【Wanqingyi Care】Follow the patient’s wishes and do not insist on comfort at the end of life, feeding without regrets

Text ◆ Leong Man Hock (gerontologist), “Ming Pao”

It’s miserable to hear about hunger and dehydration. But the conditions of hunger and dehydration in dying people are different; as their body functions gradually shut down, they will not be hungry or thirsty.

After electrolyte imbalance, the consciousness index decreases and falls into a hazy state. The patient will fall asleep and eventually die peacefully in his sleep.

So, there won’t be much pain.

(Hong Kong News) “Dr. Liang, can you come to my house to see my mother? She has not eaten for 4 days. Now she is confused and unresponsive to calls. I am really worried that she will starve to death. Can you come and see how to save her as soon as possible? ?”

Old woman is unconscious and refuses to be admitted to hospital

The patient who called to make an appointment was the daughter of the patient, an old lady in her 80s. After receiving the call, I went to visit him that day. The patient is in a dazed state and is believed to have not eaten normally for some time. Since the old lady was unconscious and severely dehydrated, I told my family that she was in critical condition and her life might not be saved if she was not sent to the hospital for treatment.

“No, doctor.” The daughter responded immediately. “My mother refuses to go to the hospital. After she was discharged from the hospital last time, she has said hundreds of times, ‘I will never go to the hospital again! Even if I die, I will stay at home.’ We can’t bear to leave our mother. Can you save her at home?”

No one is 100% sure whether critically ill patients can be fully treated. But from the perspective of medical equipment, hospitals must be relatively complete. For treatment at home, resources are limited and we can only do our best.

“First of all, blood must be drawn for laboratory examination; secondly, the patient must be rehydrated immediately, and infusion is a must at this stage; thirdly, professional home care services should be implemented as soon as possible, both for patients and caregivers, with professional nurses coming to the door. Assisting with care is all important.”

The blood test report confirmed that the old lady was severely dehydrated, and we immediately arranged for infusion at home. Under infusion and drug treatment, the condition has improved greatly in less than two weeks, and the person is fully awake and in good spirits. Although the family is not relieved, they are relieved.

The old lady could even walk from her bedroom to the hall and when she saw me, she was still energetic enough to chat with me.

Enjoy looking at photos of Africa

She said: “My favorite thing in life is to go to the African savannah to see animals. I have been to Kenya alone more than a dozen times. Each time the experience is different, including lions, elephants, giraffes, hippos, white rhinos, antelopes, There are countless herds of zebras and wildebeests. Seeing animals in their real ecology makes me feel excited and satisfied. It makes my heart itch and I will never forget them.”

Every time I come back and talk about the African savannah, I am also a fan. Although I am not as die-hard a fan as an old lady, I have already “got into it” and have many photos taken in the African savannah on my phone. In addition to animals, the most important thing in my collection is birds. It’s rare to have a “close friend”, so I immediately took out my mobile phone to share it with the old lady. Although the mobile screen is small, we enjoy watching it.

While tasting the aged Pu’er, the old lady patiently evaluated each photo from the photography angle, light and dark, and background. She said that the most remarkable thing was the bird’s leaping attitude, and finally she praised me as a “master of bird shooting”. I felt very happy and amused by the old lady.

It seems that the old lady has crossed this threshold. If she can continue to eat normally, she should be able to slowly get better. So, before leaving, I advised: “You must hold on! Continue to eat and drink more. After absorbing enough nutrients, your body will naturally get better.”

The old lady’s daughter immediately said: “Mom, you must listen to the doctor and eat more and drink more. When you are well, we will go to Masai Mara, Kenya. Book your hotel and air tickets for October now, okay?”

The old lady nodded and said yes, and I left with peace of mind. Unexpectedly, less than 10 days later, the old lady’s daughter called again and said anxiously: “Doctor, grandma refuses to eat again! She spits out a mouthful of nutritional milk; even if it is poured into her mouth, she turns around and vomits it out. What should I do? ?I’m afraid she’ll starve to death.”

Insist on not receiving any treatment

Fasting is known to have a profound impact on the body; continued fasting can directly lead to death. Patients with anorexia nervosa will refuse to eat. Therefore, in order to save the patient and maintain life, interventional treatment must be used, such as infusion, nasogastric tube insertion, and even gastrostomy feeding.

However, this home consultation is different from the last time. The old lady was in a coma last time, but this time she is fully awake. In the last treatment, she could not express her opinions; this time we have to obtain her consent before giving treatment. Unexpectedly, when asked, she resolutely stated that she would not go to the hospital, insert her throat, receive fluids, take medicine, or accept any form of treatment.

Her attitude was serious and decisive, and she made us promise to respect her wishes, saying: “Don’t forget the promise you made after I’m in a coma.”

That being the case, there really isn’t much that can be done. I had no choice but to persuade her to eat, took a cup of Pu’er tea and a small piece of cake, and invited her to eat with me. The old lady gave me enough face, took a sip of Pu’er tea, and took a small bite of cake. But she just kept it in her mouth and didn’t swallow it; after about 10 minutes, she spit out everything in her mouth. Everyone has nothing to do with her!

Accidental force-feeding can lead to death

I could only explain “comfort feeding” to her daughter

(comfort feeding) applications and codes.

The most common solution for advanced patients who are unwilling to eat is intubation.

But how can the patient be comfortable if the tube is inserted for a long time for force-feeding?

As a result, they will resist the removal, and the doctors and nurses can only further restrain them, and the patients’ hands and even their feet are bound.

In addition to causing extreme discomfort, inserting a nasogastric tube also has risks. Accidental force-feeding can lead to death. Therefore, for patients with dysphagia, another alternative that can be considered is comfort feeding.

There are more than ten or twenty items in this plan, but the key point is: don’t force it, follow the patient’s waking time and wishes, eat as much as you want. Let patients eat as they like, at any time, as they like, and with the people they like.

Ineffective medical treatment prolongs the death process and does not force eating to avoid unnecessary pain

“As caregivers, we just do our best.” I said to the old lady’s family.

Five days later, I visited the old lady again, and my body was weaker, but my consciousness was still clear.

The daughter said: “My mother lies down most of the time and only occasionally sits up. We have tried every means to persuade her to eat, but she just refuses. The grandchildren also came back and took turns accompanying her to persuade her, but they were all ineffective. The first two Even my mother’s old friend came here and spent most of the day talking to her, urging her to eat, gain strength, and live happily.”

Daughter starves to death

But the mother replied, “She has lived enough and doesn’t want to live anymore. She wants to die naturally, and she is sober and has no regrets. She even explained that she should be cremated after death; it is best to scatter some of the ashes on the Masai grassland in Kenya. If everything If she wishes, she will be satisfied.”

I was helpless when I heard this. Since the patient has clearly expressed his wishes, his family and caregivers can only respect them. Any forced intervention in medical treatment and treatment is against the patient’s wishes.

At this time, the patient’s daughter said: “Doctor, we have accepted it now. Mom won’t eat anymore, and we won’t force her anymore. But we are most afraid of her hardship, and we don’t want her to starve to death. Can you help her not to have such a hardship?”

Died in my sleep at home

Most patients at the end stage lose their desire and ability to eat. If the family members cannot bear it and insist on sending the patient to the hospital for intubation, nutrients may be poured into the esophagus, but most of the digestive and absorption functions have declined, resulting in abdominal distension and vomiting, which will only bring more pain. Therefore, under the general principles of late-stage care and palliative care, we will not force dying patients to eat. Ineffective medical treatment will only prolong the death process and add to the pain.

Three days later, the old lady passed away in her sleep at home, accompanied by her beloved, as she wished.

More than two weeks later, I received a text message on my mobile phone: “Thank you, Dr. Liang. Mom is leaving today.” Attached were two photos, one of which was a coffin with a Masai Safari yellow jeep printed on the body. Silhouettes of different animals with trees and grass. Another picture is the front of a jeep. On the left is a photo of an old lady with a bright smile. On the right is a blue-green globe with “CHAMPION” and “The Ultimate Safari” written in the middle; a large bouquet of colorful flowers is placed on it. Flowers are so striking and wonderfully vivid.

Auntie, have a good trip.

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