Hospice Care/CHF and COPD

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QUESTION: Hi Christine,
I have read some of your replies and would like to get some answers too regarding my dad. He has CHF and COPD, cannot walk or do anything by himself. He is having episodes of dementia or hallucinations.He is at home and on Lorazepam. He is having serious insomnia. But since saturday he has not been able to go any bowel movements event with laxatives and enema and lactulose which the doctor recommended since Monday. Can you tell me if this is a renal failure. What will happen if he cannot do his bowel mouvement. I am worried but i have to work and he is with a caregiver. Please let me know what i can expect. Thanks for your help.

ANSWER: Hi, Sylvie--

Thank you for writing to me.  I will try to give you some insights and answer your questions.

I am assuming that your Dad is taking more medications than just lorazepam, although with COPD, lorazepam is a good medication to keep him from feeling like he cannot breathe.  The anxiety that goes with breathlessness steals any pleasure from living.  So the lorazepam seems to be a very good thing.

You don't say how old your Dad is, but sometimes insomnia is a part of being older.  Many older people only sleep 4 or 5 hours at night and then have a nap or two during the day.  It seems to be the way they are set up.  Since I don't know all the medications he is taking, and I am not sure what you mean by insomnia, I'm not sure how to address this.  If he is fretful or unhappy because he wants to sleep but can't, that's one thing.  But if it seems he is not sleeping enough but he doesn't seem upset by it, that's another.

Dementia and hallucinations can sometimes happen in older people who have infections, especially bladder infections.  I'm not sure why it happens but it is amazing--they get an antibiotic for their infection and voila--in days they are their old selves again.  No more dementia or hallucinations. So it might be worthwhile checking with his doctor to see if he has an infection.

The bowel movements may be an issue, but are not likely to be related to kidney failure.  Bowel movements need a few things to happen.  They need the person to be drinking enough so that there is enough fluid in the bowel contents to make passing the BM possible and comfortable.  A dehydrated person, someone without enough fluid in their system, will generally not have a moist enough BM to pass it.  The next thing the person needs is enough "stuff" to make a BM.  If someone isn't eating very much won't have a BM every day because if there isn't enough in there, there isn't enough to come out, if that makes sense.  The next thing someone needs is the actual ability to get the stimulation and the follow through with the large bowel.  That means, essentially, that the nerves need to be working well.  If he is taking a lot of pain medication (or some other meds, but pain medication is usually the worst offender), they don't get the feeling like they have to go, so they don't.  If you skip enough days, even if there is enough "stuff" and enough fluid in there, then you get plugged up.

Lactulose is a great way to get a BM to happen, if there is enough in there to "go."  If that didn't work, and the enema and laxatives didn't work, a couple of things could be the problem.  One, he could have an impaction, which is basically a big hard ball of poop that is stuck in there.  Usually, though, if that's the case, the person will have diarrhea occasionally, because the impaction makes the colon irritated, so it tends to rush to get out the "stuff" that comes in behind the impaction.  The next thing that could be the problem is he could have some kind of change in the bowel that is making it impossible for the BM to move through.  Or, there could be the reasons I wrote about in the paragraph above.

I think the best thing to do is ask the doctor what he or she thinks is the next step.  It may be that an x-ray is needed to find the reason for the BM-less-ness.

All that said, there is another consideration.  You have not said whether your Dad is a hospice patient.  If he is, that means he is within 6 months of the end of his life if his medication conditions are not treated (treated in the sense of trying to cure, not in the sense of managed, which is what hospice does--to keep the patient as comfortable as possible).  If, for example, surgery were to be considered to take care of this problem (and I'm not saying that's what he needs, I'm just trying to give an example), and if that surgery caused him more discomfort and lessened the goodness in the days he has left, it's probably not a good idea.  But if he is not at that point, if he is not close to the end of his days, then the approach will be different.

You can see why I'd need more information to tell you what I think about the failure to have a bowel movement.  I do think, bottom line (no pun intended), that having a stronger conversation with his doctor is a good idea.  Constipation is never a pleasant situation, and it sounds like your Dad's dementia and hallucinations, if they are related to an infection, might be related to the constipation.  But I do not think it is renal failure, unless he also has renal failure and then there could be a relationship between the constipation and the renal failure.

You are very welcome to write me again and provide more information if I have not helped answer your questions.  With more information, I may be better able to help.

Take care--
Christine

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QUESTION: Hi Christine,
Thank you so much for your response. My dad is 82, he is on a lot of medication, Diamicron for diabetes, advair, Spiriva, Nebulizer ( Ventolin and pulmicort) prednisone,Ramipril , Lasix, spirinolactone. He is at home but he is followed by a doctor from the palliative care. He has advanced COPD and yes, he has an infection at the moment. I talked to the doctor, she prescribed sleeping pills as he is very agitated all night. He said his eyes are blurry and he cannot see anymore. I cannot at this point do the test. He cannot be moved. Has he moved his heart rate goes at 120. A nurse is coming home today to try to help him manually for the bowel movement. Thank you for getting back to me , I appreciate so much.

ANSWER: Hi, Sylvie--

Thank you for the kind comments.

I understand a bit more about your Dad.  He does sound very ill.  I thought when I read your first message that it sounded like he should be on hospice service.  Now I notice two things: you mention palliative care and also I see you are in Canada, so the terminology is a little different.  One of many wonderful things about Canada, you have marvelous health care.  I am so pleased to know that you and your Dad are getting the good support you deserve at this time.

Your Dad is taking a lot medications which manage his blood pressure by decreasing the volume of the blood, kind of like having less water in the garden hose--if it is closed off at one end and the water is full on, you can feel how tight the hose will be.  Blood pressure is like that--the down side is that if we remove fluid from the blood, sometimes people feel kind of dry or dehydrated.  His blurry vision could be from that--a few drops of sterile saline or a commercial over the counter eye drop may help a lot.

I do not know what to tell you about his heart rate, sometimes the rate goes very high when the heart's output is lower, as if the heart is trying to make up the difference: faster heart rate, more output.

I know your Dad will feel better once the nurse has been there.  Sounds as if they think he probably has an impaction.

I do hope he feels better and that you and he enjoy your time together.  He is lucky to have a daughter like you--a tribute to your raising.

Take care,
Christine

---------- FOLLOW-UP ----------

QUESTION: Hi Christine,
My dad situation is not too good. Even though he is eating a little he doesn't have any BM by himself. Yesterday he has vomited something foamy and later watery like bile. He is weaker and cannot stand on his feet even though we hold him so he is stuck to the lazy-boy. Do you think the medication which he is taking can have this effect. He is actually on Noximan 12,5 mg
Thank you for getting back to me.

Answer
Hi, Sylvie--

Yes, it does sound as if your Dad is getting worse.  I wonder if it wouldn't be a good plan to get a hospital bed for him?  I do not know how hospice works in Canada; here it would be included in the hospice benefit.

I'm afraid I do not recognize the name of the medication.  I even looked at my Canadian pharmacy that I use for some medications, and they did  not know it either.  I wish I could help you more with that.

I must assume that the medications are necessary to control symptoms that are worse than not having a BM.  He does seem like he might have some nausea, and maybe the hospice nurses can help with that.

The weakness is probably because he is not getting any food in.  If he does eat anything, you might want to make sure it is nutrient rich and high calorie.  But remember, it is up to him if he wants to eat or drink.  You can offer, but please don't push or force him.  His body knows what it needs at this time in his life.

Take care--
Christine

Hospice Care

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Christine Johnson

Expertise

I can give suggestions, encouragement and direction on what hospice is and is not, when it is appropriate, and how to go about getting it. I am familiar with Medicaid and Medicare hospice benefits. I can answer general questions about disease process, what dying looks like, how hospice handles pain and other symptoms, what to expect from a hospice when end of life nears. I can provide support, direction and encouragement related to spiritual matters and psychological matters related to death and dying.

Experience

I am a certified hospice and palliative care nurse, and have been the director of nurses for three hospice centers, under two different companies. I have also worked as a contract hospice nurse for a large American hospice company. On a personal level, my father died without benefit of hospice (it was not popular then). I have taken care of dying patients in hospitals and recognize that for most of us, it is preferable to die at home (or in our residence, wherever that may be), comfortably and without anxiety. Also I had no support when my father died; hospice clients are the whole family (however that is defined by the "patient"), and support is provided at least a year after the patient passes. These are the sorts of things (and probably others) that I can help with.

Organizations
HPNA (Hospice and Palliative Nurses Association)

Publications
none yet

Education/Credentials
Registered Nurse (TX), Licensed Marriage and Family Therapist (TX) ADN Nursing, Excelsior College, Albany, New York (2004) 4.0 GPA BA, Psychology (minor Social Work), Oklahoma University, Norman, OK (1986) 3.67 GPA MHR (MA) Human Relations, Oklahoma University, Norman, OK (1988) 3.5 GPA

Awards and Honors
Phi Beta Kappa (and others)

Past/Present Clients
Unable to name as this would violate their privacy (and HIPAA....)

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