Dr. Cranquis' Mumbled Gripes
(Disclaimer: Questions related to medical topics will be answered to the best of Dr. Cranquis' (and Google's) knowledge, but the internet-delivered wisdom on this blog CAN NOT AND SHOULD NOT SUBSTITUTE for your Real-Life Doctor's personal attention + examination, and your own common sense too! If you think you're having a medical emergency, hang up and go email 911. The author of this blog takes no responsibility for any medical, relationship, scholastic, financial, or other decisions you may make based on information found in this blog.)
Some of the saddest cases I’ve seen in my career are patients with sudden catastrophic illness or trauma for whom their families are expected to make health-care decisions — and the families don’t know what the unconscious/critically-ill patient would want. Families are torn apart, arguing over whether to continue all life-prolonging interventions, vs focusing on keeping the patient comfortable.
You may think you’re too young and healthy to need an Advance Directive, but massive trauma or overwhelming infection can happen to anyone. Do your family a favor and check out this website, which provides the simplest End of Life Wishes discussion guide I’ve ever seen, and includes links for creating an Advance Directive. Use it, and pass it on!
New York Times op-ed article.
“…As the aging baby boom generation places unprecedented demands on the health care system, there is little ordinary citizens can do — witness the tortuous arguments in the Supreme Court this week over the constitutionality of the Affordable Care Act — to influence either the cost or the quality of the treatment they receive. However, end-of-life planning is one of the few actions within the power of individuals who wish to help themselves and their society. Too few Americans are shouldering this responsibility.
Of course many people want more aggressive treatment than my mother. And advance directives aren’t “death panels”; they can also be used to ensure the deployment of every tool of modern medicine. They can be changed or withdrawn at any time by a mentally competent person.
But public opinion polls consistently show that most Americans, like my mother, worry about too much rather than too little medical intervention. In a Pew Research Center poll released in 2006, only 22 percent said a doctor should always try to save a patient’s life, while 70 percent believed that patients should sometimes be allowed to die. More than half said they would tell their doctor to end treatment if they were in great pain with no hope of improvement.
Yet only 69 percent had discussed end-of-life care with a spouse; just 17 percent, or 40 percent of those over 65, had done so with their children. One-third of Americans had a living will and even fewer have taken the more legally enforceable measure of appointing a health care proxy to act on their behalf if they cannot act for themselves.
The latter omission is especially disturbing because by 2030, more than 8.5 million Americans will be over 85 — an age at which roughly half will suffer from Alzheimer’s disease or some other form of irreversible dementia. For many members of the baby boom generation — more likely to be divorced and childless than their parents — there may be no legal next of kin.
Without advance directives, even a loving child may be ignorant of her parent’s wishes. My mother remained conscious and in charge of her care until just a few days before she died, but like most women over 85, she was a widow. My younger brother died of pancreatic cancer two weeks before she did. It was an immense comfort to me, at a terrible time, to have no doubts about what she wanted.
My mother drew up her directives in the 1980s, when she was a volunteer in the critical care lounge of her local hospital. She once watched, appalled, as an adult daughter threw a coffeepot at her brother for suggesting that their comatose mother’s respirator be turned off. Because the siblings could not agree and the patient had no living will, she was kept hooked up to machines for another two weeks at a cost (then) of nearly $80,000 to Medicare and $20,000 to her family — even though her doctors agreed there was no hope…”
…The amount of caffeine [the girl] drank in the two Monster energy drinks is about the same as that found in 14 cans of Coca Cola — and is almost five times the recommended caffeine limit from the American Academy of Pediatrics.
Apparently, if you happen to have Mitral Valve Prolapse (a usually-harmless condition, found in approximately 10% of the population), as this unlucky teenager did, it may only take 2 cans of Monster (consumed within 24 hour period) to kill you — as opposed to the “normal” prediction of 55+ cans, according to the Death by Caffeine calculator.
There is nothing healthy about energy drinks. Please people, just don’t drink ‘em.
Three years ago today, I personally had an experience with the final days of a man. I can still remember feeling watching this once proud and grown man grow weak and frail as his cancer progressed. I remember this man being healthy only months before lying in a bed, eyes closed and lips pursed, wrestling internally with the rebellious cells of his body and the toxic therapy coursing through his veins. I remember refusing to give into the truth that lay before me.
That this was my father.
A powerful and personal experience with the dying-and-death of a family member, as told by one of the best med-school bloggers around.
1. When a person dies, hearing is the last sense to go — the first is usually sight, followed by taste, smell and touch
2. A human head remains conscious for about 15 to 20 seconds after it has been decapitated
3. 100 people choke to death on pens each year. One…
Number 7 — WOW, never thought about that.
A 23 year old Taiwanese gamer, Chen Rong-yu, died while playing an extended run in the game League of Legends at a local Taiwanese gaming center in New Taipei. Thirty gamers surrounding him did not notice he was dead until 9 hours later. His body was positioned upright with his hands motionless on his keyboard.
This is a starking reminder than staying still for any low-acuity activity (not just limited to gaming) can yield negative results. When gaming or reading or watching TV, make sure you get up and stretch for a few minutes at a minimum to avoid chances of blood clots building up.
Rong-yu’s condition is likely related to a underlying heart condition, but the health advice is being spread throughout in case unknown underlying conditions cause more widespread deaths. His exact cause of death is unknown, but police suspect it was cold weather, low temperature, remaining stationary, and perhaps an underlying heart condition leading to cardiac arrest. I think a better idea would be to keep a better eye on your fellow gamer and make sure he/she is okay. Take a break, guys.
The body relaxes its sphincters upon death. So basically, this Taiwanese gamer sat motionless AND EMANATING THE SMELL OF A DIRTY DIAPER for 9 hours, and nobody thought this was strange.
Note to self: Never sit in any of the chairs in a public video-gaming center.
Today I thanked a dead man for dying. He had suffered a catastrophic stroke, and he was young – that is to say, he was young by medical standards. When you think of a typical stroke victim, the image of a 55-year old does not immediately come to mind. His wife did not want to accept the…
Powerful summary of a med-student’s actions and thoughts while confirming the “brain death” of a comatose patient. Good stuff. (I wish this blog was posting more frequently; the archives have some great posts, though!)
All credit for this motto goes to drshutterbug.
I just may need to get this image tattooed on my xiphoid process. XD
Powerful article, with insight on how many doctors refuse to receive the very life-prolonging (but NOT life-improving) interventions which they feel “pushed” to provide for many terminal/critically-ill patients.
Personally, I’m “No Code”, and ever since med-school ICU rotations, I’ve often spoken with my medical colleagues about my mental list of conditions for which “If I had X diagnosis or X medical situation, just let me die.” Who has two thumbs and isn’t going to die riding a ventilator? THIS DOC.
Furthermore, I strongly believe that we (Americans and the US healthcare system) do not utilize Hospice Care soon enough/often enough for terminally ill people. The average American terminally-ill patient is enrolled in hospice less than 48 hours before he/she dies… yet doctors can certify a patient to receive hospice services if the doctor just thinks that it would be “reasonable to expect that this patient could pass away from a medical condition within the next 6 months.” And as this article states, many hospice patients have longer QUANTITY of Life, along with infinitely-greater Quality of Life, while on hospice.
/rant
Thanks for the heads-up on this article, doctom666!
During my first and second years of med school, some rough stuff went down.
At the end of Heme phase, my uncle died from complications of metastatic prostate cancer. I missed my clinical skills lesson on “breaking bad news” to go home for his funeral.
Next, during the neuro phase, my former boss for 4 years (who was also my mom’s best friend and a close family friend) attempted suicide twice—by pills and wrist slitting—before finally shooting herself in the head. A few weeks later - 2 days before my neuro test - my mom passed out at church, which led to a stent in rehab to get her off her cocktail of Soma, Oxycontin, Xanax, and Vicodin. And when she got out of rehab (she’s been off the meds for about 2 1/2 years now), she lost her job.
In the next phase (musculoskeletal), my great-grandmother died from what was probably extended post-anesthesia delirium after a hip fracture. Not many people get to grow up with a great-grandparent, but she and I were close and I went to see her and my grandparents almost daily when I was in high school. Her funeral was just a few days before my test for that phase.
And the day after the phase ended, I went by myself to do mission work in Northern India for 6 weeks. I came back extremely jet lagged the day before the start of brain and behavior phase.
Two days before the brain and behavior test, my father (who lives about a 7 hour drive away from me) showed up at my door wanting to “hang out”. I hadn’t seen or talked to him in about 6 years.
Why did these things keep happening right around test time? Your guess is as good as mine. But it got to the point where every phase, about a week before the test, I got very anxious. Not about the test, mind you, but from anticipating what else was about to go wrong. A mind racing with worried thoughts makes studying very difficult, believe me.
A powerful post about the trials faced by a med student. I love the “lesson learned” — counseling is not a sign of weakness or failure.
I am vindicated! XD
I’ve been meaning to write this for some time and now that I’m stuck in town with a blown out tire and unable to drive to work until it’s fixed, I figured now is the best time to write it out.
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I’ve received a number of messages over my time with this blog asking about forensic pathology and…
A volunteer in a Medical Examiner’s office gives some sobering insights into the politics that result in many autopsies NOT being performed by trained forensic pathologists. Important stuff to know, if you’re a med student thinking about specializing in Forensic Pathology!
Hola Dr. Cranquis! I am a neophyte nurse and I just started to work in a geriatric facility. And with that I would like to ask if what are the usual signs that a patient is about to die? Like an hour or two before a peaceful death? I’ve never experienced handling one before, so I’d like to know what signs (vital signs, o2 sat and all) to look for in case I have one so that I can call the family who would want to be there when the time comes. Thank you so much and wishing you all the best!
Ooh, excellent and thoughtful question, Neophyte Nurse! I applaud you for being so “whole-person” oriented, and considering the needs of terminal patients’ families to “be there” when the end comes.
There are many signs that a patient is approaching death or actively dying, but NOT every patient will show all the same signs or follow the same “dying timeline”. This is probably the most crucial thing to emphasize to family members, so that they don’t (1) become too worked up everytime that one possible sign develops, or (2) get taken by surprise when their family member passes away after actively showing signs of dying in the preceding days/hours. Not enough healthcare providers actively communicate about the dying process with family members ahead of time.
This thorough list from the Hospice Patients Alliance reviews the signs and symptoms of patients in “pre-active” and “active” dying phases. You’ll notice that very few of those signs involve the classic “vital signs” of blood pressure etc. As you (and any healthcare worker who experiences death regularly) will discover, you develop a “Spider-Sense” about impending death which looks at the Big Picture and the Overall Trend. That Sense isn’t infallible, but it’s valuable.
Of all those signs, the main ones that I would point out to family members (ahead of time, preferably) would be:
- progressive lack of responding to external stimulus
- movements and facial expressions which serve no purpose (and which are usually not attempts to communicate or express pain in the active stage of dying, assuming that the patient’s pain is being well-controlled.)
- Noisy, slack-jawed breathing and rattling in the chest
- the LACK of a Hollywood-style sudden period of acute awareness and lucidity just before dying (“The treasure is buried in the old…UHHhhhhhhh……”) — This is vital information, so that family members don’t feel (so) bad about not “being there at the moment of death.”
If you haven’t encountered the world of Palliative Care/Medicine yet, you should check it out. There is a tremendous need for actively-interested and knowledgeable healthcare providers in this field that specializes in relieving symptoms of terminal illness and providing support to the patients’ families as well. I wish you all the best in your new job, and I know that your patients and their families will benefit tremendously from your thoughtfulness and compassion. :)
***Pending Cranquis-Mails: 4; InBox: Closed***
Hey, thank you, and good luck with your Medical Journey! :)
Your description of grandma’s mental-status changes (self-discontinuing medications, paranoia, anxiety, along with worsening memory) could be manifestations of either delirium or dementia (or both! Tough to say in conditions like your grandmother’s). Parkinson’s Disease can cause dementia, and pretty much anything that happens in the life of a sick elderly person can cause delirium. So it COULD be one of her Parkinson’s manifestations, but I surely hope that her doctor has experience with ruling-out delirium (checking for infections, electrolyte imbalances, hearing disorders, etc) before just chalking all those things up to Le Parkinson’s.
So yeah, aging relatives — even if they don’t have a number of debilitating and tough-to-control conditions (as your poor grandmother does), your elderly family members will always have certain crucial healthcare-related issues that need to be addressed at some point — and way too many elderly people do not plan these things ahead of time (yet another example of how lousy the American health-care system is at preventive healthcare — Heck, when we doctors finally get a semblance of “popular” support for designing a proper system of preparing our aging patients for their eventual Death and Dying, then it gets all politicized and suddenly the IDIOTIC AND IGNORANT “death panels” term gets invented…. but I digress.)
Where was I? Oh yes, Things to Prepare for when you have an Aging Relative with (or without) chronic debilitating diseases — here’s some questions that will prompt the necessary preparations:
- Where does she want to die? Intubated in an ICU, being kept alive by machines for weeks past her due date, unconscious or delirious, sustained by IV drips or feeding tubes, marinated in antibiotics for pneumonia or urinary-tract infection? Or: at home, receiving (always excellent) care from a hospice nurse/team, surrounded by family and friends in a familiar surrounding which will help to minimize delirium, quietly sliding closer to her eventual Sleep?
- Who is her legal decision-maker, and does that person (and the rest of her family) know how/where she wants to die? Too many people (young and old) assume that “My family will just know what I would have wanted/chosen in the myriad of decisions which surround a hospitalization, intubation, resuscitation, surgical intervention, nursing-home placement, etc etc”. Then when the patient is unable to communicate their desires, their Legal Power of Attorney for Health Care (POAHC) suddenly realizes that maybe, just maybe, there should’ve been some discussion about all this beforehand. And even if the POAHC knows what the patient would’ve wanted, the other family members disagree, and the POAHC caves in to the family “in order to keep the peace.” Having a written-and-discussed “Advance Directive” can make a huge difference with this situation.
- What are her goals for living? What does she consider “being alive”? Knowing these definitions will make a LOT of the future decisions easier for everyone involved.
- Is she currently safe? This raises the topic of elder abuse (a largely-ignored aspect of “being old” that causes much suffering physically and financially and emotionally, among our elderly population — Oh hey, it’s Elder Abuse Awareness Day next week, June 15 2011!), and also the topic of getting an in-home safety evaluation (since your grandma already has nursing support, they either have done or can do this for her, but you can check a lot of potential-hazards yourself) to help prevent in-home accidents which are a HUGE cause of injury/death among the elderly.
- When can/will hospice care be utilized? In the US, insurance coverage of home hospice care usually kicks in when the patient’s physician states that “It would be reasonable to expect the patient to pass away within 6 months or less” — but sadly, average “days survived after enrolling in hospice” was 18.3 days in 2007. Does this mean that hospice is killing-off patients? NO. Families and doctors all-too-often consider hospice enrollment as a “death sentence” or a “sign that we’re giving up on the patient” or “something that we may need later, but not right now”, and so they delay and delay until the patient is almost dead, and then rush them into hospice for their last few days — yet family members of patients who have died while enrolled in hospice consistently express more satisfaction than families of patients who were not in hospice care. Hospice is so much more than just “a nurse who knows what to do when your grandmother dies in the house.”
That’s what comes to mind, for now. Hope that helps.
***Pending Cranquis-Mails: 1: Ask Box: Closed***
Oh man, Coil Shuffler, I think that would be one of the neatest days of my life (assuming that I’m just gonna die of natural causes or something — less cool if I’m awaiting execution)! There’s just something about having a looming deadline (oooh, bad pun) to help you see everything as it “really is”, to make you brutally prioritize what is important and what is not. Suddenly, 90% of the stresses that daily weigh upon me would just become irrelevant, and I could focus all of my mind, energy, and love on the things that truly matter.
Now here’s how I’d spend my last day on Earth:
- Post an invitation on Facebook for any and all of my friends to come over to my house for a bonfire party that evening.
- Call work, notify them I won’t be coming in — ever.
- Empty out my savings account to hire a caterer and an event planner to arrange the party, so that I don’t have to worry about the details.
- Make breakfast in bed for my family.
- Double-check that all my finances, will, and life insurance are in order.
- Take a nap with Baby Cranquis asleep on my chest.
- Snatch up Mrs. Cranquis and Baby Cranquis and the Cranq-dog and meet up with my immediate family for a forest hike and picnic.
- Back home, spend a couple hours writing small messages to the close friends and family who won’t be able to attend the party, while listening to my favorite music.
- Party-time: 3-4 hours of outdoor games, food, music, a projector screen with pictures of my favorite memories, and lots of laughter and tears while reminiscing with old friends — plenty of time for unhurried goodbyes.
- At dusk, the bonfire is lit, and my musically-oriented friends and I whip out our various instruments and have a jam-session praise concert for everyone else.
- Slip away from the party with Mrs. Cranquis to spend the last couple hours alone in our bedroom, talking or not talking as needed.
- At midnight, my last Tumblr post auto-publishes, containing my true identity and reminding all my readers to focus on what is truly important in life: Family, Friends, God, and Living a Whole-Healthy Life.
- Go gentle into that good night.
***Pending Cranquis-Mails: 24; Ask Box: Closed***
