Portal de Periódicos da CAPES

Mrs. GH, A Resident Who Challenged Us

2009; Elsevier BV; Volume: 10; Issue: 11 Linguagem: Inglês

10.1016/s1526-4114(09)60293-6

2377-066X

Bonnie Wirfs,

Stoma care and complications

DR. WIRFS is medical director of Lincoln Lutheran of Racine, Wis., an ecumenical ministry of care for the aging. She has practiced nursing home medicine in several settings for more than 20 years. Dr. Wirfs is active in the Wisconsin Association of Medical Directors and a faculty member of the AMDA Core Curriculum. I first became aware of Mrs. GH while doing paperwork in my office at the skilled nursing facility. I heard Ethel, a veteran certified nursing assistant, raise her voice and say, “You just had me in here a moment ago, and there was nothing you would allow me to do then. What do you want now?” Wow, I thought, this is behavior unbecoming any CNA, and unheard of from Ethel. So I talked with Ethel and then with the unit nurse to learn the background on this resident. What they told me: Mrs. GH is a 68-year-old female admitted to our facility following a partial colectomy and creation of a colostomy to relieve a colovesical fistula. She has had recurrent urinary tract infections and been hospitalized several times for multiple courses of antibiotics. She has multiple antibiotic allergies and intolerances and has been hit with both methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci superinfections. Other diagnoses include hypertension, irritable bowel syndrome, chronic anxiety, and cachexia. She plans to stay for rehabilitation and then return to her own home after upcoming surgery to reverse the colostomy. After filling in these details, the unit nurse continued: “The patient complains that she has pain and then refuses to allow me to check the colostomy bag or the surgical drain. She doesn't want the CNAs to bother her because, she says, she can do it all for herself. But then she won't do any of her own activities of daily living. She says she doesn't want her morning meds until after breakfast because otherwise they upset her stomach.” As medical director, I met with the resident and her daughter in her room, ostensibly to welcome her but also to hear, and perhaps assuage, Mrs. GH's concerns. I took a medical history and learned that she had had years of urinary and gastrointestinal complaints. The resident reported that she had been well until about 2 months before the surgery. Her daughter countered that Mom has spent most of her waking hours lying on the sofa for more than a year. The reason her father has not had a memorial service, despite having died 6 months ago, is that Mom has been too ill to schedule and attend it. Mrs. GH complained of nausea and generalized itching. For her irritable bowel syndrome, she was on multiple meds: pantoprazole, sucralfate, Mylanta prn, simethicone prn, prochlorperazine prn, diphenoxylate/atropine prn, and metoclopramide prn. She was taking diphenhydramine three times daily for her itching and the antibiotic linezolid (Zyvox) for her urinary tract infection. Her other medicines were metoprolol, alprazolam prn, and hydrocodone/acetaminophen prn. When I suggested that her medication regimen was too complicated and could be causing her itching, she asserted that I had failed to understand how significant her intestinal issues have been and that she was satisfied with her drug regimen. Her daughter accused Mrs. GH of stubbornness and refusing help from her doctors. To that, Mrs. GH responded, “I'm in pain from the surgery. They want me up for therapy, and I am miserable. I have no appetite, my irritable bowel syndrome is acting up, and the nurses want me to change this colostomy bag. There is no way I am going to touch it. My husband died 6 months ago. I have been too ill to be able to schedule a memorial service for him. My nerves are on edge, and I want to see someone about my attitude.” Mother, daughter, and I agreed to together attend an interdisciplinary team conference on how to help Mrs. GH. Physical Therapist: “Our short-term goals for the resident are to be able to transfer and sit without the use of a handrail and to ambulate 160 feet with minimal assistance. Long-term goals include ambulating about 200 feet with a wheeled walker on both level and uneven surfaces.” Occupational Therapist: “We plan to see the patient return to an independent home setting. We will be working on transfers, dressing, and toileting. So far, she has participated in bed mobility exercises only.” Dietician: “The patient weighed 76.1 pounds at admission, with a body mass index of 15.5 mg/k2. She was admitted on a general diet but requested soft food because of missing molars and chewing problems. She eats only about 25% of the meals served. She tells us that she wants scrambled eggs and Rice Krispies every breakfast and requests no spicy foods.” Social Worker: “The patient has a Power of Attorney for Health Care that is not activated. We did a Geriatric Depression Scale, and she scored positive on 14 out of 30 depression questions. She refused to answer many of the 16 remaining screening questions. She wants more sweets on her tray, and she dislikes the housekeeper moving her knickknacks when she is dusting in the room.” Nurse Manager: “She seems to meet all the criteria for clinical depression, and I contacted her attending physician. He ordered low-dose sertraline at 25 mg, but she refuses to take it.” Resident: “You're right, I won't take them. Those antidepressant medicines are poisonous, and I'm not crazy, just physically ill. Besides, I have so many drug allergies. I am sure I would have a bad side effect.” Daughter: “Mom, since you are here at the nursing home, this could be a good setting for trying out a new medicine. It isn't like being home alone. If you had a side effect, the nurses would be able to contact your attending physician or the medical director.” Resident: “No. No changes in my medications. I am happy with them.” Medical Director: “Are you aware that you are on seven different medicines for your intestinal complaints, some of which have opposing effects? Yes, I know that some of them are ‘as needed,’ but if we tried to decrease the number of medicines you take, it could improve your irritable bowel symptoms as well as relieve your itching. I can work with your attending physician to decrease these, and it may help you to feel better and have more energy in the long run.” Resident: “I don't know you. I don't trust you. I don't want you to tell my attending physician to change anything without my prior approval. I also don't want you talking with my daughter behind my back. She gets these ideas that she knows better, and she has instigated things with my prior doctors.” Medical Director: “As you wish.” Physical Therapist: “The patient has been willing to participate more in therapy. We have had many cancellations on her part because she had nausea or did not feel well, but she is making progress. She is able to ambulate about 100 feet using a wheeled walker. She also needs to climb 12 stairs at home, but she has requested not to practice this yet.” Occupational Therapist: “She can do all of her daily living activities on her own. She is able to do lower-body dressing but refuses to wear any street clothing here except for her nightgown and robe.” Nurse Manager: “She refuses to learn how to care for the colostomy bag. It upsets her to even look at it. When I come in to check it, she often sends me away saying, ‘It's not convenient.’ Then she'll have a colostomy emergency, where the adhesive has come loose from her skin and feces are oozing out. I have to change the entire setup. Since her emergencies happen almost daily, I am growing suspicious. I have never had so many colostomy bag failures before.” Consulting Psychiatrist (by report): “Diagnosis: probable recurrent major depression and personality disorder with borderline features. Plan: trial of Lexapro [escitalopram] to prevent her anxiety, pointed out to her that alprazolam is short acting and Lexapro could help prevent her anxiety. She absolutely refused to consider that recommendation. Recommended counseling. She says she'll consider it.” Medical Director: “After she told me that she wanted only her attending physician to write orders or make medication changes, I stayed away. However, recently, she has begun asking to see me or leaving me requests. When I contacted her physician, he told me that he has long been frustrated with her and I should ‘have at it’ while she's here. When she complains to me of this symptom or that, I suggest a few possible solutions. Most of the time, she'll let me try a medicine, but she always has an adverse reaction with the first dose, usually nausea or itching.” We were aware from the time of Mrs. GH's admission that she was difficult. Many a staff member, after receiving some vitriol from her, held his or her tongue and quickly left Mrs. GH's room. We learned that the most successful way to interact with her was to allow her to make all the decisions, no matter how minor, but to keep her aware of the consequences of her choices. For example, when she learned that her Medicare coverage would end if she didn't participate in therapy, her attendance improved. When she learned that she would be discharged to her home before her colostomy-reversal surgery, she arranged for home health care to come daily to change the colostomy bag until her surgery can be scheduled. As long-term care givers, we sometimes become frustrated with residents whose needs we can't seem to meet, no matter how hard we try. In these situations, we must remind ourselves that it's our obligation to care for each resident to the best of our abilities and always with respect. Mrs. GH was difficult, but I am proud of our staff. They treated this patient kindly and with respect throughout her 2-month SNF stay.