July 01, 2010

This month's column offers you, the reader, an opportunity to express your opinion on a difficult clinical situation that remains unsettled at the facility where I serve as medical director. The case below is that of Mrs. OP, who has an indwelling urinary catheter though no current medical indication for it. Yet she refuses to have the catheter removed. How would you resolve the issue in your facility, with your interdisciplinary team? After reading this column, please e-mail me at bwirfs@llor.org

Mrs. OP, a 65-year-old former chef, was admitted to our facility 3 months ago after hospitalization for an acute embolic cerebrovascular accident in the right middle cerebral artery. She has significant left hemiparesis affecting her left arm to a greater extent than her left leg.

Her premorbid conditions are significant and include morbid obesity, diabetes mellitus type 2, hypertension, and chronic lower extremity lymphedema. Mrs. OP currently weighs 86 kg (190 pounds), with a body mass index of 32, but her maximum adult weight was about 305 kg (675 pounds) 5 years ago. After laparoscopic fundoplication and panniculectomy but before her cerebrovascular accident, her weight was 102 kg (225 pounds).

 

 

Medicare Recertification Meeting

Physical Therapist: Mrs. OP works daily in both physical and occupational therapy. She is able to stand in the parallel bars, but because of her lymphedema, her legs and ankles are so large and heavy they are hard for her to move. She is making steady, slow progress.

Nurse Manager: Mrs. OP has depression, and her attending recently started her on an antidepressant. She has had an indwelling Foley catheter since her hospitalization and despite efforts to change her mind, she refuses to allow me to remove it.

She says she cannot use a bedpan and that the CNAs don't respond to the call light fast enough, so she is unable to get to the bathroom in time to avoid an accident. I contacted her attending physician. He said to continue the Foley. When I told him we needed a diagnosis to continue the catheter use, he gave me “morbid obesity.”

Medical Director: “Morbid obesity”! If morbid obesity is an appropriate diagnosis for a Foley catheter, then I'll need to order leg bags for half of the population of this state. She has been sedentary for a long time. Getting up for the bathroom is exertion, and she probably would rather not exert herself. I am troubled about the risks of resistant infections. Let's see if we can do bladder retraining and get a bariatric-sized bedside commode for her to use.

Nurse Manager: I have spoken with Mrs. OP about prompted and scheduled voidings, bladder retraining, and use of absorbent pads in case she can't get to the bathroom quickly enough. She declines all of these potential approaches.

Social Worker: We don't use bedside commodes anymore. It is a patient-privacy issue. She may also be unsafe transferring to and from the commode. And if the nurse assistants don't empty the commode frequently enough, her room will smell of excrement.

Medical Director: This is exactly the patient who is at risk of developing a resistant infection. And that puts other residents at risk, as well. I really don't want our facility to suffer through an outbreak of C. difficile. So how can we get rid of the catheter? Is Mrs. OP a candidate for bladder retraining or pelvic floor muscle rehabilitation? I am not a big proponent of intermittent catheterization, but could that help this patient? Can we find a way to use a bedside commode? How good is her balance?

Physical Therapist: Mrs. OP is entirely unsafe getting to the toilet on her own or with the assistance of one person. She requires a mechanical transfer for safety. I cannot recommend withdrawing the catheter at this time.

 

 

IDT Team, 2 Weeks Later

Physical Therapist: Mrs. OP continues to improve in therapy. She is able to walk with a gait belt and assistance of one person. She can stand unassisted in the parallel bars. Her quadriceps strength is improving. She will continue in therapy.

Nurse Manager: When I spoke with the administrator about the bedside commode, the answer was “absolutely not.” The administrator says that there is no way Mrs. OP can have privacy with a bedside commode. The administrator says we are out of compliance with this unnecessary catheter and we risk being cited for it at our state survey. When I talk with Mrs. OP, she says that there is “no way” that she will give up the Foley at this time. Doctor, can you speak with her?

 

 

My Meeting With Resident

I encounter Mrs. OP for the first time while she is in the therapy gym. I see a pleasant woman who is articulate and appears determined to regain her strength. She is walking with the use of a quad cane and assistance of one person. Her gait, however, is slow and divided into segments of stance and leg swing, carefully shifting weight from left to right sides.

She has the look of deep concentration. I observe that her weight is centered in the lower half of her body: She has average-sized arms and chest, a large pannus and buttocks as well as massive ankles and lower legs enlarged with chronic lymphedema. Her ankles measure 40 cm in diameter; no ankle bones are visible or palpable. She walks in rubber-soled house slippers.

Mrs. OP: Five years ago, I weighed 675 pounds and through surgery, diet, and exercise I have lost 485 pounds. After the surgery I kept having yeast infections, red and miserable under my belly fold. So I had plastic surgery which removed 20 pounds of skin.

I have realized that my weight problem stemmed from anger with my ex-husband and depression over the divorce, as well as the delicious taste of the food I prepared at the restaurant. I have no intention of allowing the weight to return. This stroke has really set me back, but now I do have movement in my entire left side. See, I can wiggle my fingers slightly.

Here is my concern about removing the catheter: On second and third shifts, the CNAs don't answer the call light. I have waited 30 minutes or more for someone to come. I cannot use the bedpan and by the time the CNA arrives I will have wet myself, or worse yet, will have fallen onto the floor. I am making good progress rehabbing from the stroke, I cannot afford to fall and have a broken hip.

[I had spoken with her attending physician. He confirmed that Mrs. OP had lost considerable weight over the past 5 years. But in his opinion, she was markedly deconditioned prior to her recent stroke. From the last time he spoke to her, he reiterated her account of not being able to use a bedpan, not getting to the bathroom quickly enough, and slow responses by nursing assistants to her toilet requests. Her attending admitted that his order for the catheter was driven by the patient and her claim that it was simply more convenient. Since I observe her walking in slippers, I inquire about her footwear. Was she aware that custom shoes may be covered by Medicare?]

Mrs. OP: I have been unable to wear standard shoes for years. Because of the swelling I get in my legs, my feet are different sizes. When I looked into custom shoes, I was unable to afford them. No, I was not aware that Medicare would cover custom diabetic shoes, but I am interested in learning more about it.

Current Status

Mrs. OP has significant but improving left hemiparesis, but she still requires assistance to get to the bathroom and still refuses catheter removal, now 4 months after her cerebrovascular accident. The physical therapist says Mrs. OP will continue to benefit from therapy even after her Medicare Part A days end and could continue under Medicare Part B. She should be able to return home, but only with 24-hour help. She is unlikely ever to be safe on her own.

The nurse manager has informed us that Mrs. OP's daughter, who is a hospital nurse out of state, has convinced her that the inconvenience of being transferred from bed to bathroom by a mechanical device is more trouble than her risk of developing a urinary tract infection.

The daughter related that since her mother hasn't had any opportunistic or resistant infections in the past, she's less likely to have a catheter-related infection of those types. She has no antibiotic allergies and can tolerate a UTI, if it happens. Mrs. OP's daughter says that her mother's rights and needs outweigh any regulatory requirements, that the facility has to justify the catheter use.

With the urinary catheter in place, I feel the facility is at risk of an F-315 “unnecessary catheters” citation at our next state survey. Removing the catheter without Mrs. OP's approval puts us at risk of an F-155 citation for ignoring the patient's right to refuse treatment. We are still struggling with how to resolve this situation.

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