Elder abuse vs medical treatment

Brie

I hate posts like this but need to sort out some thoughts....

Mom is in hospital.  She's had a couple of small strokes and has pneumonia.  Net result is that she is confused, aggressive, highly agitated. 

As there's an issue with her throat she's not able to eat much so is on an IV which is also how she's getting her various meds.  

Because of her confusion and agitation she has needed to be restrained else she pulls out her IV and potentially might manage to fall out of bed.

At what point does continuing medical treatment constitute abusive behaviour by the medical team?  

This is not a dig at what they are trying to do for her but more a case of what can/will a medical team put up with from a reluctant patient while they are trying their best for her?

Prognosis isn't grand and there's a do not resusitate but that doesn't mean she shouldn't be given antibiotics and sustenance while she is still conscious even if she's not completely in her right mind.  But I wonder short of drugging her into submission there's no way to give her the medicine she needs to help her beyond the pneumonia.

I'm not eager for her to die but I don't like to know she's so upset by what's happening to her.

fyi - not in the UK so def not a dig at any NHS treatment.

Vegastare

OK firstly I am sorry for your troubles at present - it is a difficult time.

Sadly much of this may be post stroke related.  What have they actually told you.

You Mum is having difficulty swallowing and this likely associated to her stroke, dysphagia  (swallow problems)  and can improve or sadly stay with them, my late Mum did not have the degree of aggression or agitation, however she remained on pureed food for the rest of her time,.  Also I wonder if due to her swallow she has developed pneumonia.  When swallow is effected it can cause food to mis direct and a type of pneumonia.

I understand you fears that she is behaving in a manner that you feel medical staff may find difficult, but honestly they will have encountered it before and as medical staff they are trained  - I am sure there would be no behaviour problems. 

Can I ask have you noticed anything to concern you. 

I do not want to upset in anyway - but you seem via your post to imply that it is end of life care.

I would ask them point blank to aid her agitation with some sedation saying it is distressing to Mum, yourself and nurses.

I do not know the country you are in but your views and wishes would certainly be listened to.

Take care
  

kezzygirl

They are probably treating her under the capacity act or equivalent if you are in a different country. The alternative is,your mother dies from lack of nutrition unless they restrain her. It's in her best interests that they do this,and the capacity act provides this framework.

Savvy_Sue

It is difficult, isn't it?

I think it is worth you thinking as clearly as you can about whether or not she is improving, and what progress is likely.

You may know that pneumonia used to be known as "the old man's friend" - and then we developed antibiotics.

The thing is, the medical instinct is to do SOMETHING, anything, rather than nothing.

We've faced this twice. The first time, we were clear that after the patient had pulled out the IV, it was time to stop treatment. The junior doctor was a bit taken aback, but if 6 weeks of antibiotics hadn't done the trick, we couldn't see that they were likely to work magic now.

The second time, we were clear no extraordinary measures should be taken, and it was fully expected the patient would die overnight. When they survived, we were happy for antibiotics and IV nutrition to be started, although unsurprised they didn't work.

Flugelhorn

I too have been through this twice and as a doctor of several decades I was clear in supporting the medical staff when they felt that little more could be done and best supportive care was the best route, along with palliative care meds as needed.  @Savvy_Sue junior doctors sometimes find it hard to get "time to stop treatment" - they really do find they need to do something, one of the things that moist impressed me about those I worked for was accepting that enough was enough 

@Brie really hard (and wrong) forcing people to take medication / treatment, particularly when they may be confused and agitated because of the very  illness that they have  -much persuasion needed and ultimately discussions about "best interests"

Keep_pedalling

In tin the UK you have the option to make a living will which can give instructions to medical professionals on what to do in these circumstances. You can also draw up a lasting power of attorney giving others the power to speak for you, but without those either of those things in place the default will be to try to keep you alive as long as it is feasible to do so.

Flugelhorn

Keep_pedalling said:

In tin the UK you have the option to make a living will which can give instructions to medical professionals on what to do in these circumstances. You can also draw up a lasting power of attorney giving others the power to speak for you, but without those either of those things in place the default will be to try to keep you alive as long as it is feasible to do so.

the default is to act in the patient's best interests - following discussions with family etc and others involved in caring for patient  

Brie

Thanks for your input @Flugelhorn, @Keep_pedalling, @Savvy_Sue, @kezzygirl, @Vegastare

Sorry - should have made it clear - I'm in the UK and mom is in Canada.  She has a living will that specifies DNR and myself and siblings are all named on the POA but instruction can come from any two of us which is not a problem as 1 brother is her carer and another lives not far away.  (in Canadian terms....)

I think one of the problems is that she is was one hospital for a week, returned home and then a few days later was whisked off to a different hospital so there's not much continuity of care, other than my bro who is trying to update the medical team as well as those of us who aren't able to visit. 

She's 92 so getting to the end of her life one way or another.

TBagpuss

It's very difficult - I think a DNR is different from decisions about continuing care such as providing antibiotics and feeding, so I think the way forward would be to try to speak with the medical staff to discuss what they feel is and is not in her best interests and also whether other than the DNR she ever expressed and wishes herself - does the living will have any further directives?

Even if it is not specific, it may be very relevant in terms of addressing what she would she if she were able to make the decision. 

I think the precise rule about what the medical team can and can't do about withdrawing / discontinuing treatment will be down to local laws - it might be worth seeing whether you can find  a local charity or patient advocacy group which might be familiar with the rules and restrictions and be able to advise about what  can be done and how to frame it in conversations with the doctors .

It's also worth asking them about her level of understanding - is she confused all of the time or does her mental state fluctuate?  (in other words, are there times when she might herself be able to understand and express a wish?, even if it's only indicating yes or no to questions?  

My late grandmother had a major stroke and although it left her unable to speak clearly, she was able to understand and respond to questions and to make choices about her care.  (And the choices she made in the immediate aftermath of the stroke were different that the ones she made a year later when it was clear that she was not going to improve any further at that point. 0

squirrelchops2

In this country we have DOLS or deprivation of liberty safeguards but not sure if they do in Canada?

elsien

Is there a specialist nurse who can advise the ward staff on ways to better manage the agitation?
What do you mean by restraint? I have seen patients who may pull out IV etc with big mittens on their hands - it’s still a form of restraint but perhaps less so than other forms. Also the option of 1/1 support for the person if needed? 

But ultimately best interests is around the bigger picture - current needs, prognosis, level of distress, what she might have wanted when she was well enough to tell people. Then consideration of whether the benefits of treatment outweigh the burdens. It’s never easy and there isn’t a one size fits all answer.
But this is a conversation you should be having with the treating clinician.