Thursday, July 13, 2006

Leaving things be

Mrs. D came in yesterday for her four month checkup. She just saw her vascular surgeon within the last month and had some questions....

She was the full-time caregiver for her husband until his Alzheimer's disease got to much for her. She was 88 years old when she thought she "gave up" and moved her husband into the nursing home. "I don't think you gave up," I said to her back then. "You're not exactly a spring chicken anymore and he's more than twice your weight. I have no idea how you've been able to take care of him at home by yourself for such a long time."

The other reason she had to place him in a nursing home was that she required surgery to repair an abdominal aortic aneurysm. In addition to recuperating from the surgery, one important restriction she had was absolutely no heavy lifting -- like of her husband when he would fall on the floor at home.

Her husband died peacefully a few months later. A couple of Mrs. D's children moved back to the area to help sell the house and take care of the legal affairs. They all live in the same house here now.

Oh yeah, did I mention that this was the only surgery that she ever had and currently is on no prescription medicines. It's not because she refuses to take medicines, it's because she's THAT healthy and is still very independent.

...."My doctor told me I need an MRA. What's that?" Mrs. D's doctor initially ordered a carotid ultrasound to check for blockages. The findings were questionable, so an MRA was recommended to get more information. I explained what an MRA was and if there was significant blockages, then surgery could be done to repair it.

"Do you really think I need an MRA? I really don't want anymore surgery. If I was your grandmother, what would you say?" This is probably one of my least favorite questions in all of medicine. Usually, I put my lawyer hat on and give a laundry list of potential problems if a critical stenosis is not diagnosed or treated.

"If you were my grandmother, I'd say that you've been getting along for almost your entire life without the need for medications and doctors. Whatever you decide is probably as good or better than anything I would say. I mean, hey, you're healthier than I am. I should be taking health tips from you."

"Well, I think I'll leave things be. You don't think that nice young man," she meant her vascular surgeon, "would be mad at me if I cancelled the MRA." "No, not at all. I think that he'll understand." "Well, then it's settled." "I think it is."

17 comments:

Pattie said...

88 years old and no medicines or surgery? Yeah, I would say she has definately gotten along just fine1 I am glad you gave her such common sense advice.

Wrkinprogress said...

Good for you, Doc. Sometimes medicine is really not the right answer. Kudos for knowing when to just let things be. :)

Cathy said...

She is a tough ole bird being 88 and no meds. I'm also happy you told her what you did.

Hoping4more said...

that is WAY cool. I love that whole interaction. :) You rock, doc!

Hoping4more said...

I like that diagnostic exam, but if her conclusion would be no surgery to correct anything regardless, then of course it would be pointless anyway! You explained all that to her, and she made her decision. I think a really good one for her!

NeoNurseChic said...

I find it commendable when a physician is honest and doesn't just push surgery. My mom and I were thoroughly impressed by the neurosurgeon she took me to see who talked to us for a half hour and went through all the points, but ultimately didn't think the surgery would help me. The best part was that it was going to be for an occipital nerve stimulator implant (ONSI) and he told me that I didn't have any place where we could put the battery pack because I was too thin. Made me feel good! LOL (well...at least I laughed) I was really disappointed that it wouldn't help me because I was hanging by a thread at that point and was hardly functioning at all, but I appreciated his honesty - I would not have wanted to go through all of that for nothing. He thought a stimulator working through the supraorbital notch would have better results for me but didn't want to cut into my face. He feels that I will probably be a good candidate for deep brain stimulation of the hypothalamus but they aren't ready to do that for my condition yet...and I pointed out that people in a Belgian study died from it!

His last words of advice were to never have a surgery or procedure done that would have permanent side effects without guaranteed benefit at this point. He said that even though it may seem vain, cutting through the trigeminal nerve (for trigeminal rhizotomy) could leave half my face paralyzed, which I wouldn't want at this point in my life... He's right - it's hard to keep that in perspective when the pain is so great that you'd do anything to get rid of it...I'd eat dirt if someone told me it would help. But I appreciated his honesty and his avoidance of pushing me into surgery just because he loved to cut. :)

Hope your patient continues to live a full and healthy life. And as a side note, what is it with Alzheimer's and making you fall on the floor? My grandma has had a LOT of falls in the last year and was just diagnosed a couple of weeks ago with early Alzheimers... Is there a connection? :-/

Take care,
Carrie :)

Dreaming again said...

Carrie, interesting question! We are having my mom evaluated for Alz ... and she falls, a lot. Sometimes it's like she forgets she's standing or walking and just winds up on the floor.

:*(

Lea said...

I wish more doctors were like you Dr. A! Ethics are a wonderful thing.

Dr. A said...

Carrie (and everyone else), I used to be on the board of our local Alz Assoc chapter (until my schedule got too hectic).

I don't want to make things too simplistic, but this is what I tell people and patients. The brain has hundreds of millions of neurons. And, for lack of a better term, they are "hard wired" to one another so that they work together and we can do complex things -- like walk and chew gum at the same time.

The cause of Alz dz is a "plaque" or a protein that destroys the "hard wire" between the neurons so that they do not communicate. People joke about forgetting and confusion being the first symptoms. But, unfortunately, it's MAJOR forgetting, like not remembering giving your credit card number to a telemarketer -- Or, MAJOR confusion, like wearing a sweater in the middle of summer -- this type of behavior raises a red flag -- but unfortuately MAJOR damage has already taken place.

The most progressive symptoms are because those communication pathways are completely gone and even neuron death takes place. These are exhibited with not even remembering the name of your spouse or children and loss of bodily functions like bowel or bladder control.

So, I know this sounds like a commercial, but the Alz Association (alz.org) is a great group not only for patients but also for families. Services they offer include support groups and insights into the newest medical research into Alz Dz. Hope this helps....

Artemis said...

If Mrs. D were my patient and asked the "if I were your grandmother, what would you say" question, my response would probably be along the lines of: "I would thank my lucky stars for being part of such a fabulous gene pool!" Then, I would (hopefully) follow up with advice similar to what you gave. Nice job on the explanation regarding Alzheimer's Disease, too.
A.

Cathy said...

Dr. A. ALz.org is a great organization. Unfortunately for me, I was so involved with my mom's care that I wouldn't seek help or advise from any place. You get to the point where you believe noone else could possibly understand what this is like and then you refuse to listen even when people try to help you.

Someone gave me the book titled "The 36 Hour Day." That was what snapped me out of it. I realized that there were many people going through what I was. I then joined our local Alz. organization. My mom has been gone for 4 years and I still go to meetings and help with fundraiser's.

Their donation page is on my sidebar. I hope people click on that link occasionally.

Moof said...

My mom passed away 9 years ago ... Alzheimers. I personally believe that conditions like Alz and Cadasil are the most horrendous things to experience at the end of your life.

It steals someone away from you by inches.

Your little 88 year old lady is amazing - especially is cared for husband up until then! I'm impressed!

Got to be some Scottish ancestry in there someplace! ;o)

may said...

i agree with you, she sounds healthier than me, and i'm not even 40!

by the way, can i host the next BA meeting?

Cathy said...

May, personally I think it would be great for you to host the next BA meeting. Someone just let me know when and where....I'll be there!

wolfbaby said...

sounds like your a doc with aheart ... like i didn't already know;)

wow thats alot of info.. wish you had been posting when i had my last class lol

jumpinginpuddles said...

Shes happy and that makes her health, ewven if something happens well done for making that choice

Dr. A said...

May, sure you can host the next BA meeting. What I told Carrie was just to put "BA" in the title, so that people know where the meeting is. That seemed to work out ok. Oh yeah, just let me know what I can bring - I usually bring the Diet Coke, but I can bring whatever. Don't be surprised if these freeloading freaks *LOL* stay over for a couple of days or so....