Wednesday, November 25, 2015
The Anatomy Of A Home Death Without Hospice
I visited him in the home.
We met eight months before his death. His wife, two daughters, and I. We discussed what dying looked like. We talked of dignity, and what decisions he would make if he had the ability to rationalize his current situation. We talked of dementia and how it eventually robbed it's victims of the ability to protect themselves from infection, aspiration, and bed soars.
They wanted him to continue seeing the oncologist and take the monthly shots that were possibly keeping the cancer at bay. They wanted antibiotics and blood tests, but agreed to look over the POLSTt form that I brought them. We discussed what would happened if his heart stopped, or he stopped breathing.
A few weeks later, I came back to look in on him. The daughters were not present but his wife handed me the completed POLST form. Heroic measures would not be necessary but antibiotics and lab tests were ok.
I examined my patient. He no longer recognized me, but answered my questions as he was able. His fingers had begun to contract, and there was the hint of a pressure sore on his back side. I educated his caregiver on positioning techniques and placed the POLST form on the refrigerator where all could see.
Five months before his death, he became more confused and his urine developed a foul smell. I came to his bedside and obtained his vitals. The blood pressure was strong but the heart rate had risen. We sat again, his family and I, in the living room and hashed out the details.
He had a urinary tract infection and was becoming septic. We reviewed the options and eventually it was decided to try oral antibiotics at home. Unlike his previous episodes, there would be no hospitalization this time.
Three months before his death his mental status became progressively worse. He refused to take his medications and would often pass on meals. He occasionally spit his food back at the caregiver.
Again we huddled in the living room. They were not emotionally ready for hospice but yet were reticent to send him back to the hospital or check more tests.
He somehow made it to one more oncology visit. His labs were strikingly normal. He even woke up for the trip and put on a good show for his doctor. But by this time he needed such extensive assistance to get out of bed and into the car, that even his daughter who was in quite a bit of denial about the current situation couldn't fail to see how far his state had progressed.
A few hours before his death his wife called to tell me he was having difficulty. She held the phone up so I could hear the undeniable rattle of Cheyne-Stokes breathing. I told her that he was dying. That she had to make a decision to call an ambulance or to let him go peacefully at home. I told her that this was what all our conversations had been building up to.
She hung up the phone and called her daughters. A few minutes later, they were all by his side. His daughters arrived in time to be present for his last breath. Calm, quiet, uneventful.
I certainly wish they had allowed me to get hospice involved early, to make sure that appropriate meds and training had taken place.
But that was not their wish.
And it all turned out okay in the end.
Posted by Jordan Grumet at 1:53 PM
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