Daynotes Journal Week of 4 August 2003 Latest Update : Sunday, 10 August 2003 23:10 -0400

Monday, 4 August 2003

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8:44 - The start of another week. Mom is still in critical condition in the intensive care unit, but she's doing a bit better. She's a bit less responsive to me than she was at her best, but she opens her eyes when I speak to her. The doctor said yesterday that all her vital signs were very strong, and that the antibiotic cocktail they'd given her (Cipro, Vancomycin, and one other that I forget) seems to have beaten the infection. The new monitor they connected to the new catheter they inserted Saturday gives more reliable readings, according to the doctor. One of the numbers he says measures general cardiac condition. Mom's reading on that was 3.6. The doctor said the average patient he had in ICU read a 2.5 on that one, so mom's reading was quite good. The other number he said measures how well she's oxygenating her organs and extremities. She had an 83 on that one, which the doctor said was a reading that he or I might have.

I was concerned about the edema. Mom is swollen up like a sausage from the IV fluids they're giving her to help maintain her blood pressure. Dr. Jeff (he said, "Call me "Jeff". My last name is too hard to pronounce.") said not to worry too much about the edema. He said it was expected, that they had a handle on it, and that it should start to go away in three days or so. So, at this point, I'm guardedly optimistic that things may work out. As Churchill said, "This is not the end. This is not even the beginning of the end. It is, perhaps, the end of the beginning."

Thanks to everyone who has subscribed and renewed their subscriptions recently. I apologize for not having had time to process them yet. I'll get to them as soon as I can, but for now things are a bit hectic.

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Tuesday, 5 August 2003

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22:32 - I thought things were going reasonably well yesterday. They'd inserted a feeding tube, so that they could feed mom by stomach rather than IV. They'd cut back the boost on her ventilator to 4, which is almost nothing, and the O2 from 50% to 40%. Her pulse, BP, and pulse-ox were all good. She was maintaining decent BP on her own.

When I visited this morning, mom's BP was a bit low, but her pulse was good and her pulse-ox was at 99 and 100. What's concerned me for the last couple of days is that she's been less responsive. Before, she'd at least open her eyes when I spoke to her, but for the last day or two, she sometimes doesn't even do that much.

When I spoke to her nurse, she was very pessimistic. She thinks mom has no chance to recover, "short of a miracle". She was good enough to say that miracles did happen. It's interesting how much the opinions vary among the medical staff. One of the two residents (they work 12-hour shifts) is reasonably optimistic about mom's chances, or he was yesterday. The other is quite pessimistic. I try to take a middle ground. I hope the pessimists are wrong, but I fear they're right.

As I've said before, mom is tough, but she's also 84 years old and exhausted. I'm not sure how much more she has to fight with. As Barbara said, one of two things will happen. She'll either slowly recover, or multiple things will start to go wrong. If the latter happens, that'll be that. She simply has nothing left to fight with, so a downturn now would almost certainly mean the end. We continue to hope for the best, but the worst won't come as a surprise.

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Wednesday, 6 August 2003

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No post.

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Thursday, 7 August 2003

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-------- Original Message --------
Subject: your mother
Date: Tue, 5 Aug 2003 19:57:47 -0700
From: mhuthATcoldswim.com
To: Robert Bruce Thompson

Bob,

I've no great words of wisdom, except that you are doing the correct thing by making every reasonable effort to keep your mother alive. You've raised some important points about DNR status and misconceptions about that amoung the lay public.

No physician should ever force his will upon a patient or patients family, but in my view we can offer advice. As you suggest in your posting today, things are mixed. She's got good blood pressures, she isn't requiring a lot of ventilatory assistance, and she is attempting to recover from a huge surgery. However, sounds like she has had an intra-abdominal infection following a perforated viscus and her level of consciousness is decreased. She may not be responding because of sedation, infection, fatigue, confusion, etc. I don't know from reading your posts if she has renal insufficency, but suspect that she does.

From a medical standpoint, see if you can talk with the attending lung doctor (pulmonary doc). As you know, the residents are in training positions and the lung doctor (or the cardiologist if one is involved) should be running the show at this point. Ask the pulmonologist for his opinion, tell him you know it is an opinion, tell him you appreciate his and his residents hard work (and it is grindingly hard work taking care of critically ill patients...stressful in the extreme). If he or she is any good he'll give you guidance. I suspect he will tell you that things look bad. If he does, ask him how long to continue pushing. We do this every day and will usually give you our best answer. We never really know, but get a feel for things after many years of taking care of the critically ill.

One of the hardest things I've ever done was sit with my father and discuss stopping care with my mother. Huge mounds of guilt, but it is often the best thing.

Forgive me this next sentence, and forgive my imposition on our friendship, but was she happy with her quality of life in the last few months? If not, please give strong consideration to suspending care.

Again if I can be of help, please call me.

Thanks for taking the time to give me such helpful information. I was in the process of replying to you this morning. I'd had your message up on my monitor while I spoke to the doctor on the phone, and was taking notes about some of the stuff he said. Before I could finish or send the message, Malcolm decided he wanted to go out. I was sitting in the den with the keyboard in my lap, and he let me know of his wishes by planting his paw firmly on the upper left portion of my keyboard. What I'd been writing for 15 minutes was gone forever. Oh, well. At least he wasn't lying this time, as it turned out. He really did need to go.

I told the doctor this morning that my impression was that one of two things would happen with mom. Either she'd gradually improve and recover, which might take a long time, or she'd start having multiple system failures and go downhill fast. I said I thought from what I knew of mom and her condition that it was unlikely she'd simply stay the way she is indefinitely. He agreed with me, but said that if she does recover it's going to be a long, long haul. Obviously, he thinks it more likely that she'll start having multiple problems that simply swamp her ability to deal with them. So do I, for that matter.

I also asked him about the prospects for her if she did recover, specifically whether she'd be impacted mentally. He said that she would not be impacted mentally, barring something unforeseen, but that she'd obviously be exhausted and take a long time to recover physically.

Mom doesn't want to live permanently connected to tubes, nor does she want to live if her brain is damaged. I concur with both of those thoughts, and I'm trying to direct the doctors as she would do if she were capable. On the other hand, if there is a chance of full recovery and she is not suffering, I see no reason to withhold care that might allow her to recover. Her quality of life before this happened was pretty good, all things considered. She doesn't like being in a nursing home, obviously, but she had her television, telephone, crossword puzzles, books, and drawing materials. I think it was pretty clear from her reaction in the emergency room that she doesn't want to die. When the ER doc told her that she needed surgery or she would die, she said "Let's get it done, then."

Right now, she's stable but relatively unresponsive. For the last couple of days, I've barely been able to get her to open her eyes when I speak to her, and she no longer shakes or nods her head in response to questions. I think that's a matter of pure exhaustion, and that alone may kill her. But so long as her vital signs remain reasonably good, I see no reason to withhold supportive measures.

The resident I spoke with this morning told me that during rounds last night the attending had ordered her taken off dopamine, which they'd been using to help her maintain her BP. Her BP has always been low, and right now she's maintaining a low but adequate BP on her own. The attending also ordered a stop to IV fluids. They're very concerned about the edema and fluid burden. She's swollen up like a sausage. They're convinced that she has adequate fluid in her circulatory system to maintain BP on her own and want to get the edema down.

As far as respiratory, they now have her boost down from 15 to 4 on the ventilator, and she's getting 40% oxygen. The resident said that was minimal respiratory support, but what they really want is to remove it entirely so that she can breathe on her own. He said she wouldn't tolerate that, though, which is cause for concern. I asked about renal failure, and he said she wasn't suffering that. Her urine output is low but acceptable. What does concern them is that she's septic. They still have her on Cipro, Vancomycin, and one other antibiotic, and plan to continue those.

What I find interesting is that each time I ask someone, "Is it hopeless?", they always say, "No, not at all. She has a chance, but not a very good one." So my attitude is, if she's not suffering, and if she has a chance to recover, why would I take away that chance? If she were suffering, or if the best possible outcome were that she'd be on tubes for the rest of her unnatural life, or if she'd be brain-damaged, I'd sign a DNR in a second. But I don't think it's come to that point. I'm trying to decide things based on logic rather than emotion, which I think I'm doing. But we'll see what develops.

Once again, thanks for your support.

I tried working this morning, for the first time since my mother went to the emergency room. I wasn't able to accomplish anything. I wrote for about two hours, but when I finally stepped back to read what I'd written it was total dreck. As anyone who writes will tell you, writing requires absolute concentration on what one is writing. I simply can't do that. I tried forcing myself to, but it just doesn't work. I can barely get these journal posts written, and they're stream-of-consciousness rather than structured writing.

Barbara told me a few days ago that I simply couldn't continue visiting mom during each of the four visiting hours per day. She's right. Just sitting there in the ICU for an hour takes as much out of me as would working a full day breaking rocks. I only went down for the 2:00 to 3:30 visit yesterday, and I felt completely draining coming out of that one. Hell, I felt completely drained going into it. Something about setting foot in the hospital takes my energy level down to about 10% of normal. I feel myself rebound a bit when I leave, but I'm gradually wearing down even though I've cut back to one visit a day as long as mom isn't even aware I'm there. I call the nurses' station half an hour or so before the start of each visiting period, just in case mom has been alert, but each time they tell me there's been no change.

I'm going to go for the 2:00 to 3:30 visit again today. I'll leave them Barbara's cell-phone number, because Barbara and I are going to go out to dinner and then to our astronomy club meeting this evening. I badly need some semblance of normality, even if things can't really be normal as long as this is going on.

My apologies to those of you who have subscribed or renewed your subscription since this all started. I haven't had the time or energy to get those processed yet. Thanks for understanding.

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Friday, 8 August 2003

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11:47 - Mom is about the same. Her vital signs remain strong, but I think she's trending gradually downward. Yesterday I was sitting there in the ICU thinking about asking what I needed to do to re-activate the DNR order. As I was doing that, mom's nurse came over to me and suggested that it was time to put a limited DNR in effect. The nurse said I should think about a DNR that forbade CPR. With mom's osteoporosis and rheumatoid arthritis, the nurse said, any attempt at CPR would break all of her ribs, leaving her in excruciating pain and with basically zero chance to recover. She said that with the limited DNR in effect they'd still use medications if necessary to resuscitate, but wouldn't use CPR or crack mom's chest if her heart failed.

I agreed with her suggestion and told her I wanted to get that limited DNR in effect immediately. She called the resident over and I told him my wishes. I was surprised that I didn't need to sign anything. They simply wrote up the order in mom's chart. Although mom wasn't alert, I told her what I'd done and why. It's what she would want if she could tell them herself.

I am desperately in need of some semblance of normality, so Barbara suggested that we go out to dinner last night and attend the regular monthly meeting of the Winston-Salem Astronomical League. We did that. We had certificates from the national AL to pass out last night. Barbara and Steve Childers got their 70+ Messier certificates. Paul Jones and I got our 110 Messier certificates and pins.

We're scheduled to spend the weekend of 29 August up at the Wake Forest lodge on the Blue Ridge Parkway. I hope the weather is decent and that mom's condition is such that I can get away for at least one of the nights. If not, I'll insist that Barbara go without me. She needs a break, too. She's working full-time, taking care of the house and the yard, doing her consulting work, and basically doing everything else. About all I've managed to keep up with is the laundry. Barbara needs some time away to relax.

Assuming I can go, and assuming the weather is clear (which is a major assumption, given that it's been cloudy and/or raining nearly every night around here for the last year or so), I plan to re-do the Messier list, or as much of it as I can given that not all of the objects are visible this time of year. I've done it before with our 10" Dob, but this time I plan to do it with our 3.5" refractor, which is significantly more challenging. Impossible, in fact, from our usual observing locations. I'll need the darker skies at the lodge to have any chance at all. Messier's favorite instrument was a 90mm refractor with a 3 foot (36") focal length. We have a 90mm refractor with a 1,000mm (39") focal length. So I'm going to try to complete Messier's list with an instrument much like the one he used.

I have some advantages. My optics are much better. Lens coatings were unknown in Messier's time, and my eyepieces are worlds ahead of what he used. Nowadays, when we want to change to a different magnification or field of view, we change eyepieces. In Messier's day, scopes didn't have removable eyepieces. If Messier wanted to use a different magnification, he used a different scope. I also have the advantage of the Telrad finder, a better optical finder, and better charts than Messier used, not to mention a notebook computer.

Strangely enough, I also have clearer skies than Messier had. I'll be observing from a mountaintop far from large cities. Messier observed in the late 18th century primarily from his observatory in the middle of Paris, France. Everyone's first impression is that Messier must have had pristine skies, but the fact is that his skies were filthy. Paris even then was a huge city, and people heated and cooked with wood and coal. Lighting was with candles and oil. Messier didn't have to contend with automotive air pollution, but the manure dust from millions of horses and other beasts of burden was everywhere. A traveler approaching a large city in the late 18th century could see a smoke dome for many miles before the city itself came into view.

Finally, Messier was observing from a high latitude, nearly 49º N. I'm observing from about 36º N. For many of the Messier objects that doesn't make any difference, but for the southerly objects it does. For example, the three Messier globular clusters at the base of Sagittarius (M54, M69, and M70) have declinations between about -30.5º and -32.5º (where a minus sign indicates a location south of the celestial equator). For me, at about 36º N, those declinations mean that those objects never get higher than 22º or so above the horizon. For Messier, observing from 49º N, those objects never get more than 8.5º or so above the horizon. M7 in Scorpius is even worse, at about -34.8º declination. From Paris, M7 never gets more than about 6.5º above the horizon.

But the one advantage Messier had, and it's a huge one, is that he didn't have to deal with light pollution. Even at the Wake Forest University lodge on the Blue Ridge Parkway, which is an hour from the nearest large city and half an hour from Mount Airy, NC, we are surrounded by a sea of lights. By today's standards, the lodge is a nice dark-sky site. But if Messier found himself there today, he'd be shocked at how bright the sky is. He'd also be flabbergasted by all the aircraft and satellites passing by. The night sky in Messier's time was a very different thing. Much darker, and much less busy. The only fast movers in Messier's time were meteors. Nowadays, there's always something bright and fast-moving visible, even from the most remote sites.

At any rate, I hope to use our 90mm refractor to duplicate Messier's efforts. We'll see what happens. Even if we're clouded out, it's a nice place to spend a weekend.

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Saturday, 9 August 2003

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Sunday, 10 August 2003

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23:10 - My mother passed away at about 9:45 p.m. this evening.

Barbara visited her during the 2:00 to 3:30 visiting hours this afternoon, and told me when she returned that mom was sinking fast. She was in severe distress, and the only real options were to withdraw support or to have them do a tracheotomy. The outlook if they did a tracheotomy was very poor, so we decided, in accordance with my mother's wishes, not to do that.

They removed the respirator tube and my mother passed away quietly a few minutes later. She did open her eyes briefly, and I think she knew that Barbara, Bill, and I were there.

We are all deeply saddened, of course, but this is what she wanted. She had fought long and hard, but she simply had nothing left to fight with. It was a kindness to allow her to go.

We will have her cremated, and will scatter her ashes commingled with those of my father, in accordance with her wishes.

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