The Old and The Restless

DIETETIC INTERNSHIP: Weeks 26, 27, & 28 (of 41)

Vacation!:  Week 26

Geriatrics & Palliative care: Weeks 27 & 28

These next two weeks were filled with the old, the very old, the young old, and the very sick.  I spent two weeks alternating between Geriatrics (>65 years old, often inpatient 4-6 weeks for rehabilitation) and Palliative Care (less than 6 months to live).  I was full of emotions before this rotation began, knowing my past may interfere with my present.  Daily, valetudinarians dominated my workload, and I wobbled between emotions.

My past includes my father, a Veteran, who passed away at home 8.5 years ago.  He peacefully and painfully died at home, aided by personal administration of palliative sedation.  Any time some of these words are spoken within my earshot (particularly “palliative”), or in regards to a young individual, (my father was 54 years old), my nose begins to tingle and flare, my eyes open widely, instinctively searching my surroundings, reflective of my minds speeding thoughts and connections.  This rotation not only posed professional challenges of a new patient population and goals, but also of managing my own reactions.

While in this role at the hospital, I was not a daughter or a caretaker, but was actively involved in the daily life of many patients.  In both Geriatrics and Palliative units, I visited some patients daily or every other day, and I truly got to know their personality and/or family members.  In Geriatrics, sometimes this was  tubefeeding management visit, or a motivational time encouraging the patient to eat during the rehab process.  Goal = Return home healthier and functionally stronger.  Palliative care, conversely, had a very different goal.  Goal = Make the patient as comfortable as possible during the dying process.

On Aging
Have you ever taken the time to analyze the people around you by comparing their biological age versus physical age?  We have all met people that are mentally and functionally relatively young at age 70 or 75 years.  I don’t know about you, but these people are my ideal of healthy aging, and my icons whom I hope to emulate during the aging process.  There are others we meet that are comparatively senile in their early 50s, and appearance seems closer to late 80s.  Both of these patient sets continually shocked me as I double-checked my records.

Geriatrics
Mr. N, an obstinate 82 year old man, was known for his historical malnutrition and stubbornness at refusing to adequately eat, mainly creating excuses from excuses.  I regularly coaxed his improving consumption, and on his last day before discharge he said to me with a toothless smile, “You are a blessing to Memphis!  I would vote for you in anything you were running for!”

I taught a 1-hour Geriatrics Nutrition class to three patients; they were wheeled over by the nurses.  I had an 88-year old sleeper the entire class, and two ~70 year old awake and sprightly men.  Every Dietetic Intern joked or exalted their Sleeper to Awake geriatrics class member tally!  I fared mediocre, but one intern had 4 Sleepers!

PEG tube, not so scary

Mr. T, a young 63 year old, first entered the hospital while I was on my Nutrition Support rotation ---  17 weeks prior!  Unsurprisingly, his hospital course had been filled with a host of unexpected and near-death experiences.  Consequently, he had not had regular oral food intake, and had previously received enteral (tubefeeding) and parenteral (IV) nutrition.  Now he had diminished swallowing capability, and was unable to be prescribed an oral diet (i.e. meal tray).  Instead he had a PEG tube for tubefeedings (an ostomy, or hole, directly into the stomach), and had been hooked to a machine 24 hours/day, despite final progression to walking and recovery.  I went to see him to share the new plan:  He would go onto “overnight feeds,” something that he did not completely understand.  I explained that all of his tubefeedings would run from 6pm – 8am, then he would be “unhooked” during the day .  No more pole pushing during physical/occupational therapy, no issues with rolling over in bed, etc.  Suddenly he “got it,” and this HUGE devilish smile took over his face.  How lovely it was to be the bearer of that news!!  Every day during my visit a boyish smile would creep across his face as he told me how thankful he was of his new nutrition plan!

Another patient, at 65 years old, apparently viewed himself as The Most Eligible Benedict.  He wanted to hold my hand, swoon me with his 2012 new van and financial comfort, and persistently asked me out on a date.  I declined.  Just barely.  ;)

Palliative
For many of these patients, there was little coherent or excessive interaction with the patient.  One very early onset dementia patient (58 years old) was refusing to eat meals, only accepting occasionally sips or grape juice or candy bars.  He would not drink water to take his medications, could not feed himself, and generally was utterly inflexible in attitude.  Once during lunchtime I encouraged a small bite of mashed potatoes, to which he responded, “Hell no!  Are you crazy!??”  I stifled my laughter as I suggested sliced peaches instead.  I later tried gelatin, juices, meat, and milkshakes, each time unsuccessfully.

Do Not Resuscitate (“DNR”) orders were common in Palliative care, as patients generally were deemed < 6 months life remaining.  However, I watched one clear-thinking patient adamantly refuse DNR, stating he wanted everything done possible to keep him alive.  Warned of potential broken ribs and an anguished quality of life, he steadfastly maintained Full Code status.

This two week rotation helped me develop a professional approach to Palliative patient care, but did not absolve me of emotions.  Unavoidably, patients passed away.  However, one 65 year old patient with significant aphasia, Mr. M with his 87 year old mother never leaving his side, would smile and hold my hand at my every visit.  According to his mother and nurses, he did not respond to other healthcare members the way he responded to me.  His poor prognosis broke my heart then and now, tears and emotions filling my face.

 “It is not our abilities that show what we truly are, it is our choices.”

Albus Dumbledore in Harry Potter 2