Food for Thought: Papas Fritas

Mrs. M is an 80-year-old fully dependent, Spanish-speaking woman with severe Alzheimer's dementia seen as an inpatient by Geriatric Medicine for a goals of care discussion.

She was admitted due to septic shock (MRSA bacteremia) and possible endocarditis, requiring a prolonged admission in the intensive care unit (ICU). She was started on pressors and broad-spectrum antibiotics and underwent invasive procedures. Due to her prolonged ICU stay, her clinical status significantly deteriorated, including severe dysphagia. Eventually, she was transferred from the ICU to the general medical floor; however, her severe frailty and dysphagia remained unchanged, and PEG tube placement and other invasive procedures were brought up by the interprofessional admitting team.

Her daughter, who was her health care surrogate (HCS), requested ‘everything to be done,’ including maintaining full code status, a transesophageal echo to confirm endocarditis, and PEG placement, and refused consultation from palliative care. Geriatric medicine was then consulted for a goals of care discussion.

During our consultation, we observed Mrs. M to be a frail person living with severe dementia, whose speech was limited to yes and no answers. We called her daughter and asked if she could join us and her mother in person to identify her concerns and expectations regarding her mother's health.

After a long discussion with Mrs. M's daughter, we identified that one of her biggest fears was that her mother was not able to nourish herself due to dysphagia and, as a result, was getting weaker. This was her reason for wanting a PEG tube to be placed. We took the time to explain the importance of small pleasures at the end of life and that the PEG tube would provide more harm than good at this stage of her mother's illness. We asked what her favorite food was, and her daughter answered ‘papas fritas’ (French fries); see Figure 1: image of Papas Fritas or French Fries. We recommended a liberalized diet, and in the following days her daughter started to give her small amounts of french fries as tolerated. After that, her daughter requested a change of code status to DNR, declined PEG tube placement, and accepted a hospice consultation for her mother.

Mrs. M's story reminds us how important goals of care discussions are to identify what matters most to our patients and to make sure we work to always honor their wishes, but especially at the end of life. It also reminds us how crucial it is, even more in a setting of the diagnosis of dementia, to have those conversations early rather than when the disease is already too advanced for them to be able to determine their priorities at the end of life.

Many times, goals of care discussions are avoided due to time restraints, moral barriers, or due to perceived resistance from patients or families. In practice, we do see resistance from patients to talk about this matter, and depending on their individual culture and beliefs, this type of conversation is, at times, not welcomed.

In Mrs. M's case, her daughter initially resisted these conversations as she believed that having a PEG tube placed would be beneficial for her mother. However, once we were able to identify that a feeding tube was not in alignment with What mattered most to her mother, and being able to address the daughter's concerns and expectations, she understood that the most important thing was to provide her mother with comfort.

It is always important to have goals of care discussions with patients with dementia early in their diagnosis, ideally with both the patient and their caregivers present in a calm, non-stressed environment, which allows time to provide information and correct misconceptions regarding care and assures that when the time comes, what matters most to the patient will be respected [2, 3].

Each of the authors contributed to the writing and editing of this manuscript.

Dr. Sehgal is the section editor for the Journal of the American Geriatrics Society Education and Training Section. Drs. Nunez and Ferreira have nothing to disclose.

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