Facing emergency surgery for a perforated intestine, 77-year-old Louise Finocchio, who has advanced Alzheimer’s disease, was in imminent danger. Haytham Kaafarani, MD, MPH, the surgeon on duty that night at Massachusetts General Hospital, knew he had to make a momentous decision swiftly: Should he operate even though her chance of survival was low? Or was it time to let nature take its course with Louise?
To answer the question, Dr. Kaafarani did what members of the Division of Trauma, Emergency Surgery and Surgical Critical Care team often do when faced with time-sensitive, life-and-death decisions: He turned to Louise’s family for help in understanding her as a person.
Alzheimer’s Disease and Tough Decisions
Knowing that she might not make it through surgery given her age and medical condition, Dr. Kaafarani posed the ultimate question to Louise’s daughter, Karen Lubeck, and Louise’s husband, Richard Finocchio, both of Marblehead, Mass. “I have to ask you, will I be doing her a service by taking her to surgery?” he said. Because Karen and Richard knew Louise so much better, he asked them to help him understand, “Should we go forward with this or is it time to let her go?”
Such urgent decisions are a daily routine for Mass General’s Division of Trauma, Emergency Surgery and Surgical Critical Care teams.
Such urgent decisions are a daily routine for teams from Mass General’s Division of Trauma, Emergency Surgery and Surgical Critical Care, whose chief is George Velmahos, MD, PhD. For Louise’s daughter and husband, though, the top priority was making sure their beloved mother and wife received the best possible care. Living at home with her family, Louise is well loved and cared for, Karen says. Although she cannot speak because of her Alzheimer’s disease, “Lulu,” as Karen calls her, communicates in many ways. They range from a contented smile to a flash of eye contact that Karen calls “LuLu’s sparkle.”
Two days before the urgent scene at Mass General, Louise developed mild flu-like symptoms. “We thought she had a stomach bug,” Karen recalls. But soon, there was vomiting and then sluggishness. Finally, she became unresponsive.
An Urgent, Late-night Drive
Louise’s condition was dangerous and complicated. “It was what we surgeons call a ‘double disaster,’” Dr. Kaafarani says. Not only was her abdominal cavity filled with dangerous, infectious microbes from the perforated colon, but the entire cavity was immensely inflamed. Surgery to repair the torn intestine was the only answer and it might not work, even with intensive follow-up care.
Karen and Richard wavered. Should they expose Louise to the risks of surgery? Two CAT scans confirmed the necessity. Now, in collaboration with Dr. Kaafarani, they faced the ultimate decision.
The time-sensitive nature of such decisions in the Division of Trauma, Emergency Surgery and Surgical Critical Care adds an extra layer of intensity for staff and patients. “Our patients are usually fighting for survival,” Dr. Kaafarani explains. There is seldom time for lengthy deliberation and multiple consultations. Instead, the MGH team works closely with patients and families to quickly evaluate the options and make the best decision within the time available.
Regaining Quality of Life
“Even though she has Alzheimer’s disease, she actually enjoys life with us and has a good quality of life,” Karen told Dr. Kaafarani. “I think we should give her a chance.”
The MGH team works closely with patients and families to quickly evaluate the options and make the best decision within the time available.
“You know her better, ” Dr. Kaafarani recalls responding.
More than a year later, Louise lives at home and has regained the quality of life she had before the emergency. In a letter to Dr. Kaafarani and the medical team, Karen wrote: “Thank you for looking beyond the Alzheimer’s disease to the loving mom and wife that Lulu is. Thank you for seeing her as the fighter that she is.” She also credits doctors from McLean Hospital in Belmont, Mass., Stephen Seiner, MD, Brent Forester, MD and Carolyn Mehaffey, MD who collaborated in Louise’s care, as well as Annmarie Stout, CRNA.
For Dr. Kaafarani and the whole acute care team, the daily, timely, life-and-death decisions continue, “It’s the nature of what we do,” he says.
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