Ask Yourself: What Would You Do to Help Ava?
Ava is a 86 year old female who presents at an Emergency Room with shortness of breath on exertion and worsening fatigue, resulting in being admitted twice within last few months. She did not complain of chest pain or tightness but slight bilateral foot and ankle swelling worse over past several months. However, she mentioned that when she was in the hospital the last few months, “They put a mask on my face; I hated it! Nurses kept telling me to keep it on; it would help me breathe better! How can it help me when I felt like suffocating?”
Ava did not follow-up with her cardiologist after the last hospitalization due to fatigue and no access to transportation. Home Health Care was ordered, however Medicare did not cover the payment since the care needed was homemaker services. Ava is on fixed income and could not afford a private homemaker. She is not eligible for Medicare’s hospice benefit.
Ava has been treated for COPD and hypertension for the past 25 years and has been previously diagnosed with CHF. She said, “I used to take a water pill and other pills for high blood pressure; inhalers for COPD. Now I am taking too many pills, I can’t keep track!” She has been smoking ½ pack of cigarette a day for the past 70 years, although she had tried to quit but failed to break her smoking habit. She said, “We’re all going to die; I am 86, I have a good life so far; if I die today, I want die happy smoking”. Ava also said that, “Death is not be feared; but I not endure not be able to breathe and end up dying of choking”.
Ava is living alone in her apartment where she enjoys playing Bingo with her friends and neighbors at her adult community facility. Her daughters live out-of-state and are worried about Ava’s declining health. Ava is reluctantly to talk to her daughters about what would happen to her and does not have a living well or health care directives. She said, “My daughters kept telling me that I will be OK but I am not OK; they do not want to listen to me; they kept insisting on moving-in with them then everything would be fine. That’s not the answer I am looking for. I want them to hear me; I need to be heard before it’s too late”
COPD and CHF Exacerbations can lead to Acute Respiratory Failure (ARF) which can occur suddenly and unpredictably. It is difficult to predict the course of Ava’s chronic illnesses. Death may seem imminent many times before it actually happens. Symptoms can come and go with periods of flare-up which are the most common cause of emergency room visits and hospitalizations. There will be a time when Ava cannot make decisions for herself requiring her daughters to make last-minute decisions regarding life support on her behalf; putting intense distress, questioning their decisions, ”Is it really what Ava would have wanted for herself?
