Shelly was harried and out of breath when she sat down for the afternoon care plan meeting.
“Somebody had a nooner!” accused Melanie, the Social Worker. “Look, she’s blushing!”
“Cut it out, Mel,” Shelly grinned, setting up her laptop. “You’re just jealous.”
Melanie stroked her very pregnant belly. “I tried to keep up with you. See where that got me? Berta Harrington’s daughter is coming in at 1:15. That’s the only one we have today. Who is he?”
“His name is Travis. We met at Eddie’s last night.” She gave a detailed account of the events of the past fifteen hours. There were no secrets between them.
“You are full of surprises,” Melanie marveled. “How do you get into these situations?”
“I’m still trying to take it all in myself,” Shelly said, shaking her head. “I think he might be a keeper though.”
“Like you’ve never said that before,” Melanie ‘s voice was straining with the effort of bending down to pull a jar of peanut butter out of her briefcase.
“Yeah, well, we’ll see what happens. He’s invited me to help him move into his new apartment tonight. I’ll keep you posted. Now, if you don’t mind, I think we should try to review Berta's care plan before her daughter gets here. Have there been any problems with them?”
Melanie dipped into her jar before accessing the file. “Just a few,” she said wearily. “Not enough staffing, especially on the weekends. She lost a nightgown in laundry, hates our coffee. You know; the usual.”
“I hear you, believe me,” Shelly sighed. “Same shit different day. The staff works their butts off; there just aren’t enough of them.” She waved her hand at the empty chairs across the table. “Where are Stella and Tiffany? They’re supposed to be here.”
“Didn’t I tell you? Stella’s out of work indefinitely; some kind of leg ulcer or something. Cal’s trying to contract out for food service. Tiffany called in sick today. She probably got a groin pull last night.” She pushed up her bangs with the heel of her hand before taking another spoonful of peanut butter.
“You are bad, Mel, though probably right on where Tiffany is concerned; like I have room to talk. Too bad about Stella, but maybe we’ll actually get some decent food around here.”
“That would be fine with me. I’d love to scratch it off my list of complaints. The food is the number one topic at Resident Council meetings; even above staffing! I don’t think Stella realizes that old people have taste buds.”
“Who knew, right?” Shelly laughed. “Here comes Berta and Cynthia now.”
A well-kept, attractive woman came in, pushing her mother’s wheelchair. It was easy to see where she got her good looks; although frail, Berta was still lovely at ninety-three. Shelly jumped up and helped to make them comfortable. Cynthia sat close to her mother and held her hand. Melanie opened the discussion, leaning in to address the resident.
“Hello Berta, we’re here today to discuss your care. Do you have any concerns?”
The elderly lady offered a wan smile. “I’m alright, Melanie. You’re always so good to me.”
It was Cynthia’s turn. “I have some concerns,” she began. “I’m here every evening to help Mom with her supper. She’s almost always wet when I arrive and I’m sorry but there’s no excuse for it. She’s not one to complain or ask for help, and I worry about her when I’m not here.”
Berta shifted restlessly in her chair. “Oh, it’s alright, Cindy. I know the girls are busy, and I hate to bother them. They get to me when they can. I don’t want to get anyone into trouble.”
Shelly moved her chair closer to Berta’s. “I’m sorry this is happening, Berta. I think it may be because Dr. Kelly increased your water pill. You take it three times a day now. Do you remember when you had all of the swelling in your legs, a few weeks ago? You needed more medication to help with that. The good news is that you’ve lost five pounds’ worth of fluid. The bad news is that you need to urinate more frequently; and that is new to the staff. I’ll start you on a toileting schedule and put it on the aides’ assignment sheet, so they’ll know. I should have done that already, and I apologize.” What she didn’t say was that the nurses knew about the medication change, and could have anticipated the problem. They hadn’t though, and she was responsible. She tried to concentrate on signs of progress; hadn’t they noticed the edema and let her know? They didn’t have her clinical experience, and so it didn’t come easily to them, but they tried. Baby steps, she reminded herself. They would get there in time.
“Thank you, Shelly,” Berta said. “I’m afraid I have to get back to my room now. I have to go again. It’s such a nuisance. Then I’d like to lie down. I get so tired lately!”
“That’s alright. I’ll call the unit and let them know you’re on your way. Then, if you don’t mind, Melanie and I can finish the meeting with your daughter. Cynthia, are you able to come back? It shouldn’t take us too much longer.”
Cynthia indicated that she would return before escorting her mother out. Shelly closed the door and sat down. “I want to talk to her about Berta’s Advanced Directives, Mel. We need to get them in order.”
Melanie stood up. “Then I’m going to pee first. This family has had a hard time with this, and I’m not at my best with a baby bouncing on my bladder.”
Cynthia came back some ten minutes later with a sober expression on her face. She looked at Melanie. “Is there something wrong? It seemed the two of you wanted to speak to me alone.”
Shelly opened Berta’s chart. “We wanted to discuss your mother’s wishes related to her care going forward, Cynthia. I’m sure you have noticed, and I believe Dr. Kelly has spoken with you about this. Unfortunately, the state of her health is declining. The time is approaching to make some important decisions.”
Cynthia’s face fell. “I was afraid it would be something like this. Dr. Kelly told me that Mom’s kidneys were failing. I spoke to my brother in Florida on the phone last night, and we are considering dialysis treatments for her. How would we go about getting those started?”
“We can talk about that,” Shelly ventured, “but I’d like to review the medical record with you first. Here are the lab chemistry reports from this morning. Do you see this ‘BUN’? It reads critical at 90, and the ‘creatinine’ is 4.8. Those values indicate renal failure. The ‘BNAT’ is 1300; that tells us that her congestive heart failure is not under control. This happens in late-stage chronic illness.”
“But wouldn’t the dialysis help?” Cynthia rationalized. “It would bring the lab values down.”
“Let me show you another test,” Shelly said, flipping pages. “This is an echocardiogram that your mom had two months ago, before this latest bout with swelling. The ‘ejection fraction’ is a measurement of how efficiently her heart is pumping. It was ten percent; normal is sixty percent. Berta is receiving the maximum dose of diuretic- the ‘water pill’- and though it is helping for now, she won’t be able to tolerate it much longer because of her kidneys. Hemodialysis treatments are stressful on the heart, and have other side effects as well. Patients can have low blood pressure, fatigue and a metallic taste in their mouth that affects their appetite. They are usually placed on fluid restrictions, so they can’t drink more than four or five cups a day. If she began the treatments, Berta would be transported from the facility to the dialysis unit three days a week for approximately four hours; with transportation she’d be gone nearly six, and at this point she’s exhausted trying to sit up for a meal. Has your mother shared her feelings about the treatments with you?”
“The renal specialist was consulted the last time she was in the hospital. He tried to explain everything to her, but she wouldn’t hear it. ‘I’m too old’, she said. I don’t think she understood that, without the treatments, she could die!”
Melanie spoke quietly. “Cynthia, Berta has talked to me, and she was adamant that she did not want the treatments. She told me last week that she was ‘ready to go anytime the good Lord wanted to take her’.”
A tear rolled down Cynthia’s cheek, and Shelly handed her a Kleenex. “I just can’t let her go,” she cried. “She’s been an anchor for my family. We so looked forward to visiting her; I can close my eyes and smell the house. She would greet us at the door and spoil us for the duration. She was proud of our success, but we couldn’t wait to leave our new builds and go home for holidays. I loved getting up in the morning and putting my feet on the cold floor upstairs. There’d be frost inside the windows, but down in the kitchen Mom would be busy whipping up a delicious breakfast for everyone. We used to kid her about her stuffing; she would pack too much into the bird and it would be a little pasty. Do you know that last year, I tried to make mine turn out like that? It’s Thanksgiving to us. She’s been a wonderful, wonderful mother and friend to me.”
“We are all very fond of Berta here,” Shelly responded. “Our main goal is that she spends the remainder of her life as she wants. There is no assurance that she would live longer on dialysis. The treatments are intended for patients who have sufficient baseline health and quality of life to benefit from them. Your mother is not a good candidate for the therapy, Cynthia. We can continue to care for her here, in her home, and keep her comfortable. You and your family would be welcomed to spend as much time with her as you wish; even overnight. When the end comes, she’ll be in a familiar place, surrounded by people who love her.”
Melanie touched Cynthia’s shoulder. “She’s comfortable with the decision. Her main concern is for you and your brother; she doesn’t want you to be upset with her.”
“She would think of us first, “Cynthia smiled and wiped her face. “It’s very hard for me to think about losing Mom, but above all I want her to be at peace. I’ll try to explain it to Gerald. Is there something I need to sign?”
“No,” Melanie answered. “Your mother has decisional capacity to make her choices, and actually has already signed for comfort care. She does not want to be readmitted to the hospital, and has declined any further aggressive intervention. She has agreed to continue with medication to relieve her symptoms, and is considering Hospice care. I’ll let you talk with her about that, and I can make a consult whenever you decide. I would also be happy to call your brother, to explain all of this and answer any questions that he has.”
Cynthia collected her purse and coat. “I would appreciate that. It looks like it’s settled, then. I’m going to go home for awhile; I can’t face her right now. I’m afraid I would fall apart, and that wouldn’t do either of us any good. Could you please tell her that I had to leave, but I’ll be back by supper time?”
“Of course,” Shelly reassured her, offering a hug that Cynthia gratefully accepted. “And please call me or Melanie if you think of anything else that we can help you with.”
Melanie took Cynthia’s arm and walked with her to the front door.
“It doesn’t get any easier, does it?” Shelly sighed when she returned. “Thank you for being here with me.”
Melanie wasn’t listening. She was looking at the man standing in the doorway.
“They told me you’d be here,” Travis said. “I’m sorry to bother you at work, but I had to let you know that we can’t get together tonight.”
Here we go, Shelly thought. He’s blowing me off already. “What’s the problem?”
“I’m on my way to the hospital. I was moving stuff into the apartment and my mom’s boyfriend called. They think Von’s had a stroke.”