Comfort needs only....is this appropriate?

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Comfort needs only....is this appropriate?

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Hi. I am mainly interested in the opinions of health care professionals that have dealt with issues like this before.

My Mother is 96 and has resided in a nursing home for 6 years now. She has osteoperosis and weighs about 75 lbs. She has a fair amount of dementia too. She recognizes me and we converse, but it is a confusing type of conversation. In other words, she is able to speak intelligent sentences, but her facts are sometimes very unclear.

I got a call from the nursing home last week and they suggested, based on the resident doctor's advice, that my Mom be initiated into what's called "Comfort Measures Only". From several people, I have gotten many differing opinions on this, including completely opposing views from 2 registered nurses.

The doctor's reason is that Mom has very poor nutrition and is losing weight. However, she has weighed no more than 80 lbs ever since she was admitted to this facility. I do see she has very little appetite, but I dont see an overwhelming weight loss over the past 6 years.

And on the other hand, Mom does experience falls from time to time, and occasionally breaks a bone. I worry about her falling and breaking something critical, like her neck (which she actually did break in 2008. That was a horrible experience and difficult recovery).

So my question is, is putting my Mom in "Comfort Needs Only" appropriate under these conditions? Mom has lived a long life and I dont want to prolong anything that could become dire. But I dont want to jump the gun on this either. The doctors explanation of why this should be done sounds a bit feeble to me. Is it possible I'm not seeing what he does?

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To me, it sounds like he is sugggesting a Hospice type end of life care. Just keep her comfortable. Does he feel her body is starting to shut down? My mom was placed on hospice in my home for 1 month before she passed away. She was about 78 lbs, very frail, no appetite. My mom could not speak due to mini strokes and dementia. I wanted to force feed her but they explained that would be more dangerous. We kept her at home with hospice and family care and she died a beautiful death and was in no pain. If I were you, I would call in hospice to evaluate her. The do go to nursing homes and offer their care there and it is covered my medicare. Hospice was a blessing sent from heaven for my mom and my family. Good luck with your mom.

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The doctor is probably recommending that you let God (or nature, depending upon your beliefs) take charge. Personally, I wouldn't authorize any kind of medical intervention aimed at standing in the way of a 96 year-old person's natural end-of-life process.

Nowadays, if you don't specifically request DNR and palliative care only, there's a strong possibility that your mother will be subject to pointless (uncomfortable and even painful) tests and procedures. Also, as perverse as it sounds, a staff member or EMT could initiate resuscitation measures, including pounding on her chest and using a defibrillator.

Logic and humanity have been all but abandoned in the medical industry's treatment of the elderly. So, family members are having to make the agonizing decision to specifically prohibit treatment. Without that, it's almost impossible to die of old age in this country anymore.

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Hi Jay. I am not a health care professional, but I've been in your shoes and wrote a book about my experiences ("Inside the Dementia Epidemic: A Daughter's Memoir"). The doctor may be suggesting "comfort care only" because of your mother's age and the fact that she would probably not recover from any major surgeries or interventions. Also, comfort care means no interventions such as a feeding tube (to deal with the weight loss), no resuscitation if she has a heart attack (CPR can break bones in the very old), no intubation if she has trouble breathing, etc., and only measures to keep her comfortable, which, in my mother's case when her heart failed, was lots of morphine. Comfort care can also mean that you don't want your mother sent to the hospital at the first sign of distress, that you want her treated in the nursing home and not subject to unnecessary hospital testing. Just know that the nursing home may still send your mother to the hospital if they feel that they cannot diagnose what's causing her distress, or if they cannot provide the level of care they think she needs to be comfortable. That's what happened to my mother, who was sent to the hospital with difficulty breathing just 3 days before she died (the day before that she was just fine, so it was a rapid decline). She was put through a few tests, but I was able to get her back to the nursing home for her final days. "Comfort care only" is meant to protect your mother from a drawn-out, medicalized death with tubes and unnecessary discomfort. I suspect that your mother's doctor called you because of the weight loss and to make sure that you and your mother would not want a feeding tube. (If your mother has some dementia, she may not remember why the tube was inserted into her stomach, and pull on it, causing infection. Plus it's uncomfortable.) I hope this helps.

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He is probably referring to having a POLST form (Physician Orders for Life Sustaining Treatment) filled out, which directs the type of treatment your mother wishes to receive at the facility. In addition to Full Code or DNR, she would decide (or you for her, if you are DPOA) Comfort measures only, Limited Interventions (comfort measures plus antibiotics, xrays, etc., but no feeding tubes, respirator, or ICU in general, etc.) and lastly, Full treatment. Should she fall and break another bone, or need to be transferred to the hospital for another reason the form would follow her to the hospital as well. My mother had signed the form with Comfort Measures Only, but when her blood glucose plummeted to 22, the nursing home had her transferred to the hospital. At that point it was discovered she had a UTI, and so the staff at the hospital wanted the POLST amended to limited intervention so they could treat her with antibiotics & run tests to see why her abdomen was so distended. Of course I could have refused, but she was in a great deal of pain and I wasn't going to allow her to pass away from a UTI, so the form was amended to include Limited Interventions. In signing the form, my Mom mainly wanted to be sure that she had a DNR in place (no CPR if her heart stops, not kept alive artificially, etc.), which limited intervention still ensures. Due to your mother's advanced age and precarious condition, would it make sense to have her on full-code status? I suspect if her heart were to stop beating that CPR would do more damage (breaking ribs, puncturing lung, etc.) and they may be able to bring her back, but at what cost to your Mom? Would she live a quality life afterwards? I suspect that is why the doctor is suggesting the above, and even though it's a tough decision, it's one that should be made ahead of time with your Mom's best interest at heart. If you are uncomfortable with Comfort Measures Only, then ask about Limited Intervention.

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Okay, as an RN and someone who worked as a director of nursing for many years. I know this topic is confusing for many people. People have a lot of misconceptions regarding this. Comfort Measures means she still gets everything she is receiving now. medicines, treatments, IV's etc. It simply means that unless she needs stitches or a bone set, she won't be sent to the hospital and no aggressive treatments like chemo or radical surgeries will be done. At your mom's age, diagnosis and slow loss of weight. The doctor feels the benefits verses the risk to keep sending her to the hospital is not in her best interest. You can and should have a meeting with the doctor and social worker at the nursing facility. They can explain that you may pick and choose what you want her plan to be. Some opt for no IV, no feeding tubes, no hospitalizations( unless for items mentioned above) and do not resucitate if her heart stops beating. You can choose whatever you are comfortable with or none at all. They probably brought this up because at her weight and lack of appetite the next step is a feeding tube. The doctor probably feels it is unnecessary at this point and will cause her pain, more confusion, and the odds are she will pull it out due to her dementia. Ethically they have to offer this as a way to keep her nutrition intact. This is why they will offer comfort measures at this juncture. It is ultimately up to you.

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Also, consider that they're making the recommendation based on additional factors like declining vitals and that 5 lbs on a an 80 lb frame is a 6% loss. That's actually not something to disregard, especially if it's a trend.

If you're concerned that the facility is being lazy or just doesn't want to do the job any longer, think about this: financially, it doesn't benefit them to reduce her care, right? If it were me, I'd be grateful that they're concerned about her health and comfort, and not simply sustaining a life, because it's technically possible.

If you're seriously concerned, and the facility physician is NOT your primary care doctor, consult with her/him and see if they agree. If your mom is lucid enough, ask her what she wants, if you don't already know.

And take a deep breath. It's very, very hard to hear 'end of life.' Most of us cling to it, despite the loss of quality. I doubt any of us are ready for it, even when we think we are.

Love, Laugh, Learn
LadeeC

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Are you sure she is getting the best nutrition? I know NHs vary as far as quality of food. My father was in a rehab/NH for a few weeks this winter and they insisted on giving him pureed food. They were convinced he had too much dementia to know how to chow. He was not a good patient and they had him heavily sedated. He lost weight while in there.

Anyway he is home now and doing fine, very little dementia, mostly just age related forgetfulness and the fact that he doesn't have my mom around any more (she passed away in 1999) to keep him mentally sharp.

When you mentioned the weight loss I am wondering if more appealing food would make a difference. Food you know she likes, many pureed quality food that is easily absorbed into her body. Maybe supplement her diet with a couple of Ensures a day. I started taking food to the NH the last couple of weeks there and he would eat everything. The pureed food they would bring for his dinner he had no interest in.

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Trust in their suggestion for comfort care and go over all the details with her nurse.

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Comfort care means no invasive types of procedures ie G-Tube or NGT inserted due to lack of appetite. When our bodies shut down so do our appetites which is normal. You can choose to prolong life with force feeding usually by G-Tubes but I believe that is only a comfort to the family - not the elderly patient. We always offered food and water but did not force anyone - you will come to the right decision.

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You should be able to specify exactly what you do and do not want. You can say no CPR, you can say OK to oral antibiotcs but no IV, or you can OK treating anything that is likely to be reversible. This is hard to think about, but given that she is approaching the end, you want comfort for her and good memories for you, and you probably know best what she would and would not want if she can't really speak for herself. Prayers and a big hug...its not easy...

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Thank you all for your thoughtful and informative answers. I am impressed with the knowledge here. You have given me good ideas. One of my concerns was that my mother could have a relatively minor (she often has UTI's) which she could be treated for, but only be kept comfortable instead. So I will make sure that doesnt become an obstacle. I will go ahead with the "Comfort Measures Only" plan. Its just impossible to consider every possible medical scenario that could arise.

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My dad died in March of this year. He declined quickly in a 9 month period. This included falls where he would dislocate arms or legs. Terribly painful for him. A month before he died, he had his last fall with a dislocated hip. They were going to send him home after re-locating it! I begged for rehab and thank God they sent him there. He did fine for a week or so and then had a "neurological incident" not a stroke, but he ended up with symptoms like a stroke. He became more befuddled and began to choke on food leading him to eventually refuse to eat. He had lost a lot of weight over those 9 months, so I became really distressed. At the rehab where he was, they had a Head Nurse (can't remember the title) I spoke to her and she confirmed my research that once they stop swallowing, they are at the end of their life. Feeding tubes and IVs are harmful and we made the decision to begin Palliative Care directing comfort only and "allowing a natural death." I like that phrase much more than DNR, which sounds very cold. After about 5 days with no fluids, he became extraordinarily withdrawn, except when visitors other than me and my mom came. It was amazing how he'd rouse to say hello to people. Anyway, they kept him comfortable with morphine. There are physical changes that can be tracked as the end comes near and that knowledge allowed us to stop the rest of our lives to sit with him, cry, laugh and sing to him as he died. There are times when I still wonder if we moved him toward comfort and thus death too soon, but those thoughts pass pretty quickly because I knew that a quiet death with family was far more desirable than all of the tubes and activities of medical intervention. God Bless

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Comfort needs only....is this appropriate?

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