Status reset

At the end of last week, Mom started to think that maybe Dad should have someone from Hospice checking on him daily because he is no longer eating and drinking. So I called them, and on Sunday, Nurse Drew came to assess Dad. He checked heart, lungs, neuropathways, and his skin. Based on these areas he determined that Dad is not yet nearing transition. Transition means that death will usually occur within 48 hours, and there are physical signs that appear. The heartbeat will be weaker, breathing will be more labored, reflexes are decreased, and the skin will start to appeared mottled. None of these signs are currently present. All of Dad's basic functions are still at full or close to full capacity. 

Drew told us that even though Dad is not eating or drinking (we are now on Day 7), he could linger for quite some time. However, he would put in the call to the case manager and someone would begin checking on his status daily. Today our town is the middle of a N'oreaster, and everyone is pretty much snowbound. However, a nurse did show up early this morning to check on Dad, and he still looks pretty good. Mom also saw him and said that today, like yesterday, Dad did nothing but sleep, did not seem to want to engage, and took nothing. Today he also refused mouth care, which normally takes place every two hours. One of Dad's regular LNAs has decided to sit with him as much as she is able. 

One of the topics Drew and I discussed was the use of morphine near the end. Sometimes, he explained, a patient will begin Cheyne-Stokes  breathing, in which they will breath quickly and deeply several times in succession, then experience apnea, when they stop breathing altogether for a period as long as a minute. This is the body's way of reacting to the level of CO2 in the bloodstream. Although there isn't any data to suggest this is uncomfortable for the patient, it can be distressing for family members to see this and so morphine can be administered, which will bind to the CO2 receptors (I hope I'm remembering this correctly!), so that they will no longer detect the rise of CO2 in the bloodstream. It is our choice whether or not we want to use morphine in this situation, but Drew assured us that this is a very natural process that takes place near the end. However, there is another scenario which can in happen, in which the patient is actually struggling to breath because the lungs are shutting down. This can lead to great anxiety. This is a situation in which morphine is highly recommended, because it will immediately ease not only that anxiety, but the body will no longer perceive its lack of oxygen, and the patient will be much calmer. I talked with the director of nursing at R Center, and she confirmed that they only use morphine when they see that a patient is struggling, and they use it AFTER informing the family, in very small doses to start. This is something Mom was concerned about. She doesn't want Dad to suffer. But she also doesn't want them to start Dad on morphine without telling her and then he passes without her knowledge. The nursing director assured me that R Center has a distinct protocol regarding the use of morphine (every center is different, Drew said). But, she said to me, "Melinda, you do not ever want to see your family member dying, and struggling at the same time. It is so disheartening; you really don't want to see that." There was something incredibly weighted in not only her words, but her tone, that I took it seriously, and passed it on to Mom with the same emphasis. 

This morning when Mom got home from visiting Dad she confirmed that the order for morphine has been written in an MAR (medical record) for Dad, so it is ready if/when he needs it. He is sleeping very soundly for the moment. And so we continue to wait.