I enter the patient’s bedroom after a brief chat with the daughter who is sitting outside.
“Mom had diarrhea … she’s also got dementia … ”
“Who are you?”
“Hello, Auntie .. I’m doctor .. I came to check on you … …”
“Go away. There’s nothing wrong with me. I don’t want to see a doctor.”
“OK .. ”
I walk out of the patient’s room, and into the living room – Out of sight now.
3 minutes later, I walk into the patient’s room again
“Who are you?”
“Hello, Auntie .. I’m Jane’s friend … I came to visit … have you eaten?”
“Yes. I have”
“Was the food nice and does your tummy feel full?”
I reach out to feel the ABDOMEN – Soft, non-tender
The rest of the physical examination performed in 5 parts, getting history from the daughter outside the bedroom in between ….
These days, she’s not been able to communicate as much and doesn’t even swallow her food properly. She looked interested in our conversation, but it was unlikely that she knew what the discussion was about. But still, her expressions followed the tone of our conversation – flowing between curiosity, and concern.
At the table nearby, her daughter was relating an episode about how she felt so guilty when another doctor told her that not using tube-feeding for her mother was like “starving her to death”. At the moment, we’re hardly near that stage. But the daughter and family already know that drastically reduced food intake is an eventual consequence of the decline from dementia.
We’d already gone through options for care, including whether patients might benefit from tube-feeding. The facts objectively laid out and clear. She thought she had it all planned out and decided, until that encounter. Would have been easy if humans just relied on being rational and logical. Now she’s unsure if she’s doing the right thing, with some guilt lingering.
Being judged on what choice (tube feeding) one makes for his or her parent is never helpful; maybe even harmful. Instead, understanding that choices are always made in contexts that we can never fully appreciate is wiser. Accepting that there are very different choices which can be made, not necessarily a right or wrong choice is good enough. Just choices, and supporting the patient and family – whatever the choice.
link to NY Times article on tube feeding
American Geriatrics Society – position statement on tube feeding in advanced dementia
As noted in a previous post, pressure sores are a common problem I see on housecalls. In order to monitor pressure sores, it is necessary to assess their severity (An excellent description here from WebMD) as well as keep records of the progress. In my experience managing patients at home, it can be useful if family or caregivers are able to record the progress of pressure sores with photos.Mobile apps can be a useful tool for such monitoring purposes. The IUVO app was designed by some colleagues and myself in order to facilitate this.
I often get called to see patients with pressure sores. Pressure sores are a common problem for elderly patients with limited mobility. These patients are often bed-bound, and thus their joints and bony surfaces (heels, ankles, knees, buttock, elbows, etc.) are in constant contact with hard surfaces, leading to skin breakdown. This can worsen if not treated, and infections can develop. Relieving pressure on these areas by turning patients, changing postures, etc. is critical to treatment, as is proper nursing care for the sores.
Here is a very informative article written in ST’s Mind & Body, by Dr Barbara Rosario (Consultant Geriatrician, Changi General Hospital).