The Colonoscopy Decision
    It may be a surprise to those of you who are familiar with the events of last fall and winter that I have decided to okay a colonoscopy for Mom and she is willing to trust my decision. This has not been an easy decision for me to make. As a review, last fall because of the following factors:

1. negative occult blood fecal smears,
2. urine negative for blood,
3. no upper or lower tract gastro-intestinal digestive disorders,
4. the difficulty involved in keeping my mother in a fully hydrated state at any time and the fact that she had experienced a blood pressure crash due to dehydration in early September, 2002, one month prior to the time for which the colonoscopy was being suggested,
5. the dismissal of my concerns that the day before the colonoscopy would be a bit too rigorous for my mother, at that time, and might precipitate another blood pressure crash,
6. my inability to sort through the lack of information I was getting from the doctors and the bewildering abundance and technicality of the information I was finding on the internet about anemia in the elderly,
7. my mother's innate disdain for and mistrust of invasive medical procedures, and, thus, my efforts to keep procedures of this sort to a minimum in her life and to always, first, seek alternatives, and her insistence that she wanted this particular test cancelled,
8. the quick and spectacular success of iron supplements in curing her anemia and the extent to which all her spiked or sluggish test numbers cleared up as her anemia turned around,

I decided, after having scheduled a colonoscopy for mid December, to cancel it. I discussed this decision with both her PCP and the consulting hematologist. Both agreed that, considering everything, while a colonoscopy done at this time could be valuable as "history" (a word I have begun to look upon suspiciously when used by anyone in the medical field) it would not be unwise to cancel the procedure and wait until a more physically auspicious (or emergent) time.
    Well, Time is now Emergent. Her anemia is no longer being addressed by large doses of supplemental iron. It is so out of control that it is affecting her other body functions. And, most importantly, I now understand why it is that, as her doctors have concluded, her anemia is most likely due to internal bleeding.
    It is important that I note here that I did not understand why her doctors insisted, earlier, that she was bleeding inside when there were a variety of factors that indicated that this may not be true. Her lab results were not, from what I was able to understand, always classically in favor of internal bleeding as the cause of what we now know to be her Iron Deficiency Anemia. And, as well, after my first dive into the world of medical literature, I discovered that in a third of all cases of anemia in the elderly, both Anemia Due to Chronic Disease and Iron Deficiency Anemia, the cause is never found but this is rarely a deterrent to successful treatment of the anemia.
    My second dive into the literature has taken place within the last few months as I've been trying to form a deeper understanding of the flow of numbers coming from Mom's blood tests and why the doctors are so sure that these indicate internal bleeding, that it should be looked for (that Mom is not too frail for this) and the best place to begin to look for it is in her colon.
    First, I want to refer any of you reading to an article that, despite it being almost 3 years old, sums up almost everything I've been able to discover about anemia in the elderly, and is readable: Anemia in the Elderly by Douglas L. Smith, M.D. To summarize what I discovered without you having to plow through 11 pages, the tip-off to the doctors that Mom's anemia is due to internal bleeding is that it has been successfully addressed by iron supplements. Anemia Due to Chronic Disease or other conditions such as vitamin B12 or folate deficiency is never successfully addressed with iron supplements. In fact, in most cases, it isn't addressed at all. Thus, when the iron either stopped working or, as it is beginning to look now, works only intermittently, this most likely indicates that sometimes she's bleeding more, and sometimes she's bleeding less or not at all. At any rate, the likelihood of her bleeding enough to jaundice her and completely sap her of energy is high on any particular day now, and this needs to be investigated. If the cause of the bleeding can be found and stopped, it needs to be.
    The colon is the most likely place to look first for a number of deductive reasons which form themselves into a hard-to-ignore numbers game:

1. Bleeding in the elderly is usually discovered in the digestive tract;
2. if the person does not have a history of upper intestinal disorders (ulcers, acid reflux disease, etc.) the most likely place in the digestive tract for a bleed to occur is the colon;
3. The preparation for both an endoscopy and a colonoscopy are the same. The anesthesia for the procedures, though, is typically less rigorous with the colonoscopy in people my mother's age, especially those who smoke;
4. All other non-invasive tests have been done, including abdominal scans with radioactive dyes, and are showing her "normal", nothing out of order, but, she continues to struggle with anemia.

    The change in my decision is completely dependent on the fact that her anemia simply can't be addressed with iron supplements anymore and is weakening her sufficiently to set up a Garden of Eden for other conditions, such as worsening her COPD and contributing to not only incipient but developing Congestive Heart Failure, from which she was not suffering, previously.
    I know, I know, eventually, something will take her out. I know that, although I wish her a quick, easy death, she is just as likely to decline slowly while doctors and labs and I watch and worry about her blood numbers, trying to improve them, even as her body slyly winks and whispers, "Hey, do what you want, but this woman's reward is due and your efforts to postpone the presentation aren't going to have any effect on the timing of the ceremony."
    The more time I spend with my mother and her health (which are sometimes two separate entities, now), the more I think I'll know when it will be time to stop trying to improve the quantity of my mother's life and simply make her comfortable. When I first began my adventure with her I didn't think I'd ever come to the point I'm at now, but I made it. I trust my judgment on this, and, what's more, Mom trusts my judgment, especially since I continue to ask her, outright, when she is having a series of very low days, if she thinks it's time for me to protect her, rather than treat her, and allow her to sleep herself into death. I can tell you who are reading, though, that now is not that time. Mom still has both feet here, even on her really bad days when she swears she doesn't care what I do, she just wants to go to bed, even though she's been in bed for the past 12 hours. I can't tell you how I am sure that this is true, but I am.
    So, on July 23rd at Banner Baywood Hospital at 0820, check in at 0700, she's getting her ass scoped, as I like to refer to it in her presence. Although she's never been one to favor strong words, she likes the way I describe the procedure when I discuss it with her. I think, hearing the procedure described this way allows her to feel as though the inconvenience and barbarity of it is not being covered up by a bunch of "c's" and "o's" ("c"-"o"-mfort sounds), thus, she is not at its mercy.
    Surprised at the term "barbarity"? Those of you who know my mother know she is a Star Trek fan. One of the Trek movies she's seen more than a few times and is one of her favorites is the movie in which the crew returns to 20th century Earth to capture a whale and transport it through time. One of the scenes takes place in a hospital in which Dr. McCoy, as he dashes through the halls, takes a quick look at what is our modern medicine, calls it "barbaric" and quickly, painlessly and non-invasively heals a few patients awaiting surgery as he heads toward his destination. Mom has never forgotten his pronouncement. Whenever we watch the movie she always turns to me and says, indignantly, "He's right, you know." And, I think, she continues to feel this way, even when the barbarity of current medical practice is also state of the art. As far as she's concerned, life's accoutrements have changed so much since she was born that there is no reason why we should still be cutting people up, sticking expensive instruments into them and endangering them further than their dis-ease already endangers them. And, she's right. She's just ahead of her time.
    I do, at least once a day, have visions of something going horribly wrong as a result of the procedure. I'm feeling somewhat better about this, though, since having talked to her gastro-enterologist's scheduler. I'm not taken with the physician who is doing the procedure from a personal standpoint. She is sadly lacking in people skills and was really off-putting the first time I met her, dismissing both my questions and concerns by citing how many colonoscopies she does a year. All that told me was that colonoscopies are her meal ticket. She comes very highly recommended, though, has an excellent track record and her scheduler clued me that she is especially careful with the elderly, thus, the procedure will most likely be longer than the typical time quoted in the literature. That's what I needed to know. She doesn't have to be good with people, she just needs to be good with assholes. And, she is.
- posted by gail rae @ 00:58   email...this post