Monday, June 25, 2012

What is Meaningful Interaction?

I recently cared for a 96 year old woman who was rehospitalized for a recurrent infection (identifying details altered to protect confidentiality).  Her family struggled mightily with how to balance the goals of prolonging her life, improving her functional ability, and focusing on comfort.

The patient had a history of dementia (not advanced dementia), several chronic conditions, and had been in and out of the hospital 3 times in the last 6 months for infections, each time returning to her nursing home more physically disabled and cognitively impaired than before.  She developed delirium during each hospitalization and never seemed to fully recover.

At the time of admission to the hospital, she was not arousable, and her daughters considered a primarily comfort oriented approach.  After some antibiotics and gentle fluids, she became more responsive.  Although she didn't recall her daughters' names, she seemed to recognize them, and could answer simple yes/no questions.  She smiled and laughed when they played music for her.

The question her daughters' struggled with was how to honor their mother's wish to continue living until she could no longer meaningfully interact with family.  To some this meant more than what she was capable of during the last several months, to others the mere fact that she enjoyed their company was enough for them.

So often, despite out best intentions, these issues cannot be worked out in advance.  These daughters lamented that they didn't have more information about their mother's wishes.  But I would hazard that most people can boil their wishes down to "meaningful interaction" - and can't get much further beyond that.  These choices, so rarely black and white, are often shades of grey.

For the clinician, helping the family through the process of thinking it through carefully may be the best they can do.  The process itself may be the best balm for the hard emotional and moral choices these family members have to make.

by: Alex Smith @alexsmithmd

5 comments:

Anonymous said...

Agree. Same issue is addressed in Sudore & Fried's 2010 Annals of Internal Medicine article, "Redefining the 'Planning' in Advance Care Planning: Preparing for
End-of-Life Decision Making".

Paul McIntyre

George Handzo said...

Good post. Reminds me of work way back when by Crystal Park and Susan Folkman which suggested that most people will find meaning on their own if they are given space to talk openly and without judgement

Suji said...

Great post! I was able to experience how to take care of the elderly in an orphanage. Most of them have memory problems. Letting them feel that you are always there to assist them is one way of creating a meaningful interaction.

Anonymous said...

As alwsys Geri-Pal has such thoughtful posts and I often repost on my blog. This one hit home for me.

I do private Advance Care Planning Consultations and I often help people express to their family and loved ones what meaningful communication means to them.

This part of the Advance Care Planning process is hard to express. The whole ACP process is time consuming and emotional but this part seems to be the most difficult to articulate especially for someone younger and healthy.

2e3748b6-c179-11e1-b46a-000bcdcb8a73 said...

Hearing about the "good" that antibiotics and fluids do for an unresponsive frail patient reminds me of the effect of narcan given during an unsuccesful code in the hospital. Often the patient would open their eyes but then quickly they would fade. Are we obligated to get that last eye contact by giving narcan to every dying patient? Does any religion have an exact definition of meaningful interaction?