Wednesday, April 26, 2006

Your Truth: Decision Making Power

The following ethical scenario was proposed by reader JP.

As is custom, please read the scenario, share your thoughts or recommendations in the comments section and in a few days I will post a follow-up detailing the actual outcome in a related scenario.

Ms. Baker is a 84 year old woman with end-stage renal disease. She has been dependent on dialysis for the past ten years. She is currently in the hospital in the intensive care unit for sepsis (a bacterial infection in her blood). She also has a number of other co-morbidities including COPD (chronic obstructive pulmonary disease) and coronary artery disease.

When you walk into the room, the dialysis nurse pulls up to the bedside with the dialysis machine. As it appears, Ms. Baker tells you, "I am so miserable. It is so unfair that I have been so sick. Do you know the meaning of misery?"

The notes in her chart say that the family and the patient have decided on a DNR (do not resucitate) code status and have been made aware of her poor prognosis. You notice on the monitor that Ms. Baker's blood pressure is only 84/43. This is a very low pressure and the dialysis will likely drop it lower.

As the health care provider, you accept the responsibility for ensuring Ms. Baker is aware of her options. Accordingly, you say, "Ms. Baker, you can refuse dialysis at any time. It's actually a very peaceful way to go. You just fall asleep and don't wake up again."

Ms. Baker looks contemplative and asks, "Is that so?"

You assure her it is.

Ms. Baker looks thoughtful for a moment more. "Well, I want dialysis today."

When you leave the bedside, you search out the patient's children. When you find them, you explain to them the converation you had with the patient and why - she seemed miserable; her prognosis (as they know) is very poor and she should understand what her options are. The family is very angry that you have had this conversation with their mother and go so far as to tell you never to visit the patient again.

Some questions for your consideration:

1. Should patients be informed of their options?
2. Should families have the right to withold information from a patient?
3. How might you handle this situation from here?

Saturday, April 22, 2006

Symptomatology: Malodorous Wounds

I have been slowly making my way through the symptoms experienced at the end-of-life. The next symptom I would like to address is the malodorous wound.

People may have malodorous wounds for various reasons throughout their life. However, there are certain wounds seen more often at the end of life. Some of the malodorous wounds seen at the end of life include bedsores and fungating breast cancer lesions. The odor is caused by anaerobic bacteria in necrotic (decaying) tissue, which release volatile fatty acids as a metabolic by-product.

The odor can impact the quality of the patient's life and may lead to social withdrawal, embarassment, shame, and psychological distress.

Some possible interventions for managing these wounds include:

-Cleanse the wound with water or normal saline.
-Metrogel 1% applied to breast cancer lesion daily and covered with an occlusive dressing (such as vaseline gauze). Metronidazole (the active ingredient in Metro-gel) may also be taken orally. The oral form is less expensive, but the few studies that have been performed have shown marked improvement in odor with its use.
-activated charcoal / odor-absorbing dressings. These dressings should be changed daily or more often if the odor becomes noticeable before the next dressing change is due.
-Peppermint oil - many pharmacies carry this oil. You can place gauze in the top with the lid off and it works as an air deodorizer. Peppermint oil is a much more tolerable air freshener than most air deodorizers. Do NOT apply peppermint oil directly to the wound. You can also apply peppermint oil to a wash cloth and drape over a fan or air conditioning vent. Peppermint oil should not be used alone, as it may become associated with the smell of the wound and lose effectiveness.
-Palliative radiation is another option and may help to heal the wound.

Although this post focuses on odor, always remember to treat the pain associated with any wounds.

See Prodigy Guidance for additional information on malodorous wounds.