living your best to the end

Pain as a Cause of Agitated Delirium

“Can’t you do something about her pain?” An 85-year-old woman with multiple medical problems, including dementia, coronary artery disease, renal insufficiency, and peripheral vascular disease, was admitted to our hospital with urosepsis. Her hospital course was complicated by the development of dry gangrene of her left foot, Candida sepsis, Clostridium difficile enterocolitis, and multiple deep sacral and trochanteric pressure ulcers. When housestaff asked her son if he wanted us “to do everything,” he always answered yes. She was able to be weaned from the ventilator and was transferred to a medical unit for continued treatment of hospital-acquired C difficile enterocolitis and wound care of her multiple stage 4 ulcers. She underwent 4 surgical debridements under general anesthesia in the operating room over a several-month period but remained persistently febrile despite continuous treatment with broad spectrum antibiotics. The patient was withdrawn, tense, and turned toward the wall in a fetal position, but she screamed and cried out for her mother, moaned in pain, and tried to hit and strike out at the nurses when they performed her twice-daily dressing changes. She refused all efforts to feed her or offers of sips of fluid and received all nourishment and hydration through her feeding tube. She did not respond to the voice or touch of her son or grandsons when they visited. On day 63 of her hospitalization, a palliative care consultation was requested by the nurse manager on the floor because of nursing staff distress about their perception of having to hurt the patient during dressing changes. With the agreement of the attending physician, who had refused to give medication, on...

Dignity Therapy at Life’s End: Thank you Dr Harvey Chochinov

Dignity Conserving Care asks at life’s end: ‘What do I need to know about you as a person to give you the best care possible?’ To give an answer as a person, rather than as a health condition is a focus-changer for providers and for patients alike. As a patient – albeit feeling my healthiest –  I wouldn’t be able to answer that question without some serious soul searching.  However,  thinking about this, when depression dropped its darkness on me, I told my GP of almost three decades: ‘I so hate not feeling energetic or optimistic’. I could do that because she’s come to know me as a person. But at life’s end, will she be there with her specific knowledge of what makes me, me? My family knows me both energetic and optimistic, and fatigued and depressed. But I’ve not told my family it’s one of my worries at life’s end – oxymoron tho this may be – I don’t want to die depressed. I am aiming for a joyful departure. I feel more confident in this, knowing about Dignity Therapy: Thank you to Winnipeg’s Dr Harvey Max Chochinov  – a psychiatrist who has been forever interested in how people cope with and manage chronic debilitating and often terminal illness: Dr Harvey Chochino Dr Harvey Chochinov: “My older sister was born with and lived with Cerebral Palsy, so I was a brother who grew up knowing something about chronic life altering conditions.” Moving forward in his career, studying at Cornell, Chochinov found that in his day to day working largely with cancer patients… “what patients encountered coping with chronic, deteriorating...