Mom’s Stroke – My Dilemma

Bob

On Christmas Eve, about 0900 I took a call from a nurse at the Alzheimer’s/Dementia facility where my mother now resides. At her current age, 94, I was not surprised by the news: “Your mother’s in her bed, unresponsive; her left side is flacid, and she’s not following commands.”

Before diving into the emotional challenges this presented, I want to reassure you that as of now she’s exhibited a near miraculous recovery, with only a minimal residual left-sided weakness, which has left her a bit more at risk for falls.

So, back to the story… Ok, of course if she’s “unresponsive” she’s not following commands, but as a nurse, I saw no conflict in the report. It’s similar to what I’ve reported to physicians regarding patients in the ICU under my care. It’s the jargon…
My in-the-moment analysis – she’s had a stroke, and a significant one. What’s unknown – is it a clot blocking the blood flow to her brain, or is it a ruptured vessel bleeding into her brain.

My sister and I are both designated as decision-makers for her health care if she’s not able or competent to attend to her own needs. And, importantly, my sister and I are in agreement regarding our understanding of how Mom wants life-threatening events dealt with if she’s not able to answer for herself. She wants no heroics; no last-minute efforts to stave off the inevitable as long as possible; she’s DNR – that is, Do Not resuscitate. Further, no intubation (breathing tube driven by a machine to breathe for her), no artificial nutritional support – that is, no tube feedings.

As I dealt internally with the likely impending demise of my mother, I busied myself in gathering and confirming the documents regarding both her health care, and how she wanted to be buried – well, cremated – and her ultimate resting place next to my father. And, of course, I sent off an email to family regarding the turn of events.

For those of you who may not already know, my mother has suffered a profound loss of both long-term and short-term memory, and while not diagnosed with Alzheimer’s, she exhibits many aspects of that condition. For the last two years she’s not recognized me, nor does she remember her marriage to my father. When I last introduced myself as “Bob, your son.” She commented, “How can I have children? I’m not married.” She has, at times, identified me as her late brother, but there is no recognition beyond that.

So, I’m ok. No last-minute life-saving efforts; let nature take its course… Then comes the real-life turn of events. Late that afternoon I get a report: She’s up and walking with assistance; not following commands; and is exhibiting an expressive aphasia – that is, she speaks, but it’s a jumble of words in a non-sensical order – “word salad.”

Prior to this report I was clear about my options, responsibilities and decisions. However, her condition at this point is something unanticipated and damn challenging. She is conscious but unable to understand incoming information and unable to communicate her needs and desires. My dilemma? She’s unable to express her desires; she can’t feed herself and likely won’t submit to any type of external feeding strategies (Intravenous, or, a tube in her nose, or directly into her stomach).

Now what? If I follow her expressed desires there is no feeding by staff, by tube, or intravenously. But… She’s going to potentially experience both thirst and hunger. Furthermore, she can’t say what she wants – remember the expressive aphasia (word salad), nor can she understand any explanation as to why she’d be denied water and food. And, she can’t understand an explanation – the evidence being her inability to follow simple commands.

Back to the present.  As I noted above, she’s back to her baseline.  She still doesn’t remember who I and my sister are, but she is able to feed herself, make her needs known, and move about without assistance.

I remain unsure about what how I might handle a repeat of her event.  What to do for someone who’s unable to understand incoming information, or express their desires, but with a previously laid-out plan for “no heroics” – no rescucitation; no life-extending measures.  We really never covered the scenario briefly experience over the Christmas holiday.

Stay Well

Stroke Resources:

F.A.S.T.
is an easy way to remember how to
recognize a stroke and what to do. Spot a stroke
FAST.
Face drooping.
Arm weakness.
Speech
Difficulty.
Time to call 9-1-1

Stroke – Stanford Health Care

 

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Food and Water at the End-of-Life – What’s “Normal”?


NurseBob

NurseBob

Before I can talk about possible problems with TPN at the End-of-Life, I need to lay a quick foundation describing what the “normal” components are in the blood when we’re healthy, and how those components function to help maintain the balance of fluids in the blood and in the tissues. The scientific term for this is “osmolarity” – which in the most general sense, refers to the concentration of the various components dissolved in water. But in addition to their concentration, it also is related to how big the molecules are that make up these components. The reason that “osmolarity” is so important is that it plays a very significant role in determining whether the blood is loosing water to the surrounding tissues, or pulling it in. If the blood is loosing water to the tissues it can result in dehydration, edema, or in severe cases, anasarca.
In this blog entry, I’ll give you both some definitions of the terms I just introduced, as well as some examples.  In my video blog, I will be showing how these processes work using both some animation, and a short time-lapse video.
So, what are the major players among the blood components? Well, of course there are inorganic salts (primarily table salt)  and sugar (glucose), as well as a number of other organic components and proteins.  When it comes to managing the amount of water in the circulatory system, all of the components just mentioned play a role, but one of the more important components is a protein called albumin (which is manufactured by the liver).  When the level of albumin in the blood serum drops, the water normally contained in the blood and blood vessels begins to leak out of the blood and into the tissue.  The “why” for this leakage is due, in part, to the change in the balance of osmolarity between the blood and the fluids in the tissue surrounding the blood vessels.

Osmolarity is one of those “scientific” terms, which as I mentioned earlier, generally refers to the concentration of various substances in water.  The Wikipedia entry for Osmolarity is too complex for the purposes of my blog.  The very high-level explanation I’ll offer is that it’s a way of determining the total concentration of multiple substances in a sample of water.  If there are two samples with different osmolarity, the one that has a higher value will tend to draw water from the lower value.
This flow is called osmosis – and the direction is determined by the osmolarity.  In short, water moves from the lower to the higher concentration in an attempt to make the two samples equal. (Remember the old adage:  Nature abhors a vaccuum?  Well, Nature “hates” any imbalance!).  Another way to think of osmosis is that if there are two samples with water, each with different substances dissolved, the water will tend to flow from the sample with more water to the one with less water.  Think of it as water flowing “downhill.”
Well then, when we have blood in the circulatory system with fewer dissolved substances in it than the fluid surrounding the cells in the tissue – the water will migrate from the blood, through the walls of the blood vessels, and into the fluid in the tissue.  The net result is that you end up “dehydrated” from the perspective of the circulatory system, but swollen from the resulting increase in water in the tissue – this is edema.


Stay Well -NurseBob

visit my video blog for other health information


References Researched
References

Do We Require Food and Water at End-Of-Life? NurseBob Discusses Nutrition and Hydration for the Terminally ILL


NurseBob

NurseBob

Today I’m starting a new series on my video blog:

Force Feed Your Dying Loved-One? Nutrition and End of Life – Part 1 – An Overview

In concert with that effort, I’m going to be noting the important points here for those who prefer, or need, a text version rather than video. As the references noted below indicate, I’ve been doing my homework. I am in the process of adapting and summarizing the information for this medium.
While I have some strong feelings and opinions on whether we should do tube or intravenous feedings and hydration with someone who’s near the end-of-life, my focus here will be to provide sufficient information so that you can choose the path you believe is best for you or your loved-one. There can be significant issues with adding hydration and nutrition for someone who’s near death, and research indicates that there is little or no benefit to balance the risks and potential loss of quality of life in the last days.
I don’t know any health professionals who want to cause undue suffering for those they care for, but I have seen situations where they find themselves challenged to deal with the needs of the living, who don’t realize the full consequences of their requests – which usually boil down to: “Keep my loved-one alive as long as possible.” It’s very hard in that situation not to try to offer some lifeline, some hope, to the family, and in those circumstances, last-ditch medical technology can be offered, but without necessarily noting all of the potential risks for the patient.

It’s my goal to provide sufficient resources so that you can ask the right questions, and get the answers you need. Choices made in ignorance are dangerous to both the patient and the survivors, the negative outcomes may impact not only the patient’s health and comfort, but might also leave lasting psychological issues for the survivors.

This topic is complex, and requires some understanding of physiology, pathophysiology, and even some chemistry. Thus my choice to do the text and video blogs in segments, and where practical on the video blog, show some demonstrations of what happens when our body chemistry becomes deranged due to the disease processes involved. I hope you find the information both useful and interesting. And most importantly, if you should find yourself in the position of having to make decisions about some else’s nutrition and hydration at the end-of-life, you will have sufficient information to ask all the right questions to aid you in your decision.
Respectfully,
-NurseBob


References Researched: References


Stay Well -NurseBob

Visit my Video Blog for more health information.