Okay…here are the facts (anyone else who has an educated opinion can chime in too):
My SIL is in hospice care at home. The nurse has seen her twice in the last two days. She will see her again today and tomorrow.
In addition to cancer, liver failure and respiratory problems, she has cellulitis. This is the second bout this month. This one is much worse than the last one. Her leg is hot, red, swollen, and VERY painful, all the way up to her hip. They attribute it to a cat scratch.
I spoke to the nurse last night because she initially told my SIL that hospice care would cease if she went into the hospital to have the cellulitis treated. I reminded her that this is not the info we received when the intake nurse gave us the initial scoop. She checked with her supervisor and mea culpa’d on that. Hospice care will go uninterrupted should she decide to go into the hospital for more aggressive treatment on the infection.
4)My SIL is an idiot. She doesn’t want to go into the hospital. That said, we’d all hate to see this infection take her out.
Now for my questions:
Under these circumstances, would you want your patient to be on more aggressive treatment (i.e., IV meds) to treat the infection? She’s currently on 500 mg 3x per day (Cephlix?)
If we could get her to go in to have a pik line installed, will a caregiver be able to handle the IV treatment at home or would a nurse have to come in to do that?
Would hospice or Medicare cover that in-home nursing since it is a temporary thing?
I forgot to add that when I looked up this stuff on line before talking to the nurse, the site said that if there are existing systemic issues, the more aggressive treatment might be indicated.
Just a little bump. I want to talk to the nurse and family members who might have a little more influence over her. I think that the nurse is due there before noon today. Thanks.
The only answer I have for this is anecdotal, and therefore may have no place in GQ, but here we go: when a close friend’s father was terminally ill and needed IV antibiotics, my friend administered them, at home. Laws, ordinances, etc. may vary from state to state, of course. But putting pre-measured meds into an IV line (which is essentially what a PICC line is, just a little more permanent) is no big deal. When I had surgery in June, I had an IV port installed; after leaving the hospital, but prior to having the port removed, I was trained to flush it myself, and given pre-filled syrettes with which to do so. It was so easy that, even on heavy pain meds, I had no problem wtih it.
Thank you. That is very useful to me. The cite above said that the treatment can sometimes last months (as it did with my other friend) and it’s good to know that the technique is relatively simple.
Yes definitely if she can handle it.
2)Caregiver is a CNA then she should be able to handle it. I say this with some caution as some CNA’s cannot be certified, and the patient must have at least an LPN look after it. Obviously an RN or LPN could and would do this.
Hopsice may cover it, and Medicare is so convoluted now I cannot answer that…
Does your SIL have an Ombudsman assigned to her? If not you may look into that through Hospice.
I’m not waking Deb to verify this, (her shift is 4:30 p.m. to 7:30 a.m.), but there are issues regarding DNR care and emergency medical procedures. If a patient is on a Do Not Resuscitate order and seeks emergency care for life-threatening situations, the patient is required to sign a waiver to revoke the DNR. (S/he can go back on DNR once the crisis has passed.)
The point is that there is a responsibility of the hospice providers that presumes a terminal condition. If hospice approves the override of a DNR order, then, (and this probably varies by state), the hospice provider assumes responsibility for the the medical condition (and costs) for any efforts that prolong the life of the patient.
That said, I (with only the education one receives from hearing one side of medical conversations carried on over the phone) do not see why cellulite would be considered life threatening or that treatment of cellulite would be considered to require a revocation of DNR.
I am making no judgments or suggestions aside from the obvious one: have a responsible party call hospice and discover what their exact rules are regarding this situation rather than relying on the faulty memory of a patient in pain.
It is not a life-threatening issue at this point. I called the hospice nurse last night and she first denied that they could treat this and then retracted when I reminded her of the conversation we had with the intake nurse. The DNR is in place and at this point there would be no reason to think the infection would kill her, but I do think the IV treatment would be beneficial to her. She has so many other issues; and with the other bout of cellulitis being so recent, it makes me think maybe they didn’t get it completely the first time.
I think the deal is that this is considered treatment for an unrelated issue; not a resuscitation issue. If the infection went wild and was unresponsive to treatment, I think they’d let her go, as per her DNR.
I’m not sure about that. I can tell you that her caregiver is about as non-aggressive as could be. She is a private employee and while she administers meds and takes care of SIL’s personal care, she’s more of a companion than a medical person (in my observation). SIL is stubborn and Caregiver protects her wishes like a mother lion. I just don’t think she would consider arguing an issue against SIL’s wishes. And SIL is a stubborn as an ox. I don’t think I can bring myself to discuss this with her in any detail without getting really pissed.
She says she wants to live every second to the hilt (it’s a bed-ridden hilt, but it’s her hilt). But then when something can make her quality of life better, she acts like a two-year-old. Grrrrrrrrr…
I understand I went through this in 2000 with an aunt. The ombudsman is assigned by the state, and is free. My father is one in his retirement…They can help and what you describe is exactly what they help with. Sorry she’s a grouch. I didn’t deal with a grouch, but I dealt with a wonderful aunts extremely grouchy adult kids, my cousins, when she was dying and that was horrid. I had to remind myself that anger is a natural part of the grieving process…
You mention MRSA. If it truly is MRSA then, by definition, Keflex (cephalexin) will not work. Vancomycin would be necessary.
BTW, in someone with cancer and a swollen leg, I would wonder whether you’re really dealing with a blood clot. If so, that’s unfortunately usually quite a grave sign.
She has bone cancer and her right leg is swollen (due to edema) and black and blue. The infection is in her left leg. It is visibly red and swollen and the slightest touch causes her great pain.
That said, yes, her condition is terrible, but the nurse says she’s doing remarkably well. Go figure.
If it’s community-acquired MRSA cellullitis, it still usually responds to the tetracycline family, trimethoprim/sulfa, and sometimes ciprofloxacin. And Rifampin.
And if it’s hospital-acquired MRSA, oral linezolid will usually knock it out too.
Of course if it’s worse than cellulitis, IV vanco may be needed in any case.
I’ve experience overseeing a hospice and managing hospice patients, and personally, once I sign in as a hospice patient, all I want is pain-killers, anti-nauseants, anti-anxiety meds, and appropriate fluids. Keep those antibiotics out of me, and forget about putting in a PICC line! Just keep slapping on more and more Duragesic patches!
She’s been in hospice since April and with regard to the cancer, she’s doing mass quantities of pain meds. Enough to kill any five people, from what I hear. I don’t see the end happening in weeks, or even months, except if this bug gets her. I believe she probably picked up the MRSA in the hospital or nursing home last winter; that’s when it was diagnosed. I don’t recall anyone ever saying they got it under control.
Do medical professionals get pissed off if I try to start a dialog with them using information gleaned from a conversation like this? I don’t ever want to sound like I know more than they do, but if I ask their opinion of, say, linezolid, are they gonna give me the stink eye?
They might. They’d be wrong, but they still might. So ask away.
Treatment of the MRSA (and other bacterial infections) should be based on its antibiotic sensitivities, and what the clinical scenario is. Too many docs just throw linezolid at every skin infection they see, raising the resistance rate to the drug, and raising the cost of healthcare. A course of linezolid can top $500. Minocycline can often do the very same job on MRSA for about $12.