Brutal vs. Practical

I’m on call for our practice this week, which means I’m rounding on our inpatients. One of our patients, Henrietta, is a woman in her 70’s who has fairly advanced dementia; she is no longer able to walk, and had developed a very large blood clot in one leg, which is why she was admitted from her nursing home. She’s had a slow cognitive decline over the past decade, due to a series of strokes, due to her heavy smoking. But, in spite of serious memory deficits and no family, she was able to live in her own apartment right up until last fall, because she has an amazing circle of friends. These lifelong friends would take turns at her apartment, making sure she was clean and dressed; they prepared her meals, and paid her bills. I learned all this over the weekend from reading through her chart- I’d never met her before.

I couldn’t quite believe that anyone could have such a caring group of friends, but then, I met them also, and they really are remarkable people. Henrietta is now bedridden, with waxing and waning mental status: sometimes lively, sometimes disoriented and delusional, and sometimes catatonic. Yet they still come to see her, and spend a long time holding her hand and praying with her.

Because Henrietta is so catatonic at times, freezing up like a statue and just drooling for hours, we asked our psychiatric team to see her, to see if depression could be playing a role, on top of her dementia. Depression in the elderly can do strange things. The psychiatrist spent a long time interviewing Henrietta’s friends, as they couldn’t get any useful information from Henrietta herself. These friends spent a lot of time, and helped so much in the development of a good plan for some new medications trials. It was really very touching.

Which is why I was so bothered by the social worker. The social worker, a usually very nice lady, was asked to see Henrietta to evaluate the plan to go back to the same nursing home. Henrietta now has an extremely large blood clot in her leg, which at any time could dislodge and make its way into her heart and lungs. This is called a pulmonary embolism, and for her, this would be fatal. We had advised her friends of this possibility. The only possible treatment for Henrietta, given all of her other medical issues, was blood thinners. These really only prevent the clot from getting larger; they can’t prevent a pulmonary embolism. My question to the social worker was, can Henrietta’s current nursing home manage her blood thinners and care now that she has this clot diagnosis?

The social worker looked down at me over her wire-rimmed glasses and said, “Well, if that clot dislodged and killed her, that would be a blessing for all of us, now, wouldn’t it? Seriously.”

I was taken aback by that statement, but my response was, “Well, that’s not something we would really mean, is it?” kind of half-seriously chastising. We breezed over the statement and spoke briefly of nursing home logistics and paperwork. That was it.

I put it out of my mind for the rest of the day, but now that the busy clinic day is over, I can’t sleep thinking of what brutality was revealed in that social worker’s statement. Or was it? Was it simply a more practical viewpoint?

5 thoughts on “Brutal vs. Practical”

  • Wow, the SW’s statement was harsh, and clearly inappropriate & unprofessional to voice such an opinion out loud at work. On first instinct, it smacks of the prejudice against the elderly that is so prevalent in our society, and somewhat sickens me, as I deal with my own aging parents & relatives.

    But the real question is whether her opinion in and of itself, represents cruelty or practicality. Reading over your vignette, it seems that Henrietta still has moments of clarity & a wonderful circle of friends & supporters—i.e. reasonable quality of life, and thus, prolongation of that life would be in her best interest.

    But maybe the SW didn’t have the whole story? If she saw Henrietta only in the catatonic state, and noted that she had no family support, she may suppose that Henrietta was suffering & miserable, and that prolonging her life would only prolong that suffering. Possibly the SW, particularly if she specializes in geriatric care & nursing home placements, has seen such scenarios frequently, and wondered at our efforts to prolong life at all costs, regardless of the quality of that life.

    BTW, this is a really interesting & important question, and you have presented it so eloquently—I really adore & admire your writing style!!!

    • Thank you so much for your thoughtful comment. You are right; I suspect that the SW did not have the full picture, as I had. I feel that it was my place in the moment to (gently) point out that her comment was unprofessional, and that this patient has a better quality of life than she assumed. Why I didn’t, I’m not sure, I think I was a bit shocked; I’m trying to take a lesson from this.

  • Speaking as someome who has a Mom with dementia who lives a pretty good life considering that “everyday is a new day” I would be furious with the social worker. I enjoy the fact that my Mom loves holding her great-grandbaby and for that great-grandbaby there will be pictures and stories to tell. For my family there is time to come to terms, time to let go, and time to remember. I am angry for the friends who are still there for her for the same reasons – coming to terms, letting go, remembering. I am angry for the “death panel” that seems to be looming (at least in the social worker’s mind). While I do not hold with for heroic measures in the face of continued deterioration, blood thinners seem to be a non-heroic choice. Thanks for giving me reason to vent about this. I see dementia in my future and hope that I am never consigned to the waste bin before my time.

    • Thank you- and as an addendum, after a trial of a new medication (Ativan, of all things) “Henrietta” is loosened up, moving better, awake, and interactive. Better able to enjoy her friends at her side, which is really what it’s all about!

      • Jumping for joy for “Henrietta” and everybody else in her situation. Thanks for the update!

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