will qualify for Medicaid but OUR resources as well, and I'll be damned if I lose what I've worked to pay for to pay off a nursing home.

His wishes, our expense.

If you think it isn't fair to him that we should object to losing the shirts off our backs so he can have a very questionable quality of life in a nursing home think about our young children who will lose everything as well. After all, they have a future. I am worried I have cancer. I've been thinking a lot and you know what I will do about it if I do? Let nature take its course and be thankful I have a sizeable life insurance policy to leave the children and hopefully an estate with a very substantial net worth. That is, unless they have to be auctioned off to pay for a nursing home. I don't want to have to die worrying about that.

I don't know why I'm airing out dirty laundry here. This isn't Jerry Springer (hasn't he been reduced to hosting that talent show, anyway?)

I think that's too much info. I'll just leave it at that. I also want to thank our government for paying out millions of dollars a year to friends of politicians to do jobs like tea tasting then rip the carpet out from under families and leave them destitute and put in situations where they look bad for not wanting to lose the shirts off their backs when their relative needs to go to the nursing home.

[SuesquatchRN, BSN, RN]

MoMa, have you spoken to a lawyer about any of this?

[GregRN]

But a nursing home is out of the question because in this state WE are financially obligated to see that not only his resources have been exhausted before he will qualify for Medicaid but OUR resources as well, and I'll be damned if I lose what I've worked to pay for to pay off a nursing home.

His wishes, our expense.

If you think it isn't fair to him that we should object to losing the shirts off our backs so he can have a very questionable quality of life in a nursing home think about our young children who will lose everything as well. After all, they have a future. I am worried I have cancer. I've been thinking a lot and you know what I will do about it if I do? Let nature take its course and be thankful I have a sizeable life insurance policy to leave the children and hopefully an estate with a very substantial net worth. That is, unless they have to be auctioned off to pay for a nursing home. I don't want to have to die worrying about that.

What state do you live in? I'm not aware of ANY state that requires financial resources of family members to be exhausted before qualifying for a LTCF. You can protect your assets and his by putting them in an irrevocable trust. It's called the "spend down solution." That is, you deplete his assets by putting them in a trust, where upon his demise his current assets, which were placed in trust, will to go the designated beneficiary. Once placed in trust he essentially has no assets and then qualifies for medicaid. Speak with an estate attorney ASAP to sort this out and give you, your family and your FIL some relief.

[oMerMero]

I agree with Greg. You need to speak with an expert regarding the financial aspects of all of this. Having your FIL in a nursing home should not affect your financial situation.

It sounds to me like you are very overwhelmed with everything that is going on right now.

[morte, LPN, LVN]

she lives in what is called a "filial responsibility" or at least close to that, state....according to her previous post, more than half of our u.s. states are such in some manner or function/degree....

[Jo Dirt]

Yes, the good ol' filial responsibility law, active in 31 states.

It's war on the midde class. They have basically made it to where there will be no inheritance and no middle class, AEB the Deficit Reduction Act of 2005.

In this state, as well as 30 others, it is the law that adult children pay for the care of their elderly parents if they are at all able. Having property and an income above minimum wage means that you are able to contribute YOUR resources toward the spend down to pay for the care of your elderly parents in the nursing home.

Basically, saving the Medicaid program money by first draining everything you and your parents have until you're paupers. After all, it's your duty and obligation to see your parent's needs are met.

Sorry, I'm not going down like that, and a lot of people facing similar situations are not, either. This accounts for all the sitting jobs available around here. It's either keep them at home and fork out money for a sitter or say goodbye to your property on the auction block as well as any other assets, mutual funds, etc..

Doesn't sound like it could be real, but it's VERY real, and no doubt coming your way soon. The state I live in is one of the most strict about enforcing this filial responsibility law, threatening super stiff penalties and even prison to children of elderly who try to hide their assets from the government and are discovered.

My former boss is the latest victim of this system I know about. Her father has alzheimer's and she cannot keep him at home. She is racking up one heck of a nursing home bill, and the collector's are calling. She was going to sell her house and move closer to work but somehow they found out and informed her she was not going to get a penny of the money for the sale of her home. She stopped the sale but it is only a matter of time before they take it by force.

And that is no conspiracy theory or storyline for a movie. It's written in black and white.