Tuesday, October 20, 2009

Swine flu in the nursing home...Should patients with chronic dementia get aggressive care?

This situation will surely arise during the current influenza season.

In the Nursing Home where I work about 20% of the residents have a long standing dementia. Most are unable to recognize me although I will see each of them about every 4 weeks for one reason or another. Many have family members they do not recognize (although the bedside walls are often covered with family photographs). Most are incontinent and wear rubber panties or diapers. Almost all are getting several medications for Alzheimer’s Disease, depression, and/or behavioural problems such as continuous crying. A few have decreased food intake and are losing weight, but most eat a little. About half are bedridden. Their average age is well over 80 years.

All will be offered and probably get seasonal and pandemic 2009 A(H1N1) vaccines. All have received pneumococcal vaccine. Although this should prevent influenza infections, it may not - the very old respond poorly to vaccination and their natural host defenses are compromised by age and perhaps use.

Influenza used to be called (by those who are not yet old) ‘the old man’s friend’ because it provided relief from chronic discomfort by a quick death. But my patients, almost all, are not chronically uncomfortable. They smile, they may, if incoherently, speak. They eat, some can walk a little with assistance, they generally sleep fairly well, most with a chronic sedative of some sort administered more out of habit than necessity I expect.

Most have next-of-kin who visit regularly and have power of attorney. So it will not be for me to decide to transfer a resident with a severe respiratory infection to an intensive care bed somewhere. But I will be asked by next-of-kin for advice.

There are ponderable ethical issues; should age or dementia be disqualifiers for scarce medical care; are the demented ineligible for medical care in some circumstances; others perhaps. I don’t know the answers here.

But what are the medical issues? A recently published study of 323 nursing home residents with advanced dementia in the U.S. demonstrated that over a period of 18 months, 55% had died and that during their last 3 months of life41% underwent at least one burdensome intervention (hospitalization, emergency room visit, parental therapy or tube feeding). <1>
Certainly a viral or bacterial pneumonia would be one further cause of dying. I expect that few of these patients would survive even if admitted to an intensive care unit. But then, dyspnoea (shortness of breath) is a distressing symptom and patients deserve relief whatever their mental status or functional state. In my nursing home we have no oxygen available: such patients will have to be transferred to hospital emergency rooms for simple symptom relief even though there is a very high probability of death.

There is no algorithm for this ethical and clinical care dilemmas. Case by case, with the goal being to bring comfort to the patient.

1. Mitchell SL et al. The clinical course of advanced dementia. N Engl J Med 2009;361:1529-38

1 comment:

EMR said...

Dimentia is difficult to handle...I guess there is also no cure for the same.