Even a year before she died, Tasha was biding her time. Three dialysis treatments a week kept death at bay, while imaginary thinking fostered hope that she would someday walk again. Tasha struggled to accept Nursing Home life and the daily ordeal of Hoyer lifts and wheelchair transfers as the devil’s bargain.
During our daily phone conversations, she vented about the slow response to her call bell and the long wait to receive help from her aides. She had bedsores from not being moved enough, and a rash from sitting in wet and soiled briefs.
The room and board were basic, and any hard earned peace was often interrupted by calls for help from nearby rooms. Unfortunately, none of this is unusual at the humble level of Medicare-funded Skilled Nursing. There are well over a million Americans currently living under similar conditions.
Too many people die in a place that is not of their choosing. One reason: a stubborn unwillingness to think about death, talk about it, or plan accordingly. Most people who find themselves in skilled nursing facilities swore they would never end up there.
Preventing Traumatic Falls… Down Steps, Off Curbs, Over Pets, and Just Going to the Bathroom
Most frail seniors fear falling above all else, and for good reason. Across the United States, every nineteen minutes an aging adult dies from a fall, often from a traumatic brain bleed and a protracted stay in the ICU. Every eleven seconds, an aging adult is treated in an emergency department for a fall.
As with Tasha, one misstep can drastically change an elderly person’s life. Most seniors never regain the level of mobility, function, and confidence they enjoyed prior to a serious fall. In an extensive study, only one in five seniors were able to live independently after being hospitalized from a fall.
Many seniors, often due to vanity, are reluctant to use canes and walkers, even though these devices can play a vital role in staying safe. A little-known fact: Bifocals and progressive lens can distort people’s vision and depth perception while they are looking down and walking, which can lead to a tumble.
Accidents will happen, yet a few simple precautions may prevent an untimely fall and a world of trouble. “Fall-proof” the home. For the elderly, particularly when using a walker, a simple throw rug can become deadly. Firmly secure rugs to the floor or clear them out of the way. It’s best to keep rooms free of clutter and electrical cords. Keep stairways well-lit and have sturdy handrails on both sides.
In the bathroom, install grab bars beside the tub, shower, and toilet. Take a few minutes to reorganize kitchen and bedroom shelves to minimize the need to bend over or reach up to retrieve commonly used items. If dizziness or poor balance is a recurring problem, consider asking your doctor to review your medicines with an eye for adverse side effects.
Slow down… Realize that EVERY step counts, and that it takes only one misstep to ruin a good life. If there are simple upgrades that can make your living space safer, ask for help in accomplishing them. As for the great outdoors, potential pitfalls may be no farther than a walk to the car or the mailbox.
Tasha owes her later life to a team of first responders. A quick arrival, electric paddles, and cardiopulmonary resuscitation (CPR) brought Tasha back to life and gave her an additional twenty-one years to live. When our national 911 system began in 1968, the only emergency medical technicians (EMTs) who made house calls were firemen or the hospital ambulance team.
If a person was unfortunate enough to have a heart attack or stroke at home, it was usually catastrophic. Today there are nearly 300,000 EMTs and an additional 100,000 paramedics registered across the United States. This legion of first responders has not only changed the delivery of healthcare but also increased our life expectancy.
An estimated 240 million calls are made to 911 in the United States each year. In many areas, eighty percent or more are from wireless devices. Today’s standard response time for ninety percent of all life-threatening incidents is five minutes.This helps explain why today relatively few people still die of heart attacks.
When the EMTs arrive on the scene, they are legally and honor-bound to attempt resuscitation and provide life support. The notable exception: when there is a “POLST” document or an “out-of-hospital DNR” prominently displayed or immediately available. For lack of this, many terminally ill patients end up in the emergency department on life support, even though they had an advance directive instructing otherwise.
Physician’s Orders for Life Sustaining Treatment (POLST)
If your advance directive is sitting in a drawer at home, as thorough and well-crafted as it may be, it WILL NOT be effective in an urgent situation. Many clinicians view the Physician’s Orders for Life Sustaining Treatment form (POLST) as an essential and more useful tool to minimize undue suffering. Note well: a hard copy is intended to travel with us from one care setting to the next, in addition to being scanned into our medical record.
Ask your primary care doctor or attending physician at the hospital if completing a POLST form would be appropriate. To emergency responders and hospital clinicians, it’s the most recognizable, efficient, and effective way to communicate one’s treatment preferences. It’s standard practice to print it on bright pink paper.
First responders are bound by law to resuscitate unless a POLST or DNR form is in clear sight. Best practice: Tape a bright copy to your refrigerator or bedroom wall.
Cardio-Pulmonary Resuscitation (CPR)
CPR doesn’t work as well as Hollywood would have us believe. It works best if you’re healthy with no underlying illness, and best if it can be given within minutes of when your heart or breathing stops. CPR does not work well if you’re older and weak, if you have chronic health problems, or if you have an illness that can no longer be treated. In this case, there is a two to three percent chance that CPR will restart your heart and lungs and that you will leave the facility alive.
CPR includes giving quick chest compressions, strong enough to break ribs, for as long as needed until a pulse has been re-established, or until the patient is declared dead. In a hospital setting, CPR can be administered on and off for up to an hour. The resuscitation efforts can also include mechanical assistance with breathing, as well as electrical shocks and medications, called “pressors,” all to restart the heart and lungs.
The time to decide if you want CPR is when you’re well and have the facts you need to make an informed decision. Ask questions and talk to your doctor(s) and loved ones. If you want CPR, it would be good to understand what results you could expect given your age and condition. What would your goals be? What quality of life would be acceptable? Or unacceptable? If you don’t want CPR, you need to tell your doctor and your family and have it documented.
Tasha was one of approximately 700,000 patients in the U.S. being kept alive at any given time by hemodialysis. This four-hour treatment, often provided three times a week, removes toxins from the body when the kidneys are no longer able. Many patients have been receiving the treatments for years. For most, if they were to stop, death would come quickly, usually in a couple of weeks.
Many patients have a love/ hate relationship with their complete dependence on this technology. In a large survey of patients receiving dialysis to support chronic kidney disease, sixty-one percent reported that they regretted initiating dialysis, and fifty-two percent reported that they chose dialysis because a physician told them it was the only way to stay alive.3
There are rich and controversial incentives for the medical community to initiate and perpetuate dialysis treatments. It’s a HUGE business. Two companies, DaVita and Fresenius, control roughly eighty per- cent of the U.S. market, valued at $24.7 billion annually. For reference, there are more dialysis centers in the United States than there are Burger King Restaurants.
The Antidote: Talking More Openly with Our Doctors and Loved Ones
Despite our uniqueness, our health trajectories fit familiar patterns. Tasha’s end-stage renal disease combined with a broken hip in her mid-eighties led to a predictable end. If you’re living with chronic or life-threatening illness, such as chronic obstructive pulmonary disease (COPD) or heart disease, are you aware of how your illness normally progresses? If not, what hard questions could you bring to your doctor(s) to learn more and then to plan accordingly? For example: “Doctor, please be honest with me. What’s my best-case scenario in the year ahead? And what’s the worst?”
A series of direct, honest conversations can make all the difference.
A Medical Advice Disclaimer
The content of this blog is for informational and educational purposes only. No aspect of its contents is intended to substitute for professional medical advice, consultation, diagnosis, or treatment. The author is a spiritual care provider, not a doctor. Always seek the advice of your physician or other qualified health care provider with questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it based on something you have read here.
Next Week: Long Term Care
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Until next week, ‘Safe Journeys,