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Old 11-16-2011, 03:35 PM   #1
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Anemia, Blood Transfusions and Delirium

Hi, All:

You may recall that my mom was in the hospital last week and had a partial hip replacement after a fall at the NH, and this came 7 weeks after her first hip fracture on the other side.

So she's now back at the NH, and when I got there today she was sitting up in a wheelchair! I was impressed!

The facility doc was there and I got to talk to him. He said he's concerned because mom is still anemic. He talked about the various possible causes. We agreed that we wouldn't be doing a colonoscopy to check for internal bleeding, but he did say he wanted to consider sending her for transfusions. He said it'd be done as a planned admission to the hospital, overnight for observation and then back. He said he'd want to do one, and then possibly
2 - 3 weeks later, another.

Has anyone else been through this?

He was going to check her numbers today (including liver enzymes which were elevated in the hospital) and we're going to talk tomorrow afternoon at the latest. What do y'all think about this?

He is aware that mom wants no extraordinary measures. I asked him if we should invoke hospice just because of that. He said not now, because he knows what Medicare requires for him to say before they'll cover it, and that's not where she is. This is all such a nightmare!

Love,
Sarah

 
Old 11-17-2011, 12:12 AM   #2
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Re: Anemia, Blood Transfusions and Delirium

Good for you in rejecting the colonoscopy. As for the transfusions, I would want to know why she is anemic. I would also want to know what her previous blood work numbers were. Please do not just depend on a single snap shot given by one blood work. Dad was "clinically anemic" for the last 10 years of his life. Every new doctor would give me that same talk you just had but when I pulled out long ago blood work that showed the same numbers they would back off. It was Dad's normal.

Anemia is the a condition with lower than normal red blood cell count. The severity of anemia is measured by a personís hemoglobin level or hematocrit level. Hemoglobin is a component of the red blood cell that carries oxygen to different tissues and organs throughout the body. A patientís hemoglobin level can drop for several reasons, including nutritional problems, infections, chronic diseases, menstruation, blood loss, or surgery, to name a few. When hemoglobin drops to or below 7-8 g/dL Ė transfusions are often used to quickly raise hemoglobin levels to a normal range and reduce symptoms like significant fatigue and dizziness. If there is only a moderate drop in the hemoglobin then treating the underlying reason is a better option. A normal average hemoglobin for a woman is 12. Mild Anemia is below 12 but greater than 9.5. Moderate Anemia is between 9.5 and 8. Sever Anemia is below 8. Transfusions are only recommended for Sever Anemia though they are still used for mild and moderate.

Many times the anemia is caused by nutritional deficiencies. This can be treated with supplement such as iron, B-12, or folic acid which are all needed to produce the red blood cells. It can also be treated with erythropoiesis-stimulating agents (ESAs), a man-made hormone which boosts the bodyís processes for making red blood cells. This treatment is usually done in conjunction with iron supplement and done in the doctor's office.

Yes, a transfusion will boost her hemoglobin in the short term but will it "fix the problem". What caused the anemia, how long has it been there, is it a result of the surgery or an ongoing problem? There is a study which connects Alzheimer's with higher rates of anemia. So it is a function of the disease? I would also want to know her hemoglobin number and be sure it is sever and not mild anemia. You also have to consider all that your Mom has been through in the last 7 or 8 week and the risk associated with transfusions. Is the benefit going to be with the risk both physically and emotionally? I would have to think long and hard on this one... and get some more information

Love, deb

 
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Old 11-17-2011, 05:38 AM   #3
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Re: Anemia, Blood Transfusions and Delirium

Thank you soooo much, Deb! Once again you provide me with some context for the condition mom's in... for me, since i'm not a medical person, when the doc tells me something, I don't know exactly what to make of it... i.e., if he gives me a number, I don't know whether it's high, or severe, or slightly elevated, or what.

I do know that the last time she was in the hospital her blood work showed that she was low in B12, so they have started her on monthly shots. And she was anemic while in the hospital the first time and received 2.5 pints of blood. So my thinking is that she may have a bleed somewhere, or it's just a part of her disease, and the transfusions will be a short-term patch. And frankly, the idea of transporting her to the hospital, having an IV and sitting around for the transfusion and then being overnight there will be so very hard on her. I'm leaning against the transfusions, but you're right... I need to get more info.

I'm going to call her previous PCP and see if they can tell me about her blood count a year ago, say. Just to see if they saw any anemia. Honestly, while she is still speaking and now able to sit in a wheelchair, her condition otherwise is bad and only going to get worse. If there were some process going on that would allow her to pass on sooner than later and avoid what's coming down the pike, well, I'm not against it. I know some folks feel that you need to preserve life in any form, but we think that there are fates worse than death, and where she (and dad, too!) is, is one of them.

I'll let you know what the outcome of my conversation with the doctor is. He's very compassionate and actually works with hospice too, so he's sympathetic to our wishes (which are actually mom's wishes for herself!).

Love,
Sarah

 
Old 11-17-2011, 08:35 AM   #4
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Re: Anemia, Blood Transfusions and Delirium

Sarah, I feel exactly as you do. More than the physical side effectts of a treatment I measure the emotional toll it takes on Mom. Another night in the hospital and laying still for a transfusion is not easy for her, or for you.

They targeted her anemia as a B-12 deficiency. They have been giving her B-12 but obviously it is not fixing the problem. Could it be that she can no longer adequately process the B-12? Yes, adding more red blood cells to her blood (and they usually use blood with concentrated red blood cells) they will increase her hemoglobin count... but is it going to stay up? Probably not. You can get in a rut of taking her every few months for another transfusion.

I think every decision comes down to what is best for Mom.... and that may or may not be what is suggested by the physician. You are right to consider her emotional well being in all this. I feel that it is our goal to create contentment rather than extend life. There are things worse than death. I have always said that I would rather have Mom content for a shorter time than alive for a longer time. Physicians are good at extending life but they are not very good at the dying process. Eventually it is time to let go and let the natural process take place.

Yes, he has to sign off on Hospice. In my experience we wait too late.. and part of that is the doctor's desire to extend life. In Dad's case I waited until the doctor thought it was right and Hospice was on board for less than 2 months. This time I followed my gut having been there before... and Mom has already been on Hospice for over 4 months with no clear end in sight. But I do know she is better off than Dad was. Yep, it's all confusing and it takes a lot of information and thought to come to the right decision. Keep working on it.... and know there are no wrong choices. There are just choices

Love, deb

 
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