Not quite as planned
Nov. 29th, 2010 12:54 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
rscOr, How it happened that we both did and did not have a standard Thanksgiving dinner.
I should say at the outset that, despite how the weekend started, things are mostly OK, at least for the immediately foreseeable future.
As some of you may know, my brother (Dan) and his wife (Gretta) live in Philadelphia, and my father lives in a retirement community in Haverford, PA, about half an hour's drive away. He and my mother moved there in 1995; my mother died in March of 2008. My father's 93rd birthday is coming up in just over two weeks. He lives independently, and engages in a number of activities in the community, but he no longer has the strength to walk unaided; he uses a walker in his apartment, and an electric wheelchair-cart to get around the complex.
Usual practice is that![[livejournal.com profile]](https://www.dreamwidth.org/img/external/lj-userinfo.gif)
jwg and I go to Philadelphia for the Thanksgiving weekend and stay at my brother's house, and we all go out to my father's place to have Thanksgiving dinner in the retirement community's dining room, where they put on a pretty nice buffet spread. And so on Wednesday, as usual, we took the 11:03 Amtrak Regional, Dan picked us up at the station, and we went to his house to wait for Gretta to get home from work so we could go out to dinner.
Except that, when we got there, Dan found a phone message from Dad reporting that he had checked himself into Bryn Mawr Hospital, without much in the way of further detail. He called the hospital, and was able to talk to Dad (who I guess was in the process of being evaluated to see if he should be admitted) and ascertain that Dad had been feeling increasingly listless and weak for several days, and finally decided that he needed medical attention -- a very good decision, as it turned out.
Eventually we all got out to the hospital, where they let us stay with Dad in the ER and then in his (private!) room in Telemetry after he was admitted; we didn't leave until almost 10:00 PM, never mind visiting hours. It had been determined that his potassium was alarmingly low, as was his blood pressure, and he was seriously dehydrated; some numbers relating to his kidneys (creatinine and Blood Urea Nitrogen [BUN]) were abnormally high, suggesting reduced kidney function. He was on an IV drip to increase fluids and potassium, but didn't look too bad, and was feeling OK other than being really weak.
Thursday morning they had him sitting up in a chair, but when he tried to go to the bathroom (with assistance, of course), he became woozy and faint; it was determined that his hemoglobin level, as well as his blood pressure, was dangerously low, so they decided to give him a transfusion; during the course of the day he was given two units of blood, and he was also put on a urinary catheter. When we arrived early Thursday afternoon, His blood pressure was still very low (around 80/40), and so he was also on a very slow saline IV drip. During all this time he was steadily feeling better, apart from still being quite weak.
It's still not entirely clear what triggered all this, but from what we've been able to piece together, it's something like this. A couple of months ago he had an episode of congestive heart failure, manifested primarily as excess fluid in his legs and some shortness of breath. As a result, his primary care physician put him on the diuretic Lasix (or increased an already prescribed dose), which resolved the situation, at least for the moment.
More recently, at the urging of Dan and Gretta, he started a program of physical therapy in order to improve his strength and balance, which he entered into with enthusiasm -- probably too much enthusiasm, as he reported to Dan something about an hour of exercise at a time. This brought on a recurrence of the congestive heart failure symptoms, so his doctor recommended that he suspend the PT, and also (we think -- Dad is a little vague about this) increased the Lasix dose. This may have triggered the dehydration, which in turn stressed his already weakened kidneys; the symptoms that led him to go to the hospital are consistent with kidney failure. (The fact that he had at some time in the recent past had a course of injections of Procrit also suggests that his doctor had already detected reduced kidney function.)
So, bottom line: neither his heart nor his kidneys were really doing their job. It's worth mentioning at this point that. whatever physiological problems he's having, one organ that's definitely still pulling its weight is his brain. He's a highly intelligent and well-educated individual, and there's been no sign of any cognitive loss.
Well, back to the narrative. By Friday his blood pressure was back up to normal levels (120/70 or thereabouts). He was somewhat tired when we arrived in mid-afternoon -- he's been taken downstairs for a kidney ultrasound, which had taken rather longer than expected, but after a short nap he was more animated than he had been up to that point. He was able to sit in a chair for extended periods, although the process of getting into the chair was a little difficult, mostly owing to balance problems. At this point the principal concern was his kidneys; the BUN number was improved, but the creatinine was still high, and the nephrologist was unwilling to discharge him until it came down to manageable levels. (Assuming that, with some mild physical therapy, he would be able to be up and around in the next day or two, this was the only remaining obstacle to his being discharged.) She had asked Dad earlier that day if he would accept dialysis; according to his report of the conversation, he replied that he didn't think that he had any choice, since he supposed that death from kidney failure was very painful. On hearing that it was not (she apparently said that one would just "go to sleep"), his inclination was to refuse dialysis, but the stage at which that decision would have to be made had not been reached.
We stayed through his dinner (a not particularly satisfactory meal, but much improved by a serving of Gretta's excellent apple crisp), and he was increasingly animated and cheerful. Dan, Dad, and I had had an email exchange a couple of months ago about some of the history of Dad's family (a subject on which Dan and I have been almost entirely ignorant our whole lives), which ended with a mutually-expressed hope that we would have lots to talk about at Thanksgiving; at this point, when we were starting to think about leaving for our own dinner, I reminded him of this exchange, and said that I still wanted to have that conversation, really thinking that we would have it sometime in the near future. But Dad seemed eager to talk, so we stayed another hour while he told us stories about various relatives of whose existence we had either only had vague ideas or not known about at all. It was a nice high note to end the visit on (John and I were leaving to come home Saturday morning, and we had all agreed that it was not necessary for us to change our plans.)
Sometime during this visit Dan had had a phone conversation with the nephrologist (while he was out feeding the parking meter, as it happened), in which she had told him that if the indicators did not improve in the next couple of days, it would indeed come down to a choice between dialysis and death. The four of us discussed this aspect of the situation after we got home, and agreed that, if it appeared that something approaching his present quality of life could be maintained, we would encourage him to accept dialysis, but that it was ultimately his decision, and we were prepared for the possibility that he would refuse. Dad has made it clear in the past (see this entry if you want yet more details), and reiterated during this episode, that he does not want to be kept alive by "heroic measures". He's enjoying his life, and is in no hurry for it to end, but he also recognizes that it will end eventually (and, in the grand scheme of things, sooner rather than later), and says that he is ready.
John and I did return home on Saturday. An hour or so into the train trip, Dan called me, giving me a moment of alarm, but it turned out he was calling with good news: the kidney numbers were much improved, dialysis was off the table for the present, and the plan was to discharge Dad in the next day or two.
One further hitch developed on Sunday: They took the catheter out that morning, but by evening Dad was still unable to urinate. Apparently his prostate is sufficiently enlarged to block the urethra; he has been on prostate-reducing medication for years, and it's possible that they took him off it in the hospital (John says that such drugs are also blood-pressure reducers). Anyway, they put the catheter back in. I spoke to Dad this morning (Monday), and he's been seen by a social worker and a physical therapist, and took a walk down the hall with his walker, and is generally feeling good. He is going to be discharged this afternoon (with the catheter still in), and will be temporarily in the skilled nursing facility at his retirement community. He's scheduled to go to a urologist's office in a couple of days in the hopes of figuring out what's going on with his urinary system.
The expectation at this point is that he can go back to his normal life (still with the catheter if necessary, which would be inconvenient but not disabling) fairly soon; they'll want to keep him in the nursing facility for a little while, I guess, to build up his strength with some more closely supervised physical therapy. There will also be the delicate matter of adjusting his medications properly, which at this stage seems to be a very tricky balancing act.
All things considered, this is about as good an outcome as could have been hoped for. We've been able to joke that it was very considerate of him to schedule this crisis at a time when we were coming to visit anyway. One thing's for sure: I'm not letting it be another year before I go visit again.
Oh, and that line up there about Thanksgiving dinner? Since it was immediately clear that we were not going to be having it at the retirement community, Dan and Gretta decided to cook dinner for the four of us Thursday night -- not turkey, but a very nice meal centering on pork chops smothered in onions and mustard, plus the aforementioned apple crisp. But we ended up at the hospital at around lunchtime, and the cafeteria, operating with a skeleton crew, was serving nothing but a simulacrum of Thanksgiving dinner (turkey, mashed potatoes, yams, stuffing, pumpkin pie). It was not as bad as such meals often are, and it was free besides.
In closing, I would like to mention that, in our various interactions with Bryn Mawr Hospital over the past several years, every staff member we've encountered -- doctors, nurses, technicians, orderlies, etc. -- has been polite, friendly, and helpful, and they seem to know what they're doing. As far as I can tell, it's a very well-run hospital, and I'm very glad that it's the one that serves that particular area.
I should say at the outset that, despite how the weekend started, things are mostly OK, at least for the immediately foreseeable future.
As some of you may know, my brother (Dan) and his wife (Gretta) live in Philadelphia, and my father lives in a retirement community in Haverford, PA, about half an hour's drive away. He and my mother moved there in 1995; my mother died in March of 2008. My father's 93rd birthday is coming up in just over two weeks. He lives independently, and engages in a number of activities in the community, but he no longer has the strength to walk unaided; he uses a walker in his apartment, and an electric wheelchair-cart to get around the complex.
Usual practice is that
jwg and I go to Philadelphia for the Thanksgiving weekend and stay at my brother's house, and we all go out to my father's place to have Thanksgiving dinner in the retirement community's dining room, where they put on a pretty nice buffet spread. And so on Wednesday, as usual, we took the 11:03 Amtrak Regional, Dan picked us up at the station, and we went to his house to wait for Gretta to get home from work so we could go out to dinner.Except that, when we got there, Dan found a phone message from Dad reporting that he had checked himself into Bryn Mawr Hospital, without much in the way of further detail. He called the hospital, and was able to talk to Dad (who I guess was in the process of being evaluated to see if he should be admitted) and ascertain that Dad had been feeling increasingly listless and weak for several days, and finally decided that he needed medical attention -- a very good decision, as it turned out.
Eventually we all got out to the hospital, where they let us stay with Dad in the ER and then in his (private!) room in Telemetry after he was admitted; we didn't leave until almost 10:00 PM, never mind visiting hours. It had been determined that his potassium was alarmingly low, as was his blood pressure, and he was seriously dehydrated; some numbers relating to his kidneys (creatinine and Blood Urea Nitrogen [BUN]) were abnormally high, suggesting reduced kidney function. He was on an IV drip to increase fluids and potassium, but didn't look too bad, and was feeling OK other than being really weak.
Thursday morning they had him sitting up in a chair, but when he tried to go to the bathroom (with assistance, of course), he became woozy and faint; it was determined that his hemoglobin level, as well as his blood pressure, was dangerously low, so they decided to give him a transfusion; during the course of the day he was given two units of blood, and he was also put on a urinary catheter. When we arrived early Thursday afternoon, His blood pressure was still very low (around 80/40), and so he was also on a very slow saline IV drip. During all this time he was steadily feeling better, apart from still being quite weak.
It's still not entirely clear what triggered all this, but from what we've been able to piece together, it's something like this. A couple of months ago he had an episode of congestive heart failure, manifested primarily as excess fluid in his legs and some shortness of breath. As a result, his primary care physician put him on the diuretic Lasix (or increased an already prescribed dose), which resolved the situation, at least for the moment.
More recently, at the urging of Dan and Gretta, he started a program of physical therapy in order to improve his strength and balance, which he entered into with enthusiasm -- probably too much enthusiasm, as he reported to Dan something about an hour of exercise at a time. This brought on a recurrence of the congestive heart failure symptoms, so his doctor recommended that he suspend the PT, and also (we think -- Dad is a little vague about this) increased the Lasix dose. This may have triggered the dehydration, which in turn stressed his already weakened kidneys; the symptoms that led him to go to the hospital are consistent with kidney failure. (The fact that he had at some time in the recent past had a course of injections of Procrit also suggests that his doctor had already detected reduced kidney function.)
So, bottom line: neither his heart nor his kidneys were really doing their job. It's worth mentioning at this point that. whatever physiological problems he's having, one organ that's definitely still pulling its weight is his brain. He's a highly intelligent and well-educated individual, and there's been no sign of any cognitive loss.
Well, back to the narrative. By Friday his blood pressure was back up to normal levels (120/70 or thereabouts). He was somewhat tired when we arrived in mid-afternoon -- he's been taken downstairs for a kidney ultrasound, which had taken rather longer than expected, but after a short nap he was more animated than he had been up to that point. He was able to sit in a chair for extended periods, although the process of getting into the chair was a little difficult, mostly owing to balance problems. At this point the principal concern was his kidneys; the BUN number was improved, but the creatinine was still high, and the nephrologist was unwilling to discharge him until it came down to manageable levels. (Assuming that, with some mild physical therapy, he would be able to be up and around in the next day or two, this was the only remaining obstacle to his being discharged.) She had asked Dad earlier that day if he would accept dialysis; according to his report of the conversation, he replied that he didn't think that he had any choice, since he supposed that death from kidney failure was very painful. On hearing that it was not (she apparently said that one would just "go to sleep"), his inclination was to refuse dialysis, but the stage at which that decision would have to be made had not been reached.
We stayed through his dinner (a not particularly satisfactory meal, but much improved by a serving of Gretta's excellent apple crisp), and he was increasingly animated and cheerful. Dan, Dad, and I had had an email exchange a couple of months ago about some of the history of Dad's family (a subject on which Dan and I have been almost entirely ignorant our whole lives), which ended with a mutually-expressed hope that we would have lots to talk about at Thanksgiving; at this point, when we were starting to think about leaving for our own dinner, I reminded him of this exchange, and said that I still wanted to have that conversation, really thinking that we would have it sometime in the near future. But Dad seemed eager to talk, so we stayed another hour while he told us stories about various relatives of whose existence we had either only had vague ideas or not known about at all. It was a nice high note to end the visit on (John and I were leaving to come home Saturday morning, and we had all agreed that it was not necessary for us to change our plans.)
Sometime during this visit Dan had had a phone conversation with the nephrologist (while he was out feeding the parking meter, as it happened), in which she had told him that if the indicators did not improve in the next couple of days, it would indeed come down to a choice between dialysis and death. The four of us discussed this aspect of the situation after we got home, and agreed that, if it appeared that something approaching his present quality of life could be maintained, we would encourage him to accept dialysis, but that it was ultimately his decision, and we were prepared for the possibility that he would refuse. Dad has made it clear in the past (see this entry if you want yet more details), and reiterated during this episode, that he does not want to be kept alive by "heroic measures". He's enjoying his life, and is in no hurry for it to end, but he also recognizes that it will end eventually (and, in the grand scheme of things, sooner rather than later), and says that he is ready.
John and I did return home on Saturday. An hour or so into the train trip, Dan called me, giving me a moment of alarm, but it turned out he was calling with good news: the kidney numbers were much improved, dialysis was off the table for the present, and the plan was to discharge Dad in the next day or two.
One further hitch developed on Sunday: They took the catheter out that morning, but by evening Dad was still unable to urinate. Apparently his prostate is sufficiently enlarged to block the urethra; he has been on prostate-reducing medication for years, and it's possible that they took him off it in the hospital (John says that such drugs are also blood-pressure reducers). Anyway, they put the catheter back in. I spoke to Dad this morning (Monday), and he's been seen by a social worker and a physical therapist, and took a walk down the hall with his walker, and is generally feeling good. He is going to be discharged this afternoon (with the catheter still in), and will be temporarily in the skilled nursing facility at his retirement community. He's scheduled to go to a urologist's office in a couple of days in the hopes of figuring out what's going on with his urinary system.
The expectation at this point is that he can go back to his normal life (still with the catheter if necessary, which would be inconvenient but not disabling) fairly soon; they'll want to keep him in the nursing facility for a little while, I guess, to build up his strength with some more closely supervised physical therapy. There will also be the delicate matter of adjusting his medications properly, which at this stage seems to be a very tricky balancing act.
All things considered, this is about as good an outcome as could have been hoped for. We've been able to joke that it was very considerate of him to schedule this crisis at a time when we were coming to visit anyway. One thing's for sure: I'm not letting it be another year before I go visit again.
Oh, and that line up there about Thanksgiving dinner? Since it was immediately clear that we were not going to be having it at the retirement community, Dan and Gretta decided to cook dinner for the four of us Thursday night -- not turkey, but a very nice meal centering on pork chops smothered in onions and mustard, plus the aforementioned apple crisp. But we ended up at the hospital at around lunchtime, and the cafeteria, operating with a skeleton crew, was serving nothing but a simulacrum of Thanksgiving dinner (turkey, mashed potatoes, yams, stuffing, pumpkin pie). It was not as bad as such meals often are, and it was free besides.
In closing, I would like to mention that, in our various interactions with Bryn Mawr Hospital over the past several years, every staff member we've encountered -- doctors, nurses, technicians, orderlies, etc. -- has been polite, friendly, and helpful, and they seem to know what they're doing. As far as I can tell, it's a very well-run hospital, and I'm very glad that it's the one that serves that particular area.
