The Houston Chronicle has an unusually good and balanced article on one case in the on-going debate in Texas on the end of life care, originally published May 6th.
The article uses the example of 91 year-old Mrs.Edith Pereira, and the way that her daughter, Zee Klein, made sure that she got the care that Mrs. Klein believed she should have:
Taking action on her own
Zee Klein wasn’t about to just let her mother die, no matter what some hospital committee decided. But instead of waging a high-profile fight against the hospital, she decided to get her mother out on her own.
It wasn’t going to be easy. For one, Medicare wouldn’t cover Pereira’s care if she were transferred to Christus St. Joseph, the downtown hospital where a doctor had agreed to take the case. Her coverage for her particular diagnosis already had been exhausted at Memorial Hermann.
Further complicating matters, Pereira’s condition was deteriorating fast — by the time the hospital’s futility committee ruled, she was in respiratory distress and her kidneys were failing. Doctors wrote in her chart that the discharge was against their advice.
“The patient was unstable,” Castriotta said. “Given how sick she was, doctors felt her release would be dangerous.”
The moment wasn’t lost on Klein.
“She looked like she was in the throes of dying,” said Klein, 68, who had previously cared for her late husband when he suffered a stroke and numerous heart attacks. “We didn’t know how long she had.”
Still, Klein had a plan. She would have her mother transferred back to St. Dominic nursing home for several hours, then taken to St. Joseph’s emergency room, where federal law would require she be admitted.
But would she make it? Pereira’s condition was so precarious that paramedics gave her oxygen through a respirator and stood ready to take her to a closer emergency room if it looked like she wouldn’t survive the drive to St. Joseph.
On the afternoon of June 26, Pereira was discharged from Memorial Hermann and started the journey.
`Extremely poor’ prognosis
Pereira made it to St. Joseph Hospital, but doctors summed up her prognosis in two words: “extremely poor.”
It was understandable. On the day she was admitted, Pereira’s problems included pneumonia; sepsis, a potentially fatal blood infection; dangerously high blood sugar; severe dehydration; a urinary-tract infection; kidney failure; and respiratory distress.
Doctors worked diligently over the next 72 hours to stabilize Pereira, giving her antibiotics, putting her on intravenous fluids, balancing out-of-whack electrolytes that were causing the kidney failure.
Pereira improved significantly, and St. Joseph scheduled an ethics committee hearing to consider all the options, which included inserting a gastric feeding tube. Many doctors, like those at Memorial Hermann, thought that the case seemed futile.
But Klein had one thing in her favor. St. Joseph, which since has been sold to Hospital Partners of America, then was a Catholic hospital.
“We follow the U.S. bishops’ directive that the presumption be in favor of nutrition and hydration as long as the benefit outweighs the burdens on the patient,” said Mike Sullivan, an administrator at Christus Health Gulf Coast, St. Joseph’s corporate headquarters before the sale. “At a Catholic hospital, food and water are considered comfort care.”
The ethics committee persuaded Klein to put a “do not resuscitate” order on her mother in the event of a cardiac arrest. A week after the meeting, a St. Joseph gastroenterologist inserted the feeding tube.
On Aug. 12 — a month later, finally free of all infections — Pereira returned to St. Dominic nursing home.
On the one hand, there’s a lot to be said for the fact that Mrs. Pereira lived another 8 months and was stable for a while. Mrs. Klein spoke about her mother “firing” a nurse when she told her story to the House Public Health Committee meeting last August 9th, while Mrs. Pereira was still in the hospital. (RealPlay Video at about 8:00/12:38 to about 8:20/12:38 on the timeline) On the other hand, Mrs. Pereira was put through a lot of invasive interventions in the hospital, on a ventilator, dialysis, and other treatment for multiple organ failure, with several readmissions to the hospital over the next 8 months for infections. The last was for treatment for respiratory failure, ending with her death in a long term acute care hospital.
I especially like one of the comments from a reader, “KISDteacher,” speaking about the care of her own 100 year old grandmother:
When it takes more than God to keep her alive, she made it clear that she doesn’t want to keep going.
As I approach the first Mother’s Day after my mother’s death,I’m glad that she was spared the debates over feeding tubes and resuscitation. And I am so grateful that I was with her when she died and that I can remember rubbing her back and using a straw and spoon to feed her the afternoon of her death.
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