Dying patient who contracts an infection

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A friend of mine just died of cancer while in the hospice in-patient unit. It was aggressive lung cancer which had spread to the brain. Her reasoning ability was almost completely gone and she had to be kept fairly heavily sedated to keep her from having frequent hysterical episodes. She went into hospice with a prognosis of dying within a week or two at most, and while there she rapidly declined from being able to get to the bathroom by herself to being completely bedridden and having to be hand-fed by a nurse as if she were an infant. At that point the nurses also had her in adult diapers.

On Sunday morning we brought her the mass scriptures and Holy Communion. She was not able to talk any more, but when offered communion she still struggled to push herself upright and opened her mouth. She did this every day from her admission to hospice until the morning before she died. This and what I will describe in a moment were the only purposeful movements she made during her last two days.

My question concerns something that I noticed two days before she died. I believe she contracted a urinary tract infection, and I think it went untreated. This is bothering me morally. On the one hand she was clearly dying from the cancer, she was failing rapidly, and nothing could prevent her death. On the other hand, treating the infection with antibiotics might have made her more comfortable, and might have postponed her death by a couple of days.

At one point on Sunday while I was by her bedside she suddenly grabbed my arm hard, clutched her crotch with her other hand, and (with a strength I no longer thought she had) pulled herself to a sitting position. I summoned the nurse to assist her with toileting. They took care of her in the bed, cleaned her and changed her diaper. Twice more over the next two hours she clutched her crotch and attempted to sit up. Each time I called a nurse to help her. I reminded the nurses that she had a history of urinary tract infections, and was told they were aware of that.

I saw her next a little over 24 hours later. Her hands now felt feverish, the nurses had put a cool moist cloth on her head, and she was breathing heavily. She was almost completely unresponsive when I called her name and talked to her. 15 hours later she finally died.

In a situation such as this, is it morally right to refrain from testing for and treating an infection? We can’t stop the dying process, but it is OK to let an opportunistic infection take hold and leave it go untreated, thereby allowing death to occur a few days or a week sooner?

Complicating the matter, she was a Medicaid patient, the hospice has a limited number of Medicaid beds, and they always have a waiting list. If treating the infection prolonged her death, another patient needing hospice care who wasn’t so close to death wouldn’t be admitted, or would have to stay in the hospital (at a higher cost to Medicaid), or would have to be sent to another facility a considerable distance away from his or her home.

Thoughts?
 
I am sorry for the loss of your friend. In hospice care, the staff does their best. They might have seen your friend already suffering and felt like by treating the infection, it would only prolong the suffering. I am not saying this is right but it gets to a certain point, when a person is suffering terribly that infections could be a god send because shortens an otherwise long suffering and death.

Furthermore, considering your friend’s situation, the medical stuff might have felt it unnecessary to treat it because they knew treating it wouldn’t change the outcome. Sometimes it isn’t worthwhile giving medication that will not help the person’s quality of life.

These are only my theories but I ask you to please give this situation to God and ask him to help you find peace and forgiveness towards the medical staff with this situation. If you have trouble with it, bring it to confession and ask God’s graces to surround you in this difficult time.

Please accept my condolences for the passing of your friend,

SG
 
When someone is near death it is fruitless to treat a bladder infection. If the patient is earlier in the process, then it makes more sense to treat something like a bladder infection. Just because someone is a hospice patient doesn’t mean that they have to forgo treatment for an unrelated problem. But they aren’t obligated to either.

Hospice means that they have decided to let nature take its course for something like cancer, heart disease, COPD. It’s an acknowledgement that the patient will die, most likely within 6 months, and that they accept that and will no longer fight it with heroic measures. At any time the patient can change his/her mind. And the patient can choose treatment for things like bladder infections. They can also choose to cease any and all treatments. It’s all individual.
 
I agree with you. If it were me. I would have wanted my bladder infection treated. They are very uncomfortable or painful and lead to weakness and confusion. I guess they were thinking that by treating the bladder infection she might live longer and suffer longer.
It’s a tough decision but I guess I am not a big fan of hospice from what I have seen.
 
I find it hard to judge, but a bladder infection can be very painful and when it goes along with a high temper, it can cause delirium (hallucination) so I can understand you wanted this infection to be treated.
 
Treating a uti while dying fron lung cancer is like rearranging the deck chairs on the titanic.

Plus it may not have been easy to treat or even diagnose at that pint. You mentioned she was in diapers so to diagnose it they would have had to obtain a catheter specimen and many people would find that uncomfortable. Then if she was too far gone from brain metastasis she may have been to week to swallow pills. Would you want them tp put an Iv in? Or a central line?

There is no moral question for you to worry about. You ( patient or caregiver) get no extra points in heaven for dragging out an inevitable death with antibiotics.
 
She may have reached a point where treating the bladder infection would not noticeably change her quality of life. It sounds like she was already very uncomfortable if they had her heavily sedated. Are you sure the grabbing motion may not have been related to a frequent sudden urge rather than pain? The nurses may have also taken into account the possible side effects of the antibiotic. Often antibiotics can cause stomach upset and this could have added more discomfort rather than relieved what was there.

No matter what, I think you are not in any moral danger yourself since you notified the appropriate professionals.
 
In-patient hospice care was a tough decision for my friend’s family. She was afraid of being admitted because she was desperate to do whatever was necessary to live. The whole time she was determined to stare her cancer down and refused to admit it was killing her. She saw hospice in-patient care as the equivalent of a death sentence, and imagined that avoiding it meant she still had a chance to live. But the cancer was already ravaging her brain causing crazy hysteria, her rational thinking ability had eroded to a very low level, she needed 24-hour nursing care, and her family was exhausted.

The hospice in-patient unit was where she needed to be. Hospital care was no longer an option. The hospital doctors discharged her to hospice care (initially it was at-home hospice care) since they could do nothing more to save her. She was an in-patient at hospice for 8 days. Her family spent every possible hour by her side. To keep her from hysterically acting out her confusion and craziness, hospice kept her sedated to the point of partial consciousness where she was unable to assist with her own care.

While I think she had an infection, there could have been other reasons for the symptoms: she may have merely had a diaper rash instead of a bladder infection, and the brain cancer itself may have been the cause of her fever and unresponsiveness on her last day.

I don’t know what really happened and I’m kind of grabbing at straws. Note that I am not suggesting hospice did anything to accelerate her death. I have mixed feelings because their apparent choice of treatment (increased sedation instead of an antibiotic) may have knowingly allowed an opportunistic infection to accelerate her death.

Yet if her death was indeed slightly accelerated by a naturally-occurring opportunistic infection, it also accelerated the end of her agony and brought her family relief from their exhaustion. Allowing death to happen instead of attempting to stall it further also provided a benefit to the community; it meant that another patient could come off the hospice waiting list.

My friend’s family are all working-class people whose medical knowledge is limited. From the lengthy discussions we had I doubt they thought an infection could be accelerating her death. Out of kindness for their feelings, I did not pursue the idea.

Thank you for letting me ramble. Dealing with untimely death is difficult (my friend was only 54 years old and left two children in their early 20s). This forum is giving me the chance to deal with what happened without adding to her family’s anguish.
 
UPDATE:

I have learned more about the dying process which no one mentioned at the time my friend died. Specifically, I have learned that a fever is not at all unusual right before death, and it often does not mean the patient has contracted an opportunistic infection. Many, many dying patients contract a fever in their last 8 to 24 hours.

Turns out there were three possible reasons for her fever:
  1. The cancer had damaged the portion of her brain which regulates body temperature.
  2. Her organs were failing and starting to shut down, causing toxins to build up in her blood. The fever was her body’s immune system response to the toxins.
  3. She contracted an opportunistic infection, such as a urinary tract infection, because she was no longer able to drink enough fluid to stay hydrated.
In all of these cases, in a patient who is clearly dying the standard protocol is to do what is necessary to keep the patient comfortable. This may include Tylenol to reduce the fever, cool compresses, light clothing, and air circulation.

Antibiotics may be administered in some cases if an opportunistic infection is clearly present, but they would be ineffective in a dying patient if the reason for the fever is brain damage from the disease, or toxin buildup from failing organs.

Just something I wish I’d known at the time, so I’m sharing it for the benefit of the next person in my situation. I was expecting her hands and feet to get cool before she died. The fever took me by surprise.
 
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