As POA for my dad, I have a huge decision: Surgery or pain management?

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As POA for my dad, I have a huge decision: Surgery or pain management?

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My dad is 85 years old living in a long-term care home. He has severe dementia, AFib, COPD, his kidneys do not function at 100%, and skin cancer. Now I just found out he has aneurysms in both legs. Doing a CT scan means injecting a dye that could lessen his kidney function. Doing surgery to remove the aneurysms is risky for his heart, COPD and dementia. Doing nothing risks the aneurysms rupturing causing heart failure or amputation.

Alzheimer's & Dementia Care Decisions Palliative Care Senior Health

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Get an evaluation by hospice.

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Ditto what Glad says.

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Definitely hospice.

Remember that you are not making yourself an instrument in his loss by seeking comfort treatment. That’s just not the way it works.

My LO did very well on hospice for a year, and is now slipping away from me, but she is peaceful and cozy and beautifully cared for. And at this point, although I wish I could do more, this is the best I can do for her.

Be at peace that you have no “good” decisions to make on his behalf, investigate the hospice services he has access to, and make his safety but also his comfort be your guides.

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I agree with previous posters. I am so sorry he is going through this and for you too for trying your best. I can't imagine his suffering and confusion.

Please consider hospice and allow him to go gentle into that good night.

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I believe man’s medicine often gets in the way of God’s plan..

Recovering from a surgery like this may not happen.. and be in worse shape…

I worked years ago at a hospital as a physical therapy aide. We had to get this 90 year old, women up just to stand. She had a pacemaker placed the year before…it made an imprint on my heart , as she cried to just die…

i would get Hospice involved ,

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I saw more complications for surgeries on the extremities for circulatory problems than on any other surgeries, and that is no matter the age. It isn't only that you are operating on vessels but it is after surgery, the need and the complications of thinning the blood for some time. Often a clot was the result
Aneurysms have often been with us from birth, may develop at any time, and are often not found for decades. Yes, they may rupture at any time. And they may NEVER rupture. One cannot know. When in his 90s and already admitting he was terribly tired of living and ready for rest, my Dad was diagnosed with a very large abdominal-aortic aneurysm. They let him know but they far from "recommended" surgery. Basically let him know when that puppy ruptured he might not even have time to say ouch. He had no surgery.
I would not for myself choose surgery. You cannot discuss with your father; as you said this falls to you. I would listen to the recommendations of the doctor and of the SURGEON himself; I am hoping they will make very clear to you the risks and complications. Because your father has dementia the hospitalization alone will be tricky and will be terrifying for him.
My answer would be no. It is always hard for people to make these decisions for another. My guess would be that you will have your Dad longer without surgery. Do know that AFib ads another huge complication here due to the irratic nature of the heartbeat and the tendency for clot complications heightened thereby. And the COPD, well, you can guess.
I will be very very surprised if a doctor encourages you toward surgery in this case. VERY surprised. In fact I would want to know if he just lost in Vegas or something and has bills to pay.
I wish you luck. Your Dad counted on you to make these decisions when he has no dementia. I hope you will have talked with him about end of life and quality of life care and know somewhat what HE would want. That's what you are guessing. And I will remind you again, our opinions are only that; this is entirely your decision. And whatever way it goes it is not your responsibility or your guilt to bear as you are doing the best you can with a tough decision. Best to you.

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thank you.

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My FIl has had six operations including two brain and two heart ops since his stroke a year and a half ago. He had been on blood thinners for a fib, copd that contributed to his aneurysm and brain bleed, hence said operations.

He is alive, yes, but given all this general anesthesia, the falls started happening. Since fracturing his back and pelvis, he now can stand, only with help, to transfer onto the commode for no 2.

The docs answer to this is of course investigating more surgery, this time for what they think is a torn tendon. The pt and recovery are painful and protracted, and fil has never complied fully with pt anyway.

Seems to me that the surgery will probably mean he loses the last bit of him being able to stand amidst more pain. I hate that careless loser opiate addicts have made pain management so complicated. Gabapentin won’t do s against actual post surgery pain and either will your nsaids. Did I mention he had two thirds of his intestine removed plus has one kidney?

You shouldn’t have to go on hospice to get pain management. Thanks, useless opiate idiots for making it so hard, when in fact over 90 percent of legit users only use them to alleviate physical pain as opposed to partying with them.

Pain management could be such that he retains his ability to stand with less pain without surgery, or increase his resolve to do pt after it. Putting surgery first without addressing pain management will probably mean he loses his ability to stand at all.

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I personally would opt NOT to have any further testing or surgery.
I would contact Hospice and let them help manage pain.
Recovery from any surgery is difficult when you have but 1 of the conditions you mention. Add in another and another and recovery is even more difficult. (that is if he survives the surgery, sorry)
You have known him for your whole life, what would he want? He chose you to make decisions based on what you know he would want and knowing all the risks or those decisions. And lastly..if this were you what decision would you want someone to make on your behalf?

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don't be sorry. I was thinking the same thing. that he may not survive surgery.

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Aneurysms in his legs are no as serious as aneurysms in the chest or abdomen. Surgery is only indicated if the aneurysms are about to burst. If they are small, a wait and watch period is the best way to go. If surgery becomes absolutely necessary, it could be performed with spinal anesthesia, not general. He has a good probability to recover.

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well his doctor disagrees. The aneurysms in his legs are very dangerous but so is the surgery. He is setting up a consult with the surgeon to assess his risks and see if he is a candidate for surgery. I think this is a good idea. Because if the surgeon tells me that surgery is too risky, then the decision is taken from my hands.

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Letting go is so very difficult for most. Thankfully Hospice and Palliative Care is available. Did Dad file his end-of-life medical forms along with his will? If he didn't prepare for his end-of-life, then I guess you will need to do that for him.

Have you contacted an Elder Law Attorney? Please learn from this lesson and make sure YOU prepare for your end-of-life needs so that no one has to make decisions for you.

I have been working on this issue a lot, lately, because this forum has shown me that what happens to me is up to me. I'm just trying to figure out how and when to act in different scenarios...........it's quite a challenge to die pain free and with my dignity. I pray that I have a quick event in my sleep and that I don't linger in misery.

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I would not do the dye test if his kidneys are compromised. My Mom had one Kidney that worked 50%. She had a lump in her neck they wanted to check out. The NP happened to mention before they did that, her kidney function need to be checked because the dye is not recommended for people with kidney problems because it can cause kidney failure. TG I was there, because Mom needed no more prodding. She also suffered from Dementia and was in her 80s.

I would not put Dad through any of this. With his heart conditions he could die on the table.

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that is exactly what I am worried about.

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I should wait for the vascular surgeon's advice and just try to let the decision rest until you have it. None of the options seems attractive, you can only take the least worst. They already did an ultrasound, did they?

How is he? Are his legs bothering him currently?

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Yes he had an ultrasound. His legs are hurting when he walks. His mobility wasn't great before they noticed the aneurysms. He refuses to use walker or wheelchair and then falls quite a bit. Because of his confusion he tells everyone there is nothing wrong with him but then complains about the pain when he does walk.

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thank you all. You have been very helpful. No one has judged me and I appreciate that. I spoke to my husband and my son and basically they said the same as all of you. They also said to wait to talk to surgeon. But I think that is to allivate my guilt. My mind knows what needs to be done, but my heart doesn't want to accept that.

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Cherbal, have you ever read a book by Atul Gwande called "On Being Mortal"? When my mother was declining, it clarified for me what was important.

One thing I like to remember about caring for elders in that at some point, there are no "good" choices, only "least bad" ones.

My heart goes out to, needing to weigh these 2 not so great choices.

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If your father had one you would have mentioned it, but does he have an advanced directive? This is a legal document that explains how a person wants medical decisions made if they can't make them. Most likely he doesn't have one but you might look through his papers. One might say that he probably has let you know what he does and does not want done medically, but I think a lot of people actually never discuss that, even with their medical POA agent. You might check to see if he has a Do Not Resuscitate order in his chart.

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when he did up His POA papers it was just basic. My mom was the first mentioned and on her passing, it mentions that I would be his POA but no pacifics.

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You have a difficult choice, and both choices are risky. It's too late to talk to your father about his medical wishes, but do you have an idea of what he would want to do, given his state of health? Does his doctor have any suggestions for the aneurysms, other than surgery? Is it time to discuss hospice with his doctor, where his medical care won't be to fix anything, but rather to provide comfort care? I did this with my mother, and with advanced dementia she lived a much more peaceful and better lifestyle with hospice care, for the last couple of years of her life, rather than constantly being sent to the hospital.

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So this is basically what my husband says. As it is, his quality of life is not good and he has many health issues. I guess I know this is the best but not ready to accept it. He could die on surgery table or he could die without surgery. I think the surgery would cause more harm than good. He has outlived the average life expectancy for Vascular Dementia. He actually has two types of Dementia. The secondary one is Front Temporal Lobe Dementia. I know that if he was aware of his situation, he would agree with you. But the thing is, he doesn't even know there is anything wrong with him.

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Chergal, as you know, this operation will not increase function or quality of life. This is strictly about quantity, with not a passing mention to what dads quality of life is now.

You take him out of the nh, that means taking him away from his surroundings and any staff or residents he has bonded to. Should he be in hospital for even a week and a half, he could forget all about them, reintroducing the usually negative period elders have in entering a nh in the first place. That is if the nah doesn’t just make his bed available for the next patient.

So, ok, he is living, but now comes an adjustment period that may be worse as his dementia has progressed. If he has any quality of life where he is, best to keep him where he is.

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You are so right about moving him to another facility. He would be so confused that he would start to get agitated. And that would not be helpful to his situation at all. As it is now, sometimes he can not find his way back to his room.

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Put yourself in his place. What would you want? IMO I would think pain management would be the best decision. If it were my father, who also has severe dementia, I would manage the pain and let nature take it’s course. I feel I’ve already lost him twice, once when the disease took his memory and again when he had to go into memory care. He needs peace.

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Your only questions are will it improve his quality or life or create more difficulty?

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Chergal, Honestly, I'd take this "step wise". Do the CT with contrast agent and see the extent and severity of aneurism(s). Yes, there is some risk of worsening renal function, but then you'll have a better idea (and so will his physicians) about the need for surgery. All of these medical decisions are a risk:benefit analysis and not a right or wrong decision... Wishing you luck...

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Tough decisions! I know my parents both wanted quality of life versus quantity of life. He has lived a long life, but has many health challenges. Not sure surgery would improve his life quality. Lots to consider!

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Chergal, Your question was close to home for me. I was POA for my dad who had COPD, AFib, and Dementia. He was the about same age as yours when I took him to the ER with confusion and blood in his urine. He had a UTI but during tests, they found a small spot that could be benign or cancer. A urologist came and sat on the edge of Dad's bed telling him they'd make an appointment in his office for a scope, then if surgery is required and the rest you know. Dad didn't even realize he was in a hospital so I checked that doctor and his bedside manner off my list. I discussed at length with Dad's Primary and we agreed that the testing would cause difficulties for Dad and I would not put him through surgery at that point. My dad lived another year and a half without new health issues, other than the expected UTI on ocassion and progression of Dementia. He died just before he was ready for memory care. I've never regretted the decision I made. Best to you and your dad.

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Chergal,
You're asking for an opinion on what is a heart-breaking decision. Here is mine.
At your father's time of life and with all of his serious health problems, he shouldn't have to be put through more tests and procedures.
Is he in pain? I think the goal now should be quality of life not prolonging his misery.
You say he has severe dementia along with all his other health problems, is elderly and lives in a care facility. He has no quality of life. Putting him through tests and procedures is not going to improve his life and health. It may even make it worse.
Let him pass into God's mercy. This is what I think is best.

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It can always be a tough decision. You need to have this discussion long before anyone gets sick. There are advanced medical directives and power of attorneys that can put your wishes in writing. Everyone will be different as to how they want to end their life. So no advice here. But always consider what humane really is

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This a very difficult decision I realize. Do you have durable poa and is there a living will? Luckily my dad had both in place. Especially his living will. He was in and out of the hospital in 2021 at least 5 times from having tia. The last one he had at the nh in rehab. The next day my sister emailed the social worker about them having the poa and living will. We assumed from the times before when he had been there that they had this on file because we had given it to them but they didn’t. So she faxed it again. Anyhow the social worker said that they needed her to sign a dnr because if they would find him not breathing or no pulse they would have to begin cpr and that would continue until the paramedics got there in which at that point they would take over the cpr and if when he got to the hospital and he was still unresponsive they would put him on life support and his living indicates that he would not want this. He had a really big soar on the back of his leg it got down to the bone because he had his poa and living will they could only keep him comfortable as much as possible. They could never find out why he kept having tia and even if they had surgery would not have been a good option because he probably wouldn’t make it plus all the legal stuff he had in place. He also had developed dementia afraid his fall in March 2021 in which he got 2 brain bleeds. It truly wasn’t that bad until about the end of August when he was in nh in rehab. At the first of August we had to make the decision to put him in long term care. On September 20 he went on hospice and moved to ltc. On hospice they won’t do anything that would be considered life sustaining they will only make them comfortable which meant no more drawing blood except to ck his potassium. I was glad because I know having the blood drawn was painful and his arms were so black and blue. His kidneys had started shutting down in August so they took him off his atorvastatin and hydrochlorothiazide. I would ck and see if he doesn’t qualify for hospice. This doesn’t necessarily mean he is totally at the end. It means given his problems the doctors feel like he only has six months left, it doesn’t matter if he lives longer he can still stay on hospice. I’m no expert but it sounds like he is ready for hospice. I’m surprised his social worker hasn’t talked to you about it. I know people think it means the end but it really was a relief and very helpful because they took over all his care and you only had those people to talk to and got response pretty quickly without having to try and track down all his care takers. I know it is a very hard decision but the most important question you need to ask yourself is is this the kinda life he would want to live. Please don’t take this wrong but in my opinion I would not do anything. Just make sure he is comfortable. I wish you the best in whatever decision you make. May god bless you in whatever you decide.

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End of life is a tough decision for the caretakers,
Wife and I were in the eighties, both had knees problems
I had hip replaced, found out wife had dementia, we moved into an assisted living place, wife did not like but we had to,
she always wanted to go home but where she grew up as a youngster, she remembered past times but not what she ate that morning, scheduled a knee operation before the move but she cancelled the day before,
On driving before we moved she missed a turn two times, she got home and refused to drive anymore, I mentioned that she should keep up the driving she said if needed she could do,
was in pain and some time she asked if it was ok to wish to die, once I told it was ok, she got more relaxed, after a few months she was under care of hospice care then after we assured that it was ok to wish to die, she stopped eating, hospice people were very caring, did a wonderful job, She passed away in the morning while our daughter was singing Do Not Be Afraid, and I was holding her hand, they said that the sense of hearing is the last thing we loose.
We were married 62 years, she was a good mother to our four children and a very good wife, I do mis her very much,
after I said it was ok to wish to die she got more peacefull, I hope to be able to see her soon.

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Thank you for sharing. Peace be to you.

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OMG. First of all my prayers are with you on this decision. Sometimes it is painful to be the POA. This is a very individual decision and neither wrong. If it were my dad with advanced dementia ,COPD( which is extremely difficult with anesthesia and sometimes difficult to get off a ventilator after surgery),atrial fib ( if he is on blood thinner ,they may have to stop before surgery to prevent excessive surgery)and his age being high risk for surgery I would say no to surgery and give him pain management and comfort care.This surgery will not improve his overall level of living and that is why , with love,I would do pain management.It is difficult to loose your dad but loosing him with dignity shows love. God bless you in keep you strong in this storm.Trish

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Dementia is kind of the deal breaker here. I went through similar a year ago. I really wouldn't consign anyone to dementia one second longer than they had to have it. It is a terminal disease and the end stage is as ugly as anything you've seen with any other disease. It is a disease without mercy. If I could do it over again, I'd spare my Mom that procedure and let nature take its course. Now, in retrospect, it was cruel to do that to her. It goes against every instinct you have to not "fix" something with a surgery or procedure but there's a lot to weigh and dementia is a big component in the overall picture.

Peace to you and whatever you decide.

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Some very good insights in these posts. I just wanted to add that I work in cardiac OR and see both reasonable and unreasonable decisions about surgery made frequently. We have more medical modalities available to us all the time. Just because we CAN do something, does it mean that we always SHOULD? Often western medicine is inclined to have us medicate and repair without looking at the patient as a whole. It can become difficult for patients and family to navigate the decision process since there are often doctors wanting to move forward with treatment or surgery.
My 92 yo, demented father had cardiac valvular stenosis. The opportunity to perform a less invasive valve replacement was suggested. We chose not to do the procedure. He ended up declining, due to his dementia, fairly rapidly last year and passed away under hospice care. If he had received surgery, his limited time left would have been consumed by recovery in a rehab facility. Instead, he was able to be at home until the end.
Listen to that little voice in side your head. Mine hasn't lead me wrong.

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exactly. OP, don’t do it. hug!

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So sorry about your dad. If course his age and physical condition puts him at risk for surgery, None of those health conditions you mentioned taken alone are reasons to not have surgery. Kidney function declines with age for everyone. A nephrologist could possibly give insight into the risk of using a dye, but amputation of both legs is surely a greater risk for postoperative complications and death. Can the vessels with the aneurysms be minimally surgically treated? The anesthetic alone stresses the body of someone with frailty and compromised health. The acute problem is only one of many problems that contribute to risk and outcome. Sometimes the surgery is a success, but the patient dies anyway due to complications. His quality of life in his final days/weeks will not be improved. I would choose palliative care.

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As POA for my dad, I have a huge decision: Surgery or pain management?

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