I recently read a blog post from bio-ethics specialist, Viki Kind, regarding strangers deciding whether a person in a nursing home or hospital should live or die which I found very stimulating and informative (www.kindethics.com)
However, should you advocate for an elder with an Alzheimer's related dementia who has had a history of depression, has been known to be suicidal, has some wandering / sundowning issues, but whose POA wishes to disconnect her pacemaker --recently implanted under recommendation of another adult child less than five months ago? The senior is still ambulatory, enjoys outings with her caregivers, loves her cat, has good appetite, and generally has no agitation except when long distance children overstimulate her while visiting. This was the case a few weeks ago when she became violent with the caregiver immediate following her son's departure. So now the POA is proposing that her primary care physician disconnect the pacer and provide a hospice consult because of an acceleration in his mom's decline; not wishing to protract her suffering. Is this ethical? Is it not? Will the primary care doctor order that the pacemaker be disconnected? What do you think? Would love to hear your comments. Please click on comments link below to submit.
per the limited info provided, it sounds like disconnecting the pacemaker is issuing a death sentence. How much responsibility does the primary care phys have in deciding to do or not do.......
ReplyDeletehow could they even consider disconnecting the pacemaker. outburst agitation and violence is part of alzheimers and declining is part of alzheimers. would you stop giving insulin to a diabetic because their blood sugars were out of control and they became violent and had outburst which can happen as well for a diabetic. perhaps the POA needs counseling in order to learn the alzheimers stages and process and learn acceptance of his moms disease. learn to accept that while his mom has bad moments it sounds like there are some enjoyable ones as well. as the disease progresses perhaps the ratio of good to bad becomes way out of balance and perhaps, based on the moms history, this POA is fatigued from memories of depression and suicidal episodes the family has had to endure. the POA sounds like he or she wants to end their own suffering. the POA needs help.
ReplyDeleteThe scenario you describe really saddens me. Your client (surprisingly) still lives at home with caregivers—even though she has behavioral issues, like wandering and sundowning, which many families cannot manage at home and which results in institutional placement. Probably through your case management this client is still able to enjoy some quality of life. Hospice is about quality of life. “Turning off her pacemaker and hospice placement” sounds like the family is tired of dealing with her problems. Be assured, hospice is about celebrating the remaining life; it is not about hastening her demise. I cannot imagine her physician going along with that thinking.
ReplyDeleteThe physician makes the ultimate decision about hospice referral. The following link was helpful in understanding how a pcp makes that decision as to the six month window. Ultimately, the cardiologist will also be involved in the pacemaker decision.
ReplyDeletehttp://www.gilbertguide.com/articles/determining-hospice-eligibility-for-dementia/
Thank you for your comment.
It is unethical to pull the pacer. That's akin to pulling the plug when a patient isn't terminal (like if they were on a respirator after surgery temporarily.)
ReplyDeleteValerie,
ReplyDeleteYes I agree that the primary care physician should not be asked to pull the plug. I do know that the elder had a scheduled follow up with the cardiologist. Wonder if the family will discuss with the cardio as well.
Thanks for your comment.
Olga
Cortes,
ReplyDeleteYes, you've hit the nail right on the head. The POA needs counseling /help /mediation with this one. I understand there have been years of suicidal threats which have eroded the relationships among the adult children and this particular senior. The recent agressive behavior against the caregiver was just the last straw.
Great observation!
-Olga
I am here to help if your family needs it. It takes a lot of courage in these moments to do the right thing in spite of our grief. Here is my phone number. 805-807-4474 Please call if you or your loved ones need support.
ReplyDeleteThank you.
ReplyDelete- Olga
I doubt the physicians would go along with the POA's pacemaker removal plan at this point, however I would be very concerned if the Alzheimer's client needed any further medical support or life-saving measures.
ReplyDeleteI would imagine the other family members could challenge the POA on this, and for that matter challenge the current overall suitability of the POA. But I am certainly not an attorney...
Coincidentally, my own blog post titled 'DNR's' last month was the result of experiences with a client at a Boca hospital.
While it may not be helpful for this case, the DNR issues are something to consider for others, going forward:
http://eldercarenotebook.blogspot.com/2009/07/dnrs.html
Very interesting that you should mention another family member challenging the POA. We are usually in touch with a female sibling who has been the acting Health care surrogate for the past 3 years, but is unofficially acting in this capacity. She is always very concerned about the parent's best interest and calls her mother daily. Anticipate I'll be seeing her this week. Thank you for acknowledging this and thank you for your comment.
ReplyDelete- Olga