Doctors: End of Life Question

My ex-MIL is in her final days. She is at home and the nurse is coming to evaluate and place her into hospice care. My ex-SIL (also my best friend) wants to get her on an IV. I can’t remember, but as I recall, that is not part of hospice care, is it?

She is 93 years old and is dying of old age. She has a blood clot and kidney stones, and dementia. No cancer or anything that would require morphine, as far as I know. In my mind, an IV would just prolong the inevitable. Am I off track here? I want to help my friend with her mom’s passing…but I think requesting an IV is probably not the right route to go for her.

Anyone?

IANAD, but I don’t think giving her an IV is going to prolong much, it will just keep her hydrated and more comfortable.

Kidney stones are painful and they may want to give her some pain relief from them.

Well, I’m pretty sure she’s not in any pain. She’s completely non-responsive. Not taking food or water. Her eyes are unfocused and glazed.

My BILs are calling 911 and having her transported to a hospital. I think this is nuts! She’s dying. Will the hospital even accept her? There is a lot of internal drama here with wills, powers of attorney, mental illness and power trips. The thought of this woman being carted all over town is just mind-boggling.

When she was released by the nursing home yesterday, the crazy BIL refused to accept her at home because the ambulance driver didn’t have the required transport papers for insurance filled out. Screaming match ensued and the ambulance driver called the sheriff for an escort for MIL into her own home!

So tell her you know she is facing a difficult time and you want to lend her whatever emotional and practical support you can. Volunteer to run errands so she has more time to focus on her relative; take her to coffee or invite her to dinner, etc. etc.

Oh, and perhaps not involving yourself in their highly-charged family disagreements about standards of end-of-life care.

When my own MIL was dying, we talked to the people at Hospice and the first thing they told us was that most people wait about six months too long to talk to them. Hospice only works with terminal patients. The problem is that most people wait until terminal is a week away rather than a few months away. They’re not just about helping the dying - they’re also there as a support resource for the family in preparing for what happens when death really does become imminent. In the case of my MIL, she had only about three weeks before she died, but in those three week, we actually had Hospice people coming to just talk with her because that was the one thing she always complained about.

Hospice will also have answers to questions like whether moving to a hospital is good or even possible and whether or not an IV is a good solution.

I agree. However, the brothers called 911 and are rushing her to a hospital without the input from the visiting nurse or hospice. The doctor said she was in pretty good shape (albeit bedridden) in recent months. The infection from the kidney stones and the blood clot are new developments. She was in the nursing home for the last month, but they never indicated she was rapidly declining. In fact, they were planning additional procedures on her for treatment of the stones.

The patient is my son’s grandmother so we are family.

What do her doctors say? Just because she can’t respond doesn’t mean she can’t feel the pain and suffer silently. Dying of thirst and hunger is not a painless way to go.

But if the docs say she cannot feel these things, then please ignore the above remarks.

The doctor said to take her home. That’s all he said. Before the hospice and visiting nurse could arrive for the evaluation, the brothers freaked out and called 911. So we’re waiting to hear what they have to say.

I asked my SIL and when my father in law died at home he was not on an IV. They use little sponges to keep the lips moist during the final days. If you can’t drink, you can’t drink. It’s normal for people who are dying to stop eating for quite some time before they die. It’s not dying of hunger and thirst. It’s simply dying.

Kalhoun…
No time right now for a long answer.
I am really sorry.
Your instincts are correct.
More later if I have time.

Obviously this isn’t specific advice; it’s just a general agreement with your question about what value there is for an IV in such a situation. Hope to be able to get back to this later. Prob too late for you, I realize.

Thanks, Chief. I am guessing she has days; not hours, so your opinion and advice may indeed be helpful.

When my mother was dying, she became totally unresponsive during the last 12 hours, after being brought back from cardiac arrest (after having been totally alert prior to the event). Though she was unresponsive, the doctors had no idea whether or not she was conscious or could feel discomfort or pain. She was on six different IVs, including painkillers.

When my father was dying, with dementia and other things, the doctor said that his body may be sending pain signals to his brain, but the brain probably couldn’t actually interpret them as pain.

Whether or not an IV is a good thing depends highly on the individual situation. IV fluids and hydration can make some people who are dying more miserable if their systems are shutting down and they can’t clear the fluid. (pulmonary edema, kidney failure, heart failure…none of these are comfortable or painless; drowning internally in excess fluid is a pretty miserable way to go.)

It may be useful to have an IV access to give pain or other comfort medication. This doesn’t necessarily mean that fluids will be hanging all the time. Sometimes an IV will hang at a very minimal rate (around 40 cc/hr) to provide an open line or to make family or the patient feel a bit better psychologically - that ‘something is being done’.

Every patient is different…communication with the doctor and hospice nurses about what is best for your family member is key. They’ll have some ideas for you about how best to keep her comfortable and what she needs for that.

My best to you and your family.

The whole idea of hospice care is comfort for the dying. It is not prolongation of life. Start all decisions there. An IV provides medication access and hydration. It is not usually painful or even uncomfortable to dehydrate when you compare that route of exit with the drawbacks of the IV itself; moreover an IV starts you back down a road you left when you elected for hospice care over life-prolonging events.

Philosophically, there’s a time to die. A time to let go. We are particularly bad at this in modern medicine, and families are particularly bad at making the decision as well. No one wants to cross the line to be the one who actually made a decision to let someone go because the responsibility of doing so is too close to “She died because I didn’t want to do anything else” (as opposed to "She died of natural causes).

It is very, very hard to actually allow someone you love to die. There are times when it is nevertheless the right thing to do. Most of the time people accepted into hospice care have already passed that decision point, and an IV without a very specific reason (and hydration is not one of them) is not helpful.

Best.

Thanks, Chief. It looks like she made it through the night. Her BP was very low yesterday, but now it’s up so she’s on morphine FOR THE BROKEN LEG SHE RECEIVED AT THE NURSING HOME (that they kept telling my friend was a blood clot that deformed the shape of her leg):eek::eek:. Evidently they thought it was a good idea to give her a shower. We suspect they dropped her. When she was still lucid, she told my friend that they broke her leg, but the doctors/nurses kept insisting it was a blood clot and she was a senile old lady. She was finally x-rayed at the hospital where it was discovered what the true issue is.

Needless to say, “pissed off” and “lawsuit” are words that keep coming up in conversation.

Absolutely lawsuit. I know it’s likely she’s in her last days, but that’s inexcusable. I understand that accidents happen, but the cover up is horrible…delaying care for an injury because they don’t want to admit wrongdoing? That’s criminal.

Dude, I hear ya. It went untreated for like two weeks! I’m a little miffed with my friend that she wasn’t more aggressive when she noticed the deformation, but I think the stress of the whole thing weighed on her ability to approach the issue correctly. She said they did a doppler on her. This is just freaking me out. This is the nursing home my mom died in (hospice care; not nursing care) and I talked it up to everyone. It has since changed hands and obviously nursing care and hospice care are not the same thing.

…and another thing. This woman has been bedridden for 3 years. The also had the indignity of having three or four male attendants giving her a shower! She should have had a bird bath and nothing more.

This totally makes very much sense. Hadn’t thought of any of it. Thanks for fighting this one’s ignorance.

This, very much.

It is, in my experience, much harder to stop doctors once they are started. It tends to be all, or nothing, and doing even one thing means they will do everything else. You start an IV to hydrate, and then they have a route to start pumping in antibiotics for pneumonia, and so on, and so on.

That is one of the advantages of hospice over hospital - hospitals are full of people who think in terms of prolonging life above all else, and they can always think of something to do to get her “over this crisis”. And the next, and the next.

If you get a DNR, make sure that everybody, on all shifts, knows that it is there. If she has a living will, make sure it is in her chart. If you and the rest of the family come to consensus on what to do, make sure it is documented in her chart.

There was a major brouhaha at the hospital system at which I worked some years back, where the physicians resisted a sticker on the outside of the chart saying that there was a living will on file. They didn’t want to know.

Don’t know if it is still that way. My condolences to you and your family.

Regards,
Shodan