|Florence Gromko, at left, with daughters Linda Gromko|
and Bonnie Gromko Mearns in December 2013
At 94, she moved into an Assisted Living Community, and did reasonably well until she had a fall in April 2014 - sustaining a distal tib-fib (ankle) fracture. About a week later, she fell again, fracturing her pubic ramus. This required hospitalization and about a month in a rehabilitation facility. She then moved to an Adult Family Home with only six residents and more one-on-one care.
Like so many elderly folks, Mom had diminished kidney function, CKD Stage 3. This was likely due to hypertension - or more likely, to being 96-1/2.
A urinary tract infection took her into the hospital in August. She was very dehydrated from vomiting and diarrhea, and on admission, her creatinine had risen to over 3, and her eGFR was only 12. (You start thinking about dialysis with this eGFR - and with an eGFR of 15 in a diabetic.) Of course, this was an acute situation; vigorous volume repletion got her tuned up to an eGFR in the 20s by the time she was ready to return to the Adult Family Home.
But she hated the whole ordeal: pulling out her IV, and begging me to answer, "Why is this woman trying to hurt me?" - as a very sweet nurse tried to start another IV.
The amount of fluid my Mom received by IV was appropriate, but we could see there was no way on earth she'd be able to keep up with it on her own. Another bout of diarrhea, another few episodes of vomiting, and she'd be sliding down again. I figured she'd be in trouble within a month or so.
When my husband's eGFR was 5, and he was started on emergent dialysis via central line in the setting of Acute-on-Chronic Renal Failure, it made so much sense to initiate the "full court press." With a twelve-year-old daughter, he was hopeful for a successful transplant - and willing to pursue home hemodialysis in the interim.
But with a woman as elderly as my Mom - voting with her behavior by removing her IV lines, and declining the amount of fluid that would protect her volume status, it seemed time for palliative care.
She's still happy and glad to see us. Last week, she was saying, "You've got to have goals. I've got to get things done."
I asked her what goals other 96-year-olds had, and she replied instantly, "Oh, they're all dead!"
Different circumstances clearly call for different interventions.
Linda Gromko, MD