Azygos
Flags For Our Troops
Israel
I'm on Fire
posted 20 Sep 07
I would like to relate a recent story about a 96 Y/0 gentleman living in a nursing home and the battle that ensued over his care. For those of you out there wishing for Universal Health Care you might want to view this as a warning. Just to be clear this was a real patient and this happened within the past six months.I am a Nurse Practitioner and was working in Long Term Care (a euphemism for Nursing Home) and caring for about 100 patients.
Some of these patients are always nearing the end of life as was the patient I am writing about. He was a very frail 96 year old white male with dementia, psychosis, and in a state of failing to thrive. His dementia had advanced to the point that he had almost forgotten how to eat. This is normal for a diagnosis of end stage dementia. The patient also had a long-standing history of needing antipsychotic medication to control his psychotic episodes, though he currently was not on any antipsychotic medication because we had been able to control his condition without them.
His psychotic episodes differed from other patients I have had with a history of psychosis. His psychotic episodes consisted of him believing he was on fire. He would scream “I’m burning” over and over and beat on his body trying to put out the flames. His psychosis was terrifying to his state of mind so much so that he was hindered from eating or participating in daily activities. He became increasingly psychotic to the point that the usual means of redirecting him was no longer working.He also no longer recognized the person who was his Power of Attorney (POA The person who was making medical decisions for him).It was late on a Friday afternoon when I decided it was time to discuss with the POA starting him on an antipsychotic medication as his condition had deteriorated severely over the previous week. He was already on a Hospice service as we expected him to die soon and the POA wanted him as comfortable as possible. After a long discussion with the POA we agreed that Haldol, an old but potent antipsychotic that he had been on before, would be an acceptable treatment regimen.
As the patient was in a state of acute psychosis it was necessary to start at a low dose and rapidly increase it to get ahead of the psychosis. So I started him at 1 mg haldol every 6 hours to no effect. After close evaluation I increased it to 2 mg haldol every 6 hours, to no effect. After further evaluation I increased his haldol to 4 mg every 6 hours. At this dosage the patient suddenly started eating 100% of his meals and was able to recognize his POA. He began participating in daily activities and the psychosis seemed to be resolved. Before he was unable to communicate his needs or eat even 20% of his meals, now he was capable of carrying on a conversation without difficulty. It was truly an amazing resurgence of his intellect and the POA was ecstatic with the change.
To be sure I was not over-treating him I reduced the haldol to 2 mg every 6 hours and his psychosis returned. I again increased the dose to 4 mg every 6 hours and all was fine. The maximum dose recommended in the government guidelines (Keep the word GUIDELINES in mind please) is 3 mg of haldol per day for a person this age however I have had patients taking 90 mg haldol three times a day with no ill effects so I felt we were safe in treating him with 4 mg four times daily.It was that time of year for the state department of health to do their yearly survey and so they came. About 10 AM I was called and told to see the administrator immediately. I met with him and was informed the building was to be shut down by the state inspector because this patient was on 4 mg haldol every 6 hours and the guidelines were that a maximum of 3 mg per day could be used.
Lets review- 96 year old psychotic male beating himself to put out the flames. Starts taking an antipsychotic and now is participating in eating and social events that he was not participating in before. I’m told if I don’t stop the medication immediately the building will be shut down. This is an 8.4 million dollar a year business, the owners are not happy with me. I sit down with the director of nursing and the administrator and arrange for a psychiatric nurse practitioner to see the patient later that day. The state inspector accepts this and backs off his threat to close the building. Keep in mind the state inspector is a licensed Registered Nurse.
The psychiatric nurse practitioner sees the patient that evening and stops the haldol and later tells me she stopped it because of threats and intimidation by the state. I arrive at the building at 6 AM to check on my patients. I check on this one and he can be heard screaming from a unit away. When I get in the room he is pounding his fists on the wall and screaming “I’m on fire, put out the fire.” His left hand is severely swollen and black and blue. I order an X-ray of his hand and write a long note detailing what has occurred including charting the name of the state inspector making the threats and intimidating statements.
I write in the chart that the patient is experiencing harm psychologically and physically because the state inspector is practicing medicine without a license and perhaps I should call the board of nursing and report him to them (This was basically me threatening the inspector).Later in the morning the inspector reads my note, more threats to close the building were issued by the inspector. The inspector is also mad at me because I put his name in the chart which makes him legally responsible for practicing medicine without a license. I also gave his name and phone number to the POA who called and called him on the carpet for interfering with a patient’s treatment.
The patient was harmed because bureaucratic morons strictly adhered to guidelines they did not understand. I don’t treat guidelines I treat people, and that is the fundamental problem with bureaucrats. They follow the guidelines to the letter even when it is clear and apparent that one needs to step outside the guidelines. If we allow universal non-health care to be enacted this is the type of treatment we can all expect to encounter. This poor old man was tortured at the demands of the state.
The POA fed up with the state interference moved him to an inpatient hospice where he died much sooner than he probably would have if the state had not interfered with his treatment. The nursing home had been his home for 13 years and the POA was heartbroken that she had to move him from his home.
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