Al

[hensylee]

my brother is extremely ill. He was in renal failure but they brought him back and he's now in nursing home rehab. He's been on coumadin for years to prevent a stroke (a-fib and a-flutter all the time). He knocked over his wheelchair the other night, hurt his head, limbs - which are now bruised. The in-home doctor is taking him off coumadin because she fears a bleed out. She says she's more afraid of a bleed out than a stroke. Is this wise thinking?

 

[geebee]

Ann,

Sorry to hear about your brother - I will add him to my prayers.

I know this thread was really for Al but, since I can't sleep, I will add my thoughts. It seems to me that taking your brother off coumadin after the fact will not help but could only hurt. Since it takes a couple of days for coumadin to get out of the system, if he were going to "bleed out", it would happen anyway. Taking him off coumadin only increases his risk of stroke.

Obviously he needs to be watched for signs of bleeding but the doctor is just adding another problem to the mix by stopping the coumadin.

 

[hensylee]

I have to agree with that, even with my limited knowledge of coumadin.

Starting Monday she has ordered complete blood workup. He has kidney infection again in his remaining kidney and they have put him on antibiotics. He has a stent from bladder to kidney because of a stone stuck just above the bladder and another high in the kidney. He's receiving med to dissolve these stones.

He is at the point of non-communication and I am sure he will not make it - at least not very far down the road before he succumbs.

I just want him to be comfortable during the time he has left. He has suffered enough and his life is pretty much a matter of suffering to the end of it.

Thanks for your prayers - I only pray that he no longer suffers as he has for such a long time.

 

[Granbonny]

Good Mornin, Girls

Good Mornin, Girls

We can all have a cup of coffee together.. Ann, thanks for your e-mail...I'm keeping Richard in my prayers..and..you, too Bonnie

 

[Ross]

I concur with Gina.

 

[Yaps]

Sending prayers for your brother,wish I had an answer for you.love Yaps

 

[Wise]

I don't any answers, of course. But, I can pray and I have. I hope for the best for you and your brother.

 

[twinmaker]

Ann, you and your brother are in my prayers. LINDA

 

[Phyllis]

Just wanted to add my prayers and best wishes, Ann.

 

[Karlynn]

Ann, your brother is in my prayers.

 

[Guest]

Ann,
You and your brother are in my thoughts, too.

Once a person and the family members are in agreement that life will problbly end in six months or less, I question the value of warfarin.

When a person is unable to take in nourishment to a proper level, the serum albumin (protein) starts to drop. Most of a dose of warfarin that anyone takes gets bound to the albumin and is just caried around in the blood as an inactivated chemical. Being malnourished over time will lead to a smaller and smaller proportion of warfarin being bound. This will lead to more and more active warfarin and as we all know that means higher and higher INRs with the accompanying risk of bleeding.

(I have talked to many family members about this in my clinic and it is never easy. Each person has to make their own decision on this.)

If you were sitting with your brother which would you be more tolerant of:

1. He has a stroke and slumps over in his chair or bed and gradually slips away over the next week.

2. Blood begins to gush out of his nose. He is rushed to the hospital and given transfusions and other heroic measures and finally is declared dead after all efforts to revive him fail.

Thirty years later this still brings tears to my eyes as I write it. My first wife died from a brain tumor in the manner described in #1. She was surrounded at home by her husband, two small children, her mother and father, and a beloved pastor.

While you may not be able to care for him by yourself at home in the final days, I think that you get my point.

 

[Glenda]

Ann, I so agree with Al. In ICU I see so many really sick patients that for all medical reasons will not make it and their families will keep them alive on a venitalor for weeks. This is such a strain and financial burden on the family and friends. A patient needs to be given the right to die with dignity and without pain. My prayers are with you and your brother.

 

[Praline]

I do not have any answers for you...

I do not have any answers for you...

but I am sending prayers your way.

 

[hensylee]

Al, thank you for your wisdom and kind words. Yes, I get the idea.

the point about the food intake is right on target. He's not eating, except he eats a fair breakfast, so I suppose the warfarin was gathering up in his body. The doctor apparently has made a good decision.

I believe the doctors have already 'kept him alive' when he went into renal failure - they brought him back to 'nothing'. Maybe they had to do it, but I will always believe in 'do no harm'. They did harm.

He now has infection in the remaining kidney again (lost the other one to cancer about 5 yrs ago.)

I will forward your post to our sister, Nancy. She will appreciate knowing this, too. I fell apart and turned my brother over to her and she willingly stepped in and is being a real trouper. Ten years is a long time and at the end, I just couldn't handle it, ending up in the hospital myself but that's another story.

I didn't know about your wife and I am so sorry for you and your children. YOu loved her very much, I can tell. I expect it changed your outlook on life as you knew it. Perhaps that's how you got into your profession. You have come a long way from that time.

Thank you so very much, Al. You are invaluable to all of us, you know. In so many ways.

 

[Guest]

I believe that we are called/sent to be where we are needed the most.

BTW I survived. My son was in 4th grade when his mother died. The next year I married his 4th grade teacher. Beware of parent-teacher conferences. LOL We have been happily married over 28 years.

 

[EVELYN]

Hi Hens

I'm so sorry to read this thread.....I haven't been on much; got a new laptop and am trying to figure it out!!! WAAAAY too advanced for moi.

I will put you both in my prayers. I'm so sorry to hear this terrible news.

Ev

 

[hensylee]

From Nancy:

From Nancy:

I sent this link to Nan and here is what she sent to me:

Thanks. Dr. Christopher said just what Al said. Did we want Richard to
have a stroke or possibly a wound and bleed to death. I think she has
suggested the right thing.

 

[DrAllan]

The physician in me makes me want to comment. A stroke is the interruption of blood supply to the brain. It can occur basically from two mechanisms. First, and a primary concern of those of us on Coumadin is a portion of clotted blood traveling from where it formed to the brain. The second is the breaking of a blood vessel in the brain itself. The concept gets more complicated in that depending on which part of the brain is affected determines the clinical picture. If a motor area is involved then one sees weakness or paralysis. If it affects the areas of speech then various types of communication are lost. If it affects the portion of the brain that controls breathing then one can slowly or quickly die by suffocation. There are many other scenarios. What I wish to point out is that many times a stroke victim remains alive but severely disabledfor long periods of time. Choosing to terminate ones life by withholding Coumadin probably works because one tends to have multiple emboli of clot to multiple areas of the brain. It is rare to have a massive embolic stroke that instantly kills one.

 

[Guest]

Dr. Allan,

I agree with you.

My point was that it is possible for someone who has a stroke to die peacefully surrounded by family. It may take a few days for death to occur (as I pointed out). However, it is usually easier for for family to withhold feeding tubes and IVs for someone who may not be able to hold a cup or spoon than it would be to sit and watch them die by bleeding.

I've had this discussion repeatedly with physicians. I respect their point. They are trained to do everything possible for a patient presented to them. It is just that if there was some miraculous treatment that would bring the person back, it would have been performed years ago.

I was thankful that my first wife's physicians asked me if I could care for her at home. Both the neurosurgeon and the oncologist had seen her just two weeks prior to her going into a coma. We went to both offices the same day. When we left both offices both physicians had tears in their eyes. She had a gliobastoma multiforme that grew from 1 cm to 5 cm in one week after diagnosis. I was told in November 1974 that she could not live to see Christmas. She lived until February 1977. She had a pretty good two years except for the rapid deterioration over the last six weeks.

Now I am faced with a dilemma with my mother. She is unable to walk or even stand. It would be advantageous to have her on warfarin. However, each time it is started she gets a GI bleed and needs blood prodcuts. She will probably die of a blood clot to her lung. She does not want injections every day.

My father probably died from a blood clot in his lung. He was about 80 when a tumor in his bladder was discovered. About every 6 months the urologist scoped his bladder to monitor progression. He was on warfarin, but they stopped it to scope the bladder. The previous two times the warfarin was stopped he developed massive clots in his legs. One required a bypass graft. I told him that he was probably going to die from having his warfarin stopped to have his bladder scoped. Sure enough three days after the next time it was stopped he was eating breakfast and said to my Mom, "I don't feel good" and he crashed to the floor. She was unable to get down on the floor to give him CPR. He was dead by the time the EMTs arrived.

I just want people to know that I am not just basing my advice on some theory. I have lived through two similar deaths and am facing a third.

 

[hensylee]

Dr Allan, I am so glad you stopped in. I want to thank you for your alert. After your previous statements when he had blood in the urine, I had him to two doctors - neither picked up on the problem. Lab showed nothing either. By the time the assisted living nurse decided he was in real trouble, staring into space and speech was unintelligible, we had him ambulanced to hospital where they found a kidney stone just above the bladder and one high in the kidney. He's receiving medicine to dissolve these stones. He also had pneumonia and was totally dehydrated (dry as dust, the dr said) and in renal failure, would die if not given dialysis. He was transferred to a larger hospital where a stent was put in between the bladder and kidney so that urine could pass, then dialysis was done twice. The stent is still there and the nursing home doctor said the urine is cloudy and she has begun antibiotics and ordered blood workups for Monday. Would a stent cause infection? After a time in the hospital (two or three weeks or more) he was sent to nursing home rehab where he still is and the staff there tell us he will never leave a nursing home. His speech is still unintelligible, but he recognizes us, then immediately stares and reaches out for something that is not there. He is non-responsive to conversation. He has become very thin, eats breakfast but little else during the day. They say he puts orange juice on his grits; probably thinks it's butter, but he seems to like it! He is now non-ambulatory, but he was walking well two days before he was hospitalized. He does not appear to have had a stroke (no physical signs that I can recognize) but something has happened to cause his inability to communicate and the inability to stand up alone; it makes me wonder about some sort of stroke. He has non-classical parkinson's, as well. also a-flutter that becomes a-fib from time to time.

We are just at a loss as to what is going on here. I've kept up on his situation for ten years and studied as much as I can find in order to be informed and understand whatever his doctors say. But this has become a real puzzle to me now.

Thank you for the information you have given. This site is a Godsend when we are in trouble. There are always members who give us another view.