Monday, May 14, 2007

D/C Coumadin

Mom and I return to her regular doctor for her first check-up since my disastrous attempt to move her to skilled nursing.
I explain that it just didn't work out at Country Villa Mar Vista. The caregivers had too many patients and she even went through three meals without her false teeth.
Because it was a UTI that prompted the whole episode, I tell Dr. Rosen that my brother recommends just putting Mom on a prophylactic antibiotic to prevent bladder infections.
She's happy to order Macrodantin, 50 mg per day, which will kill most bacteria that cause chronic urinary tract infections.
"But the bacteria that caused this last infection was Klepsiel," she reminds me. "That one's not susceptible to Macrodantin."
"I understand," I say. "As long as it kills most of them."
"We're still not ready for hospice," I say. "But we do want to avoid medical procedures that cause her discomfort, like blood draws and catheterization. We want to take her off Coumadin so she doesn't have to have her blood drawn every week, sometimes twice a week. She refuses her meds sometimes, so that throws off the effort to stabilize her anticoagulation levels, and she doesn't eat meals on a sleepy day, so that throws it off too."
"No future straight caths," the doctor writes in her chart.
"We could reduce the Coumadin to a low dose, 1 mg, and stop checking her Pro-thrombin times, or we could d/c it altogether," Dr. Rosen offers.
"Let's stop it completely," I say. "My brother says she could have Plavix or aspirin instead."
"No, Plavix is for the heart," she says. "But I can order her 325 mg of Aspirin per day. The question is, do we treat a pulmonary embolism if it occurs? Because she had one in September, 2005, and it could happen again."
"Well, I guess not, if she's dying. But if she's just uncomfortable..."
"We have to ask, 'What are the goals of care? We want to keep her comfortable, but what are we willing to treat?' I think we treat a UTI, pneumonia, PE. But we don't want to treat, then withdraw treatment; treat, withdraw."
"No, that doesn't make sense," I agree.
Then I explain that Mom's thirty-year old bed with the lifting function for the head and feet was pronounced worn out by the repairman from Wishing Well, and that he said Medicare would pay for a new bed if the doctor ordered it.
She writes an order.
We also discuss bed sores, so she orders a gel mattress for the bed.
I wheel Mom out, grateful for having accomplished so much on this visit to the doctor.
~ ~ ~
I don't tell her that an hour earlier I got a call from my daughter's rehab place with the news that Ellen is missing. Apparently she was taken to a movie with several other patients, asked to go to the restroom, and escaped.
She has been AWOL, using cocaine and methamphetamine at a "tweaking pad" since last night. They didn't call us until this morning, just before I left for this doctor's appointment.
Ellen has called in and promised to return as soon as she can get her nerve up to do that--but meanwhile all I can do is worry.
I don't tell the doctor that really I don't care about my mother and her Coumadin, Macrodantin, etc. I just care about my daughter.

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