Dr. John Lerma Weblog

Hospice, funeral homes, legal issues will be addressed here

11 News - Houston’s cost of dying
It’s one of the toughest times we face as families: When an elderly parent is terminally ill, how much should we do to keep them living? Watch the video

Hospital Care Intensity Report. A study that compares hospitals across the country.

Hospices I recommend: Charity Hospice
LEGAL ISSUES:
1) Medical power of attorney - A family member, close friend or respectable estate planning lawyer should be chosen, and only after careful consideration, so as to execute your wishes regarding medical treatments or lack thereof, only after one is rendered incapable of making any cognitively proper decisions regarding health issues. This person or persons should understand the meaning of “quality of life” and place at the forefront, the monumental importance of being ones advocate and being passionate about the palliation of spiritual, emotional, interpersonal and physical pain.
More specifically, I recommend that this person, when possible, mimic ones desires with a highly spiritual understanding of this life and the next, and if possible, an understanding of general medicine and the rights of patients.

2) Durable power of attorney - Someone with good business sense and trusting i.e., family member, close friend, institution or respectable estate planning lawyer, is vital to caring for ones estate. That does not include medical issues. This person or persons, will pay your bills, may have access to your banking accounts, care for your home or other valuables, etc., when one is incapacitated or incapable of making any cognitively proper decisions with respect to ones estate. A reputable attorney which concentrates on estate planning will direct you in the right direction.
3) General will/Living will - In the event you are suddenly incapacitated, possibly dying and unable to communicate and make personal decisions regarding your health care, as with a massive stroke, massive heart attack, severe head injuries in a car accident and so forth, it is imperative that one not procrastinate in obtaining a lawyer driven living will. It is in this document that one expresses his or her wishes with regards to end-of-life care. If one does not have a solid living will, the next member of the family closest to you, will legally be allowed to make health care decisions. This person(s) may go contrary in critical medical decisions to yours and the physicians, as most do not want to be responsible for deciding whether one dies or lives. This type of undue pressure on a loved one could be easily eliminated with a living will.
It is important that you keep the original in a safe place, have copies placed in your physician charts and give copies to those family member(s) you chose to carry out your wishes.

4) What is a DNR form? This is part of the living will.
In the event ones heart or respiratory function fails, it is imperative to choose whether one wants to be resuscitated or not and to what degree.

For example:
a) In the event ones heart stops, as in a heart attack, one may choose to do nothing and allow the natural course of events to play out as long as one is kept comfortable. This is called a DNR -Do Not Resuscitate
b) Others may choose to be fully revived, termed “full-Code”.
This is not recommended if one is terminally-ill.
This involves:
1) Cardiopulmonary resuscitation (CPR) where forceful compressions using ones hands are imparted directly on the chest wall. Occasionally, ones ribs maybe fractured, especially if one has osteoporosis.
2) Electrical shocking of the heart with two paddles placed on ones chest wall
3) Pulmonary intubation (placement of a tube into ones lungs to provide oxygen)
4) Chemical intravenous injections including adrenalin and atropine to spead the heart, which was previously very slow or non-existent. Theses drugs all have significant negative side effects.
5) One can choose any combination of the above.
Note: The above parameters are painful and often prolong the suffering for those that are terminally-ill.

B) CHOOSING A HOSPICE:

1) Remember that not all hospices are created equal. That means that due to financial constraints and philosophy, they may not all provide certain medicines or procedures for comfort including but not limited to the following: parenteral or subcutaneous hydration, blood and blood products, lab work, and certain medicines.
a) A preferred hospice is one that is a patient advocate first and as such would be willing to provide a terminally-ill patient any medication, procedure or parenteral fluids that would bring about total patient comfort at the end of ones life.

b) A preferred hospice would have a free-standing in-patient unit with a home-like atmosphere, one patient per room and family friendly, and especially where doctors are hospice and palliative board certified and make daily visits.

2) Do all hospices provide and/or agree that fluids maybe needed for a terminally-ill patient? No! This is a huge problem that I have personally encountered with a few hospices, one being one of the largest in our nation. This is a travesty.

a) For example: A hospice I worked for just recently refused to provide a dying patient of mine parenteral fluids for thirst, claiming the only place he could get parenteral saline was in their inpatient facility, which was over 30 miles away. The patient decided against going into the inpatient unit as he wanted to die at home. He died several days later without fluids. This is why choosing a hospice is so important. I was severely criticized for fighting to have this patient and others who were not drinking, obtain fluids in the form of a simple, painless method, called hypodermoclysis (subcutaneous administration of fluids).

b) When one is unable to swallow and not in pulmonary edema (too much fluid in the lungs), they should allow for subcutaneous or intravenous fluids, as this inexpensive and basic treatment can and does provide critically necessary comfort to terminally-ill patients.
Education of the family and patient with regards to dehydration in the end-of-life and treatment options is necessary.

3) I would be happy to help anyone find a reputable hospice around the country or answer any questions with respect to end-of-life medical, interpersonal, and spiritual care.

THE LAST DAYS OF LIFE describes, from a physicians point of view, what to expect the last months to days to hours of life and how to facilitate ones transition in peace.

In the last few days of life, the dying person retreats within his or herself as a way of preparing to release his or her soul. They tend to relive events in the distant past with varying feelings and often need help in obtaining closure. This is important to the timely release of the soul. During this time, the patient may begin starring intently at corners in the room or have brief conversations with unseen spirits of deceased family members or angels themselves. It is these spiritual beings that bring comfort and peace, and aid the patient in resolving unsettled emotional and spiritual issues, with the ultimate goal of transitioning peacefully to the afterlife. One may think the patient is hallucinating or delirious, however, the patient considers these visions real and important to their comfort. These negative assertions not only prevent the patient from openly discussing their spiritual experiences, but more importantly, it prolongs their suffering. To foster peace, the family or friends should attempt to create a secure and loving environment, free of criticism. This action allows for the relief of emotional, interpersonal, and spiritual pain.

A strong desire to go home is expressed, even when the patient is at home. He or she may start speaking of needing to “catch the train”, “catch the bus”, or “go through the door“, to get home. This simply means the patient is preparing for the final journey. The patient may reach upward as if attempting to feel the intangible. Many patients describe this reaching as an attempt to hold hands with their deceased loved one’s. At this point, the spiritual beings are now summoning the patient to walk towards them and into the light.

As evening approaches, delirium surfaces. The patient may begin picking or pulling off clothes, bed sheets or their intravenous lines or catheters. This is known as delirium, and is caused by a multitude of factor’s including but not limited to the following: pain, inability to fully empty the bladder, constipation, dehydration, liver and kidney failure, fever, infection, low blood oxygen content, and last but not least, the advancement of the disease process. The treatment varies and may include, opiates like morphine for pain and suffocation, catheter for release of retained urine, laxatives for constipation, intravenous or subcutaneous fluids for dehydration, oxygen via a nasal cannula or mask, and sedative’s like haloperidol, chlorpromazine, or less often lorazepam, are administered and provide rapid and lasting comfort.

At this point, the use of opiates and sedatives, whose main side effect is sedation, are usually necessary to comfort and protect the patient. The balance between relieving pain and maintaining cognitive awareness the last few days of life, will decrease dramatically, but with necessity. With the bodies toxin’s elevating exponentially the last few hour’s to days of life, this will further compromise one’s ability to remain alert. One has to remember that this is the body’s way of removing the patient’s awareness of dying in order to protect the patient from the processes traumatic effects. Families and friends would love to have their loved one’s awake throughout the entire process, but, the fact is, this would be too distressing for the patient.

It is imperative that family and friends allow the patient to sleep as often and as much as the patient desires, during this last phase of dying. With the understanding that the hearing nerve most often survives the caustic processes of dying, family and friends, especially the patient, will find that brushing their loved one’s hair lightly, moisturizing their dry lips and parched mouth, and providing soft verbal reassurances that all family and friends are united in love and in prayer, will bring them a sense of closure and peace. Continued encouragement to follow God’s angels as well as the patient’s deceased loved ones, will assure a peaceful transition to the heavenly realm.

With a decreased level of consciousness, congestion of the lungs, lack of palpable radial pulse, and cyanotic extremities, one is sure that death is hours away. By this time, the patient has total closure and is left feeling elated and exhilarated. Within minutes of departure from this world, one might notice one last tear and smile. This last tear is called, Epihora. The survivor(s) are left with an immense feeling of reassurance that their loved-one was carried on the wings of angels to God’s heavenly kingdom.