Brother with end stage liver disease

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latinadaydreamer
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Date Joined Dec 2011
Total Posts : 8
   Posted 12/13/2011 10:11 AM (GMT -6)   
I have a brother who is dying from stage 4 liver failure. It is made even harder for him and us in the fact that he is mentally disabled for an injury as a infant. Eddie was an alcoholic for around 12 years and has stopped for 2 years now we were told that the liver could heal itself but that is not the case here. I recently took him to the doctor only to find out he is stage 4 and is getting worse by the week. We have been told that he most likely not qualify for a transplant because he also has diabetes. Does anyone know of support groups here in Seattle Wa? I am so confused and I am having a really hard time time trying to help Eddie, my elderly parents and my own family. I am the crutch in our household but some days I feel helpless. I am looking for more info on his disease what to expect and is there any hope for my brother. I have looked at diffrent sites and have found only minimal info I want to be more informed so I can be more help to my family. I dont know whether to listen to his doctors now about accepting that he is dying or look somewhere else anywhere else hence a support group locally would be great thanks for any info you can share.

healthynow
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Date Joined Oct 2010
Total Posts : 1714
   Posted 12/13/2011 10:46 AM (GMT -6)   
Hi Daydreamer,

Welcome to Healing Well. I am so sorry that your brother is sick with liver disease. I am glad that you found this forum. We are a group of patients and caregivers, not doctors. This is a kind group of people that will share their experiences with you. I am sure that one of the moderators will be along shortly to welcome you also.

Please read the Hepatitis resources folder at the top of the threads. There is lots of information about liver disease there, not just hepatitis. It is important that you get as much information as you can so you can help your brother.

It is important that your brother not have ANY alcohol. He should have lots of fresh fruits and veggies. No red meat, this is very hard for the liver to digest. He should also limit his salt intake. Before having any vitamins, supplements, etc. he should check with his doctor.

Is he seeing a hepatologist? (Liver specialist)

How old is your brother? Is his diabetes under control? Is he experiencing any complications from his liver disease? The more information you can give us, the more information can be shared.

Again, welcome.

Emma

latinadaydreamer
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Date Joined Dec 2011
Total Posts : 8
   Posted 12/13/2011 12:21 PM (GMT -6)   
Well he is 47 years old and is currently seeing a gastroenterologist. He has recently moved to a adult assisted living home around 3 months ago. He was moved there because of behavior issues he had been in the hospital twice for high ammonia levels and is now on meds to lower his levels. We feel that we are not getting all the information about his health from his doctors we are just told he is very sick. he is due in a few days for upperendoscopy. My brother has been sober for around 2 years now and I didnt know about red meat being hard for him he is getting his meals through the place he lives now. they have several nurses that watch the residents there but was never told about him being on a low meat diet. We have been working on his diabetes with him but the meds he is taking for his liver is raising his levels up and down so it is a ongoing battle. On top of trying to get him to eat right he isnt understanding what foods he needs to eat we have taken snacks from him that have sugar and have restricted it from his meals at his home. But he is free to visit other tenants where they have given him candy ect. Right now in just the last 2 months I have noticed my brother becoming weak, is bruising is having trouble with motor skills, sleeps a lot, it has come to the point that I am having to assist in dressing him at times. I cant remember the name of the meds he is taking for his liver but he complains that it is giving him diarrhea. I have also noticed his eyes look glazed and he is having trouble speaking. I ask the nurses if I should should take him in to the doctors because he doesnt look well they tell me no he is fine. So I am never really sure what to do. I was just told by my mother that they are now checking his urine routinely at his home thats something new and news to us. I will asking why they are doing this today Well all together we re feeling like we are not being told what is really going on from the different doctors he is seeing and was just told about 3 weeks ago that he was at end stage. I wanted to ask more questions but didnt want to upset my mother. So here I am asking questions from others that have knowledge or info. Am I just a worry wort and the signs I am seeing in my brother nothing to be concerned about or should I be on alert and taking more drastic actions.

hep93
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Date Joined Jul 2005
Total Posts : 12014
   Posted 12/13/2011 12:25 PM (GMT -6)   
Hi, Latinadaydreamer, and welcome to the forum! I am very sorry that your brother is so ill. Apparently, the damage was already done to his liver by the time he stopped drinking. In other words, there was not enough healthy tissue remaining for it to regenerate. He most likely has Stage 4 cirrhosis, which is end-stage liver disease (ESLD.)

It's possible that he would not qualify for transplant due to his diabetes, as the antirejection meds can cause steroid induced diabetes. In someone who already has diabetes, this could go dangerously out of control. I think the other issue is probably his mental disabilities. There is a long, involved evaluation process for getting listed for a new liver, involving many tests. He would need someone with him for all of these. Post transplant, he would need a 24/7 caregiver to make sure the right meds are taken, help him physically with showers, wound care, and drains, etc., etc. However, the goal is for him to do this himself within weeks. In your brother's case, this may not be possible.

Emma gave you some very good advice. Please do check out the Hepatitis Resources folder as it has a lot of excellent information about liver disease, including the various stages of ESLD.

If there is a large hospital near you that does transplants, that would be your most likely source for a support group--even though he wouldn't be getting a transplant. I know that Mayo has both Caregiver and Transplant Patient support groups. However, they only meet once a week. This forum is here 24/7 and very active. You can always vent, ask questions, seek support here at any time. Please also check out the Caregivers thread. You would be in good company there.

Is your brother having problems with abdominal swelling (ascites) or lower extremity edema? Is he on diuretics? What meds is he currently on? Is he experiencing a lot of forgetfulness or other mental/emotional problems beyond the norm? This could be from an accumulation of toxins in the brain. There is a medication that helps with this, Lactulose. Do you know if he is on that?

It would seem that your brother is not likely to get better. However, he could stabilize somewhat by eating a healthful diet, as Emma summarized, and taking appropriate meds. I would also be interested in knowing if he is being seen by a hepatologist and if that is who said he wouldn't qualify for transplant. Has he has scans of his liver, lots of blood work, perhaps a liver biopsy?

The more information we have, the more we can help you.

Hugs,
Connie

P.S. As I was writing the above, you were posting. Lactulose is the medication he is on to remove toxins (ammonia) from his brain. It works through bowel movements. It will cause diarrhea. This is normal. He should be having multiple loose stools per day. The change in him that you notice could well be because of high ammonia levels. And this is why he ended up in assisted living (not really a bad thing.) However, you need to find out if they are giving him too many sedatives or other meds that would make him sleepy. However, sleeping a lot is one of the signs of ESLD. They may be taking urine to check his ammonia levels. Also, the color can determine how ill he is. If it turns dark, that's a bad sign. Can you find a hepatologist (liver specialist) to see your brother? I'm sure you would have to take him in to the office for an appt. However, you could do this as a "2nd opinion." GI docs know more than primary care docs about liver disease, but not as much as hepatologists.

You know your brother and are aware of changes in him. So do not accept the nurses' opinion that "he's fine." Get him seen! I get the feeling that his GI doc and the staff at the assisted living facility are just "writing him off." And it could be that there is nothing more to be done for him....but I'd want to be sure.

No doctor will tell you that he should avoid red meat. That is something that we patients have discovered and passed on to others. We feel noticeably better after stopping red meat and feel ill if we eat it. In your brother's case, sugar will exacerbate his diabetes. Somehow, other patients need to be put on notice not to give him sweets.

If you will do a search on here for ESLD or ammonia level, you will be able to find posts regarding those issues. There is also an excellent book on liver disease, Dr. Melissa Palmer's Guide To Hepatitis & Liver Disease. You can order it online from amazon.com or other book stores.

The question that most people have is "How much time does he/she have left?" And that is one that can't be answered. It varies so much with each individual. Also it depends on the care they are receiving, diet, their will to live, and many other factors.
hep93
Forum moderator - Hepatitis


"But that was yesterday, and I was a different person then."

Lewis Carroll, Alice in Wonderland

Liver transplant recipient, Oct. 27, 2011, at Mayo Hospital, Jacksonville, FL

Post Edited (hep93) : 12/18/2011 6:15:51 PM (GMT-7)


A.Ziffle
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Date Joined May 2011
Total Posts : 1828
   Posted 12/13/2011 12:48 PM (GMT -6)   
Hey Latindd , I would suggest you find out exactly what medications he is currently on and in the process get to know the staff at the facility a lot better .
Look at the lunch planner or menu schedule to find out what they are serving and if he has options . You would be surprised how even the smallest things can make a difference in his health care and showing the staff that you want to be highly involved is a great start .
The diarrhea could be a result of Lactulose , It's prescribed to bring down his ammonia levels through bowel movements . A drug called Xifaxin is commonly used with good results to assist in removal of toxins also , Doctors prescribe both of these drugs together usually . Ask his doctor if he is taking them .

Try not to get overly worried because this disease has extreme highs and lows ( Like a roller coaster ) . Properly educate yourself on whats going on and it will help you from getting to worked up . We have a pretty resourceful community here and most of your concerns can be answered .


A. Ziffle

latinadaydreamer
New Member


Date Joined Dec 2011
Total Posts : 8
   Posted 12/13/2011 2:59 PM (GMT -6)   
Thank You ALL so much for your time and answers I am going to talk to my family about getting a second opinion from a specialist and I think that he might have to be moved to a home with more special needs care than Eddie is receiving now. They give him options at his home for meals but dont restrict him from eating what he shouldnt eat example cake and starchy foods this has been an issue for us. Some staff helps others not so much. Well it is something to consider. And I will be ordering the book that was mentioned for my mom so she can understand more about what is happening. Yes my brother is on lactulose I know that a so many other meds insulin anti depressants meds to keep him from vomiting up his lactulose. It is hard to help him when he doesnt even understand whats happening to him or he doesnt want to understand Im not sure. The only way we were able to keep him from drinking was when he had seizures from alcoholism, He had gone through rehab several times prior to that. That was enough to scare him sober. As I mentioned second opinion will be our next goal.

MamaLama
Forum Moderator


Date Joined Oct 2010
Total Posts : 3719
   Posted 12/13/2011 4:26 PM (GMT -6)   
Hi LDD, What a worry this must be for your family.  To have a disabled brother, and one with ESLD.  The lactulose is really helpful, but it must be difficult to figure the difference between his regular problems and hepatic encephalopathy.  My Mike was out of his mind much of the time before his transplant, but that has resolved.
 
I hate to say this, but I would think the chance for transplant for a challenged man is unlikely, as they make a determination about the person's ability to manage the after transplant requirements. And with him not really able to self manage his diabetes and med routine now,  I would think he would not pass that part of the pre transplant regime.
 
So the trick will be to keep him as well physically as possible even though he is in the last stages of liver disease.  Some on this site have been operating pretty well, symptoms relatively well controlled, and having a good quality of life.
 
I am glad you have found a center for him.  The center may have more experience with this type thing than you imagine. It is doubtful your bother will get "well," though he may have some good times yet.  That is unknown. But if he is not unhappy with his situation and the family is near enough to visit and keep an eye on things, I think he may be as "fine" as he is going to be.
 
I am sorry to sound so down. 
 
Mama Lama

hep93
Elite Member


Date Joined Jul 2005
Total Posts : 12014
   Posted 12/13/2011 4:29 PM (GMT -6)   
Sounds good, Angie. I agree that your brother probably needs to be in a home with closer supervision. This is more easily arranged as a transfer than to take him out of the place he's now in and trying to then place him in a different setting.

You are on the right track. Believe me, you are going to learn a lot. As Mr. Ziffle noted, the more educated you become about liver disease, the better you will be able to advocate for your brother. He is very lucky to have you in his corner.

Hugs,
Connie
hep93
Forum moderator - Hepatitis


"But that was yesterday, and I was a different person then."

Lewis Carroll, Alice in Wonderland

Liver transplant recipient, Oct. 27, 2011, at Mayo Hospital, Jacksonville, FL

Angie1953
Veteran Member


Date Joined Jul 2011
Total Posts : 933
   Posted 12/13/2011 4:53 PM (GMT -6)   
Latinadaydreamer
Welcome to forum, so sorry you need to be here. My hubby also has Stage 4 cirrhosis and had diabetes and high blood pressure. After he lost a lot of weight (35lbs) from being so sick with cirrhosis, he was still getting high blood pressure and diabetes meds (as well as meds for ESLD) and got weaker and shakier, until we finally quit the diabetes meds and high blood pressure meds (after checking with Dr and monitoring him) and he got a lot better. He had been taking diabetes and high blood pressure meds that he no longer needed and they were making him barely able to walk or talk.

He has done better without them and has not had to return to those meds, but he is getting worse and worse from ESLD. (But at least he is not taking meds he doesn't need...Dr. thought the big drop in weight was responsible for no longer needed diabetes meds) This probably isn't true of everyone.

But my hubby was about ready for the ER, so thought we would try eliminating some meds first. Worked for us. It is a very fine line between what works and what is so much that they sleep almost all the time. Also, sometimes it's hard to know when loved one has heptic encephalopathy or is is denial themselves about the seriousness of their disease, or just being difficult. Keep educating yourself. It is hard to accept that this disease will eventually take their life and we caretakers cannot save them (except by transplant).

My hubby is in a nursing home (short term I hope) and we have problems with the food issue. He ate so so much healtier at home.
Best to you.
Angie1953

latinadaydreamer
New Member


Date Joined Dec 2011
Total Posts : 8
   Posted 12/18/2011 7:44 PM (GMT -6)   
WOW it is hard on a family having a loved one so sick I had to take my brother to E.R. Friday he couldnt even walk or dress himself. He was just released today from the hospital to a rehab center. So I guess the next step is finding him a new home with more help I dont think he can go back to just assisted living I think he needs more care. I guess Im wondering when looking for a care facility does any one have any advice on what to look for? I know I want him to be comfortable but what should I consider when looking because I am almost sure that this will be his final home.

hep93
Elite Member


Date Joined Jul 2005
Total Posts : 12014
   Posted 12/18/2011 8:28 PM (GMT -6)   
I have not had to make a decision regarding a nursing home; however, I have been in a rehab facility myself twice (after hip revisions) and also visited my aunt in her NH. The first thing I notice is the smell or lack of one. In some places, the smell of urine or feces can knock you over. This means that adults in diapers are not being changed frequently enough, or those with "issues" haven't made it to the toilet (perhaps because of lack of assistance to get there) and are sitting or lying in their own waste. This also touches on cleanliness. Notice the floors, the patient rooms, the bathrooms. How clean are they? Also important is the number of staff per patient. NHs use more patient care techs than nurses, though nurses will give out meds and chart them. Is PT/OT available and how often is it given? What about meals? Who chooses what the patients will eat? Do they pay attention to individual diets, such as diabetic or low-sodium? What about medical care? Is there a doctor regularly there and when? Are the patients staying in wheelchairs, staring at nothing, or confined to their rooms? Is there a common rec area where they can be with others to watch TV, talk, play games, etc.?

I would certainly visit prospective homes before deciding which would be the best for your brother.

What did they do in the hospital for your brother? Did they find out why had was unable to walk or dress himself?

Hugs,
Connie
hep93
Forum moderator - Hepatitis


"But that was yesterday, and I was a different person then."

Lewis Carroll, Alice in Wonderland

Liver transplant recipient, Oct. 27, 2011, at Mayo Hospital, Jacksonville, FL

latinadaydreamer
New Member


Date Joined Dec 2011
Total Posts : 8
   Posted 12/18/2011 9:06 PM (GMT -6)   
Thanks for the advice I did notice the smell of urine when I was there. My brother was transferred there from the hospital because he is very weak right now. He was being weaned off of lactulose for an upcoming procedure this tuesday so when they did that his ammonia levels became toxic. So I was the one who noticed he wasnt right and took him to er myself the staff where he lives right now at assisted living didnt see the emergency so I am hesitant to have him return there. I actually heard a cleaning lady laughing and talking to a care giver about the fact that she found my brother wandering the halls in his underwear looking for someone to help him get dressed... If that isnt a warning sign I dont know what is. He was sent today from the hospital to the rehab center he is at now. where I mention it smells like urine. Yeah the place is nice and new and fancy ect but I want the best care for him and the rehab center said he could stay there and be moved over to permanent care with them in another wing but after what you mentioned Im not sure I even want him there now I will be watching closely thanks for the advice> My brother is supposed to be there for as long as it takes to build up his strength and if he doesnt send him to full time care.

hep93
Elite Member


Date Joined Jul 2005
Total Posts : 12014
   Posted 12/18/2011 9:53 PM (GMT -6)   
The place he was in doesn't seem like a good place for him to be. As far as where he is now: Look, observe, smell...see if it's the same the next time you visit.

Hugs,
Connie
hep93
Forum moderator - Hepatitis


"But that was yesterday, and I was a different person then."

Lewis Carroll, Alice in Wonderland

Liver transplant recipient, Oct. 27, 2011, at Mayo Hospital, Jacksonville, FL

healthynow
Veteran Member


Date Joined Oct 2010
Total Posts : 1714
   Posted 12/19/2011 4:41 PM (GMT -6)   
I agree with Connie. I would be completely repelled by the urine smell.

Emma

latinadaydreamer
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Date Joined Dec 2011
Total Posts : 8
   Posted 12/19/2011 5:21 PM (GMT -6)   
I went by the rehab center again today and it seems that the smell was was from one specific room not that it ok but we will be given a list of future homes for my brother so with the advice that was given make a more informed choice thanks

hep93
Elite Member


Date Joined Jul 2005
Total Posts : 12014
   Posted 12/19/2011 9:58 PM (GMT -6)   
Way to go, LD! Good luck in finding your brother appropriate placement.

Hugs,
Connie
hep93
Forum moderator - Hepatitis


"But that was yesterday, and I was a different person then."

Lewis Carroll, Alice in Wonderland

Liver transplant recipient, Oct. 27, 2011, at Mayo Hospital, Jacksonville, FL

latinadaydreamer
New Member


Date Joined Dec 2011
Total Posts : 8
   Posted 12/21/2011 9:43 AM (GMT -6)   
HAPPY My brother is doing better. Went yesterday to visit him at the rehab center just last Friday he couldnt walk, dress, and was really shaky I found out that his lactulose had been stopped to see how he would react well obviously not well. I really thought we were going to loose him he was that bad. Turns out his ammonia levels were toxic and so that was brought down. He is now eating an appropriate diet for his disease and diabetes he felt so good Monday night i asked him is he ready to go dance with me now he replied yeah dance and EAT lol. I haven't seen him this well in a really long time. I know that he wont get better but for now its a great way to start the holidays. Thanks everyone for helping me I felt pretty low last week. Fortunately I have meet some really great people here and in my brothers healthcare, and some not so good I felt a bit bad for complaining about a cleaning woman at my brothers assisted living home whom I found making fun over a radio with another employee about my Eddies disorientation last Friday. I found out she was fired but at the same time angry that people can be so insensitive. Ups and down emotionally can really make a person tired. Again thanks everyone

hep93
Elite Member


Date Joined Jul 2005
Total Posts : 12014
   Posted 12/21/2011 10:30 AM (GMT -6)   
That is SUCH good news! And you did the right thing in reporting that cleaning lady. Staff of any kind working in a medical facility are bound by both ethics and HIPAA laws to NOT discuss patients unless vital to the patient's care. She basically broke the law and got caught doing it. I'll bet she never does that again!

Hugs,
Connie
hep93
Forum moderator - Hepatitis


"But that was yesterday, and I was a different person then."

Lewis Carroll, Alice in Wonderland

Liver transplant recipient, Oct. 27, 2011, at Mayo Hospital, Jacksonville, FL

arneeb
Veteran Member


Date Joined Nov 2009
Total Posts : 2290
   Posted 12/21/2011 2:24 PM (GMT -6)   
Such wonderful news.... and so glad you did report the gal who made fun of him... and even happier that the assisted living center did the right thing also... makes me feel that there is hope in this world.... keep up the good work and advocacy for your brother... and yes enjoy this Christmas... nothing better than having him... be himself... enjoy.. each moment and make a memory as my Mike always said make a memory... Sandia

latinadaydreamer
New Member


Date Joined Dec 2011
Total Posts : 8
   Posted 1/8/2012 7:26 PM (GMT -6)   
well I havent been on for a few days I have had so many up and downs. Now I have more questions that I do answers. Well my brother was doing well last time I posted and then he went down hill really fast. He had been released from the hospital to a rehab center a few weeks ago. while in the hospital he was doing great about a week in to rehab his health went down. We asked the staff why he was getting so ill so quick and asked for them to do a blood test to check his ammonia levels more like we demanded they do a test. So they did and again his ammonia levels were high so the Dr. whom we never met that was was the attending Dr raised his lactulose from 30mg to 45mg we waited for a couple of days to see if there would be improvement he only got worse. My family questioned the facility about his health and we were bed side as often as we could be. he went from a man who could walk to us feeding him and him sleeping 20 hours a day only waking to eat and at that he would eat with his eyes closed. Is this normal? He had a follow up with his Gi Dr and was told that we should be suspicious of the rehab center and we should physically give his meds ourselves. previously there was one day it was newyears eve where the staff and myself couldnt wake him up it took us 20 min. between the 4 of us to wake him and I told the nurse to get the DR she called him and he asked her to check his vitals which were good and said to us there is nothing to be done. We took him in for his follow up on the 3rd when we were told to watch his med intake ect. Well we didnt wait anymore we took him out of the rehab and when we tried the nurses confronted us and said he is fine that at this point it is not an emergency that she would call the Dr. So while she did we went ahead called 911 and they took him to the hospital where he spent the last 4 days. and happy to say he is walking again and is now in a different rehab center one we chose. I guess my questions are could it be the previous rehab centers fault for his decline or is this the way the disease works. The hospital gave him the exact same meds but he was better even after only one day. And the other one I have questions about is he is now on a dose of 45mg i was told that is the most that will be given. Is this the beginning of the end? I sk the Drs. but I never get any firm answers about anything ahhhhhh I feel so confused and mad.

MamaLama
Forum Moderator


Date Joined Oct 2010
Total Posts : 3719
   Posted 1/8/2012 7:49 PM (GMT -6)   
Hi Sis,

What a roller coaster you are on.

But please know, that disabled or not, the disease is a roller coaster.

Prior to transplant, Mike did well for about 3 weeks and then he went down hill so much that we took him to the hospital. It was different things different times, that got him admitted, but during his 5 day stays (they were always 5 days), they gave him IV fluids, sometimes antibiotics, frozen platelets, albumin, and whatever else he was messed up about. His kidneys would act up, so they were tracking his sodium and had him on a restricted fluid diet. Each time he came home feeling much better and then the cycle would repeat. We have even had him in the hospital after transplant a couple of month ago, and they pumped him with fluids, electrolyte stuff, and some blood boosting shots.

He may not have had the best med attention at the rehab, but the disease is like this!

The sleeping can mean the end is near. Some sleep themselves into a coma and pass.

Each patient is different.

Best to your family,

Carol
Mike received liver transplant May 1, 2011, Jackson Memorial, Miami, FL

hep93
Elite Member


Date Joined Jul 2005
Total Posts : 12014
   Posted 1/8/2012 8:29 PM (GMT -6)   
Latina, I'm so sorry that your brother hasn't been doing well. As Carol/ML mentioned, the disease is a roller coaster ride. It doesn't usually stay stable or remain the same for long. Patients can get much worse and then rebound and be okay for a while longer. It does sound suspicious that in the rehab he got worse, but better in the hospital. My thought is that they weren't doing labs often enough or paying attention to things like electrolytes, ammonia levels, etc. Liver disease can really make the body go haywire.

If he has more of these episodes and they are longer each time, it most likely means he is on the decline. He will reach a point where he is sleeping almost 24 hours a day and possibly go into a coma.

I hope that the rehab center he is now in will pay closer attention to him and his labs, signs and symptoms, etc. But since he is not a transplant candidate, it is probably time for you and your family to accept that he will continue to decline until he passes away from the disease. Have you thought of getting Hospice involved? They can be a big help to both the patient and the family. They could visit him at the rehab center.

Thanks for updating us. I hope you will continue to do this. Also, remember to take care of yourself.

Hugs,
Connie
hep93
Forum moderator - Hepatitis


"But that was yesterday, and I was a different person then."

Lewis Carroll, Alice in Wonderland

Liver transplant recipient, Oct. 27, 2011, at Mayo Hospital, Jacksonville, FL

Angie1953
Veteran Member


Date Joined Jul 2011
Total Posts : 933
   Posted 1/9/2012 12:56 AM (GMT -6)   
LatinaDayDreamer,
  So so sorry your brother is so ill.  Yes, this disease is UP and DOWN and it makes us caretakers crazy as we struggle to try to figure out what happened,,,,if anything to make them feel so poorly.  When the Dr.s office suggests you physically give his meds, then it was a good idea to move him.  Good for you.  You have to look out for him.
 
  My hubby's Doc accidently said, "Unfortunately, this is the only nursing home where I can continue to be his Dr."  Then he looked at me and noticed I looked surprised and said, "well, maybe not unfortunately"...but I got the drift that even the Doc didn't think it was the best place for him.
 
  It is hard to tell sometimes what is causing the decline..or is it just the natural progression of the disease.  ???  Hard to tell sometimes, seems like.
 
  I hope the new facility is better for your brother and your family.  
Angie1953
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