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Suggest Treatment For Massive Stroke And Atrial Fibrillation While On Morphine
Question: My mother is 80 years old and had a massive stroke on her right side, where 2/3 of her brain was destroyed. She also has a stint in her brain from inserted years ago for an aneurysm, and a drain in her abdomen to help because of diverticulitis. She has a afib. From a previous hospital stay they had a DNR which only allowed for a feeding tube. This story is really long, but in the first 24 hours my mother was able to say things like I love you, and in the first 48, she was able to respond when asked what her last name was. Then the brain swelling started, the doctor in the neuro ward gave her a brain swelling med, and after telling them that we wanted the best care, (a little too late, although they were told before), we opted for the ventilator and more of the brain swelling med. Keep in mind the doctor's and nurses have been skeptical this entire time. On Saturday we were told she had to come off the ventilator, she had only been on it since Wed. evening. Saturday had been a week since the stroke, she was more responsive and even the doctor's said that her neurological state had improved. Then we were told she needed to be put on a trach tube. We decided against that, because our mother had been breathing on her own. Then it went from we don't want to do the trache tube because it would be very painful. This is where palliative care came in. They presented a nice picture. We will keep her comfortable, and give her meds if needed. Or at least that is the way we understood it. However, now they have moved her to regular room, no monitors no meds, except morphine, and they want us to remove the feeding tube. We were not aware of all of this, they did not explain it to us in this manner. Now we don't know what to do, she is not able to speak for herself, or move, and sleeps most all the time. We feel like she needs constant monitoring, and while we are there most of the time, we can't be there all the time. They never gave my mother a chance,they wanted us to make decisions right from the beginning to allow her to die,, which we didn't agree with but they persisted. What do we do, do we remove her from the feeding tube, knowing she is going to die with the situation like it is. It is hard, because I know my mother has been alive and responding to things and now I just don't know!
Brief Answer:
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Detailed Answer:
I read your question and I am sorry about what you are going through.
This is a difficult query for me because I feel that it is not so much a medical dilemma as it is an ethical dilemma.
Given your description it is obvious that the stroke she has suffered is a massive one and it will leave behind some irreparable damage, probably will remain completely dependent. Once the damage has been established there is no cure for that and all that can be done is palliative care. So having to deal with these patients every day I do understand the medical staff being reluctant to be too aggressive in their approach. I as well would have hesitated to intubate an 80 years old with massive stroke as the outcome on disability is not affected much, often they suffer respiratory complications related to the intubation and do not survive anyway (but that would be my personal opinion and the final decision would be discussed with family members naturally). I also agree that after a certain time the patient should be moved to the palliative care as there would be no extra benefit from her staying in intensive care and there are also cost benefit considerations the doctors who deal with such patients all the time have to make.
Regarding the present situation though I understand your perplexity. I don't see why she should be on morphine and why they are giving her no other meds. She should receive the necessary treatment to prevent another stroke, at least blood thinners considering her atrial fibrillation. Also if she's unable to be fed by mouth the feeding tube should be left.
Of course if she doesn't awake, remains completely unresponsive, not reacting to external stimuli as months go by, you should perhaps reconsider your decisions. You do not mention how much time has passed since it all started, most improvement happens during the first 3 months up to 6 months. If the situation remains unchanged after 6 months then you should rethink what you want to do, personally I would consider stopping feeding through tube at that point, there wouldn't be much hope especially at 80 years old.
As I said at the beginning though it's a personal decision, a matter of debate and at times of court procedures, so you should make your own considerations.
I remain at your disposal for other questions.
Read below
Detailed Answer:
I read your question and I am sorry about what you are going through.
This is a difficult query for me because I feel that it is not so much a medical dilemma as it is an ethical dilemma.
Given your description it is obvious that the stroke she has suffered is a massive one and it will leave behind some irreparable damage, probably will remain completely dependent. Once the damage has been established there is no cure for that and all that can be done is palliative care. So having to deal with these patients every day I do understand the medical staff being reluctant to be too aggressive in their approach. I as well would have hesitated to intubate an 80 years old with massive stroke as the outcome on disability is not affected much, often they suffer respiratory complications related to the intubation and do not survive anyway (but that would be my personal opinion and the final decision would be discussed with family members naturally). I also agree that after a certain time the patient should be moved to the palliative care as there would be no extra benefit from her staying in intensive care and there are also cost benefit considerations the doctors who deal with such patients all the time have to make.
Regarding the present situation though I understand your perplexity. I don't see why she should be on morphine and why they are giving her no other meds. She should receive the necessary treatment to prevent another stroke, at least blood thinners considering her atrial fibrillation. Also if she's unable to be fed by mouth the feeding tube should be left.
Of course if she doesn't awake, remains completely unresponsive, not reacting to external stimuli as months go by, you should perhaps reconsider your decisions. You do not mention how much time has passed since it all started, most improvement happens during the first 3 months up to 6 months. If the situation remains unchanged after 6 months then you should rethink what you want to do, personally I would consider stopping feeding through tube at that point, there wouldn't be much hope especially at 80 years old.
As I said at the beginning though it's a personal decision, a matter of debate and at times of court procedures, so you should make your own considerations.
I remain at your disposal for other questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
The stroke occurred on Saturday evening, the 6 of XXXXXXX I assume they are giving her morphine to keep her sedated. Additionally, the build up of secretions means they are having to give her something to dry mucus and phlegm up. She gets to the point where she is choking on her mucus before they do anything. She starts making horrible choking sounds and sounds terrible. I told my sister it may be a death rattle, but I don't know. Also, she had been so responsive on Saturday, and today my sister even said she was sure that she heard her talking to my sister, because she seems to get excited with her breathing. We feel that we are murdering someone, and with the life still in her it makes it so hard. Since she is on a feeding tube, and we refuse to remove it, I assume her death will be slower. How long do you think she will survive. This entire process is so difficult and sad.
Brief Answer:
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Detailed Answer:
Thank you for bringing some more information. There seems to be something wrong in your info though. If the stroke occurred Saturday evening that is less than 72 hours. In the meanwhile in your query you speak of her being able to speak for the first 42 hours, than brain swelling, then being put under a ventilator on Wednesday, then off of it on Saturday, followed by tracheal tube proposal and at the end being put in palliative care, looked like a few weeks at least.
I still don't understand morphine use, if she's in a coma why should she be sedated? The aim is to mobilize the patient as soon as possible after the stroke not to sedate her. The build up of secretions is a common occurrence (certainly not helped by sedating the patient) and the medical staff whether in palliative or intensive care should aspirate her secretions from time to time.
As for how long she will survive it's tough to say, after the first week patients are more at risk of death from the immobilization complications like pneumonia rather then the stroke itself. So it depends on the state of her lungs and other prior conditions as well as the attention to general care like aspiration, feeding, antibiotic treatment when there's an infection, mobilization to prevent bed sores etc. It is a difficult and sad process I completely understand you. One can't make many predictions, the older the patient the likelier it is to succumb to complications though.
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Detailed Answer:
Thank you for bringing some more information. There seems to be something wrong in your info though. If the stroke occurred Saturday evening that is less than 72 hours. In the meanwhile in your query you speak of her being able to speak for the first 42 hours, than brain swelling, then being put under a ventilator on Wednesday, then off of it on Saturday, followed by tracheal tube proposal and at the end being put in palliative care, looked like a few weeks at least.
I still don't understand morphine use, if she's in a coma why should she be sedated? The aim is to mobilize the patient as soon as possible after the stroke not to sedate her. The build up of secretions is a common occurrence (certainly not helped by sedating the patient) and the medical staff whether in palliative or intensive care should aspirate her secretions from time to time.
As for how long she will survive it's tough to say, after the first week patients are more at risk of death from the immobilization complications like pneumonia rather then the stroke itself. So it depends on the state of her lungs and other prior conditions as well as the attention to general care like aspiration, feeding, antibiotic treatment when there's an infection, mobilization to prevent bed sores etc. It is a difficult and sad process I completely understand you. One can't make many predictions, the older the patient the likelier it is to succumb to complications though.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
My dates are all mixed up, I apologize, the date was May 30 when she had he stroke. She was responsive for the first 48 or so hours. Then by request and because we wanted optimum care, which hadn't even been allowed at the beginning, they put her on a breathing tube and the swelling medications. Then after 48 hours, they removed the life support and the story changed every few hours. However, right before the removal of the breathing tube, she had significant neurological improvement. At the beginning they were going to move her to a floor, they also said she needed to be on a ventilator. The stories changed, and after talking with a palliative care doctor, and being offered many reassurances and support, they moved her so she could receive palliative care. But after being there a few hours, we discovered that she was taken off of all medications and only receiving morphine. Additionally she was only being monitored by a RN every 2 hours and a aide every 1 hour. If my sister had not been there, she would have died on her own secretions.
Unfortunately, after a day and night of extreme breathing difficulty and drainage, my mother passed away about 6 AM this morning. My sisters said the suffering she went through was horrible, that my mother was not comfortable at all. The nurses said her heart rate went up to 185 at one time, and at the very end, there was peace.
I hope no one has to go thru this like we have had to. We have come out of this very informed, but want others to know that palliative care is really another name for a type of hospice care. Also, they don't give you all the details about the type of care your loved one is going to receive when in their care. Thanks for your answers to my questions, I feel that I have gotten more info from you than the one's who actually cared fro my mother.
Unfortunately, after a day and night of extreme breathing difficulty and drainage, my mother passed away about 6 AM this morning. My sisters said the suffering she went through was horrible, that my mother was not comfortable at all. The nurses said her heart rate went up to 185 at one time, and at the very end, there was peace.
I hope no one has to go thru this like we have had to. We have come out of this very informed, but want others to know that palliative care is really another name for a type of hospice care. Also, they don't give you all the details about the type of care your loved one is going to receive when in their care. Thanks for your answers to my questions, I feel that I have gotten more info from you than the one's who actually cared fro my mother.
Brief Answer:
I am sorry.
Detailed Answer:
Thank you for taking the time to tell me. I can only imagine how hard it was for you and your sister and I am really sorry about your loss.
I am sorry.
Detailed Answer:
Thank you for taking the time to tell me. I can only imagine how hard it was for you and your sister and I am really sorry about your loss.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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