Helen’s personal Doctor arrived first thing in the morning, greeting her, and asking her how she was feeling. Dr. Chai was her Concierge doctor and she trusted him in all matters. She let him know about her anxiety and her stress of living in the skilled nursing facility. He kindly and compassionately listened to her and her anxiety decreased.
But then he told her that her daughter-in-law had called him and told him that she – Helen – wanted to be euthanized. Helen was mortified and became very agitated – She said what? Her doctor explained to her about California’s End of Life Option Act. This is where someone of sound-enough mind, with a terminal illness and less than six months to live, could legally request and take a prescribed medication to peacefully end their life. Unfortunately, the doctor used the word euthanasia and Helen panicked. End of life choices are not euthanasia options – it is a personal decision that can only be made by a person with six months or less to live.
Helen had spoken to her daughter and daughter-in-law the prior afternoon about her end of life options. Her daughter-in-law, who had been very dismissive of Helen’s needs and concerns, had immediately contacted Helen’s doctor to let him know she wanted to invoke her right to die. Helen had intended this decision to be her own private matter and became immediately anxious and embarrassed about who else her daughter-in-law had told about her choices. She told her Doctor that she did not want to end her life. He spoke to her for about 45 minutes, compassionately reassuring her that he would take care of her and keep her comfortable and pain free. He explained that he would continue to oversee her care. Helen trusted him and expressed relief.
Later Helen confided in me that she was terrified that her daughter-in-law wanted to kill her. I spent the next 30 minutes explaining to Helen that only she could make that end-of-life choice, no one could make the decision on her behalf. If a doctor deemed her cognitively unable to make such a decision herself- then the option was not available to her – and specifically not to someone with power of attorney. She lay back in her bed, with her head on her pillow, she closed her eyes and rested.
I watched Helen rest. She was more than 100 years old and should not have to be suffering from such horrific stress.
Helen felt like her daughter-in-law, her son and daughter wanted her gone. She was very hurt – and scared. But they couldn’t make this decision for her! When she later confronted her daughter-in-law, Helen point blank told her that she would make her own decisions. But her daughter-in-law corrected her, “We have power of attorney.”
Power of Attorney? Helen was coherent, able to maintain a dialogue, – she appeared to have capacity to participate in her care. Did she have 100% capacity? I do not have the answer to that question. She would sometimes ask me to ask her what her name was, what day it was, what she had for breakfast that day. I did and she answered correctly. As a mental health professional I recognized these questions. They were used in mental status exams – something she was being asked by someone – and she wanted to be sure I knew she was OK. This made complete sense to me. The Gardens’ social worker had told me her awareness was “fluid.” It seemed that this designation (of fluid) was being used by staff and Helen’s family to exclude her from care decisions. Were they suggesting the onset of dementia? I was concerned she was suffering from Transfer Trauma. Was this why the staff was excluding Helen from changes in her care plan?
For me, an accurate diagnosis of Helen was critical. Transfer Trauma is a nursing diagnosis. When a nursing diagnosis is made, a treatment plan can be developed. When dementia Is diagnosed, a treatment plan can be developed. The differentiation is important – the treatment is different!
| Transfer Trauma | Dementia |
|---|---|
| Confusion. Hopelessness. Restlessness. Fatigue. Inability to focus. Poor hygiene. Changes in eating and sleeping habits. Increased susceptibility to physical health conditions. Additionally – “…according to Tracy Greene Mintz, LCSW, the nationally recognized expert in transfer trauma, also known as relocation stress syndrome, includes a cluster of symptoms that occur in a senior after moving. The mood, behavior and physiological symptoms include: Sadness Anger Irritability Depression Anxiety Agitation Confusion Combativeness Screaming Complaining Wandering Withdrawal Refusing care Poor appetite Weight loss/gain Increased coping through bad habits Indigestion Nausea Sudden onset of irritable bowel syndrome https://carepatrol.com/blog/what-is-transfer-trauma-and-how-to-avoid-it/ | Although the early signs vary, common early symptoms of dementia include: Increasing confusion apathy and withdrawal or depression Memory problems, particularly remembering recent events Reduced concentration personality or behaviour changes Loss of ability to do everyday tasks. Additionally – Rapid mood swings Feeling easily upset, annoyed, anxiety or agitated, especially when they’re out of their comfort zone Experiencing symptoms of anxiety or depression Becoming paranoid, fearful, or suspicious of others Losing sleep at night or being extremely tired during the day Imaging things that aren’t there or having visual hallucinations https://www.health.com/dementia-warning-signs-8383227#:~:text=Some%20of%20the%20primary%20early,normal%20age%2Drelated%20memory%20decline. |
As this chart demonstrates, Transfer Trauma and Early Dementia can look similar.
The treatment plan for transfer trauma includes recognizing that the resident is losing control over many things in her life – from no longer living in her home, loss of familiar routines and people, and health issues that create loss of independence she once had. Included in the treatment is learning about the individual, carefully and patiently explaining the routines and choices that are part of life in the facility. Ensuring that she have control over anything possible. Also vital to this treatment is being patient and answering the patient’s questions, even if the questions have been asked before.
This treatment should also include answering call lights promptly and if staff cannot help immediately, the resident should be told how long it will be before she will be helped. The opposite of this was happening and the stress wore on Helen.
In one instance, Helen was helped to the restroom by one CNA when her care plan required a two-person assist, and she was accidentally pivoted into a wall, hitting the side of her ribcage. When the Charge Nurse came to talk to Helen, Helen described her pain and said she usually had two people helping her. Helen insisted only one person had helped her. The Charge Nurse corrected Helen twice, telling her that two CNAs had helped her. As Helen spoke louder, insisting there was only one person, I intervened and suggested all five of us meet – the Charge Nurse, the “2″ CNAs, Helen and myself – to discuss this situation. The Charge Nurse agreed.
Ten minutes later the CNA who had assisted Helen, entered Helen’s room with another staff person, and leaned into Helen and whispered “I am sorry, I thought I could move you by myself.” I was sitting next to the bed and could hear what she said. As she turned and left the room, Helen exclaimed Did you hear her? Did you hear what she said”?
Yes, I replied.
Helen suddenly could not catch her breath and lurched backward onto her pillow. She asked for more oxygen and said her heart was hurting. I pushed her call button, and the Charge Nurse entered the room. She can’t catch her breath and her heart hurts. Please – take her vitals. The Charge Nurse took Helen’s oxygen and heart levels and her oxygen was fine, but her heart was beating at 165 bpm! It would go up and down – to 154 and back up. A heart rate should not be over 100 bpm. The Charge Nurse left to let the Doctor know that Helen was experiencing “tachycardia.” The Charge Nurse returned ten minutes later to report that the doctor ordered a prescription. She did not address Helen by name and didn’t ask how she was feeling, but instead just turned to leave the room.
I stopped her by saying, Would you take Helen’s heart rate again?
Let me get my pulse oximeter, she replied and hurried out. When she returned, she snapped the oximeter onto Helen’s finger. Her heart rate had dropped to 94! The denial of her reality – that two CNAs had moved her that morning when in fact only one CNA had assisted her, had gaslighted Helen and had caused her heart rate to jump dangerously high.
Thank God the CNA had admitted to Helen that she was the only CNA assisting that morning. I immediately wondered how long this gaslighting had been going on and completely understood why Helen had asked me to do that mini-mental status assessment with her. My mantra became, What kind of place is this?
Next week: Helen requests to be placed on hospice, her daughter-in-law springs into action again to find her a hospice.