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Try not to get too distracted and preoccupied with the medical issues. There isn't much margin of error when dealing with an elderly person. Decisions are difficult and it doesn't take much to suffer major consequences. Let the doctors handle that otherwise it will only delay the grieving process. There's a lot of emotional issues you have to deal with but under no circumstances did you do anything other than care for your mother in a loving manner. It's normal to want answers but none will seem satisfying. One can not second guess and go back in time to change what happened. You end up with empty feeling thinking that if others had acted differently there would be a different outcome. One can't go back in time. In the end all you will be left with is memories. Some will be living memories because you carry a part of them in their values and upbringings. When one loses a parent it almost feels like one is becoming an orphan without external parents. They become more internal parents. One never forgets.
If you're right, then anticoagulants must somehow be able to make holes in blood vessels..To"bleed," the blood has to be able to get out of the veins & arteries, right?
The doctor said the bleeding only stopped with the reversal agent but then started clotting. I was thinking about asking them to give her a CT scan for stroke when they thought everything seemed ok at INR-1, but they didn't give her the test until stroke symptoms started. I don't think it would have made a difference if they found the stroke early enough to give her the clot busting drug because it would have made her bleed again. If she has to die from this bleeding episode, it's better the problem is the blood clot causing her no pain and peaceful sleep, than painfully bleeding to death from her bleeding muscle injury and clot stopping drugs. The doctor said her reaction to the procedure was bad luck and unpredictable, but maybe it was good luck that it went the non-painful way for her.
It seems to me staying on warfarin with all the inconveniences only because there is an easily available reversal agent isn't a good enough reason when the agent comes with stroke risk. The doctors made the reversal procedure sound so simple and never told me about the stroke risk, so I went from expecting her to be ok and coming home to planning her death in four days.
I was worried about bringing her home (when I thought she was ok) because I was wondering if her pelvic muscle would tear again with any stress like coughing or toilet straining and that's exactly what the doctor told me yesterday, if she survived, this would happen over and over again.
Anyway, I'm posting this info not to dwell on it, but hopefully what happened to my mom will help someone else in her situation.
The doctor said the bleeding only stopped with the reversal agent but then started clotting. I was thinking about asking them to give her a CT scan for stroke when they thought everything seemed ok at INR-1, but they didn't give her the test until stroke symptoms started. I don't think it would have made a difference if they found the stroke early enough to give her the clot busting drug because it would have made her bleed again. If she has to die from this bleeding episode, it's better the problem is the blood clot causing her no pain and peaceful sleep, than painfully bleeding to death from her bleeding muscle injury and clot stopping drugs. The doctor said her reaction to the procedure was bad luck and unpredictable, but maybe it was good luck that it went the non-painful way for her.
It seems to me staying on warfarin with all the inconveniences only because there is an easily available reversal agent isn't a good enough reason when the agent comes with stroke risk. The doctors made the reversal procedure sound so simple and never told me about the stroke risk, so I went from expecting her to be ok and coming home to planning her death in four days.
I was worried about bringing her home (when I thought she was ok) because I was wondering if her pelvic muscle would tear again with any stress like coughing or toilet straining and that's exactly what the doctor told me yesterday, if she survived, this would happen over and over again.
Anyway, I'm posting this info not to dwell on it, but hopefully what happened to my mom will help someone else in her situation.
I must confess that I've given very little thought to the need for a reversal agent in the three years I've been on Eliquis.
I have envisioned the need for stopping Eliquis temporarily for a tooth extraction, which is, of course, planned and scheduled with no reversal agent coming into play. But I've considered the risk of a scenario with sudden internal bleeding, necessitating emergency reversal, too small to warrant worry beyond that of any of the multitude of other life risks that can happen, but never do to most people.
So this thread and your mom's case has been a lot of food for new thought and more reading on the subject. It would seem that the question of benefit derived from anti-coagulation reversal remains open and unsettled. Almost like you're damned if you do and damned if you don't.
Quote:
A leap is then often made to imply that less bleeding directly translates into improved morbidity and/or mortality. A morbidity or mortality benefit, however, has not yet been definitively demonstrated. It is critical to determine if expensive reversal agents that may promote thrombosis are actually beneficial.
Perhaps gives rise to more question of bottom line effect on lifetime morbidity of going on anti-coagulants in the first place. Or staying on them past a certain age. That is the main issue that sticks with me for the moment.
I must confess that I've given very little thought to the need for a reversal agent in the three years I've been on Eliquis.
I have envisioned the need for stopping Eliquis temporarily for a tooth extraction, which is, of course, planned and scheduled with no reversal agent coming into play. But I've considered the risk of a scenario with sudden internal bleeding, necessitating emergency reversal, too small to warrant worry beyond that of any of the multitude of other life risks that can happen, but never do to most people.
So this thread and your mom's case has been a lot of food for new thought and more reading on the subject. It would seem that the question of benefit derived from anti-coagulation reversal remains open and unsettled. Almost like you're damned if you do and damned if you don't.
Perhaps gives rise to more question of bottom line effect on lifetime morbidity of going on anti-coagulants in the first place. Or staying on them past a certain age. That is the main issue that sticks with me for the moment.
Bottom line is my mom had no choice, bleed to death or try the reversal drug. I'm glad my posts are helpful to you and hopefully to others so at least some good will come out of her eventual passing.
There is risk to being put on blood thinners ie anticoagulants and having a bleeding episode with significant morbidity and mortality and we also know and knew that there is serious risk associated with clotting episodes with quick reversal of anticoagulation with both anticoagulants. One can not stop abruptly the use of Xarelto because one can get clots. It has to be tapped off.
Clinical decisions are made with the known facts one is presented with and one does not know enough about any situation to be able to predict who will form clots and who won't especially if they don't have a history of a blood clot.
The warning on PCC's to reverse anticoagulation are clear.
"Important Safety Information
WARNING: ARTERIAL AND VENOUS THROMBOEMBOLIC COMPLICATIONS
Patients being treated with Vitamin K antagonist therapy have underlying disease states that predispose them to thromboembolic events. Potential benefits of reversing VKA should be weighed against the risk of thromboembolic events, especially in patients with history of such events. Resumption of anticoagulation therapy should be carefully considered once the risk of thromboembolic events outweighs the risk of acute bleeding. Both fatal and nonfatal arterial and venous thromboembolic complications have been reported in clinical trials and postmarketing surveillance. Monitor patients receiving Kcentra, and inform them of signs and symptoms of thromboembolic events. Kcentra was not studied in subjects who had a thromboembolic event, myocardial infarction, disseminated intravascular coagulation, cerebral vascular accident, transient ischemic attack, unstable angina pectoris, or severe peripheral vascular disease within the prior 3 months. Kcentra might not be suitable for patients with thromboembolic events in the prior 3 months.
Kcentra is contraindicated in patients with known anaphylactic or severe systemic reactions to Kcentra or any of its components (including heparin, Factors II, VII, IX, X, Proteins C and S, Antithrombin III and human albumin). Kcentra is also contraindicated in patients with disseminated intravascular coagulation. Because Kcentra contains heparin, it is contraindicated in patients with heparin-induced thrombocytopenia (HIT).
Hypersensitivity reactions to Kcentra may occur. If patient experiences severe allergic or anaphylactic type reactions, discontinue administration and institute appropriate treatment.
In clinical trials, the most frequent (≥2.8%) adverse reactions observed in subjects receiving Kcentra were headache, nausea/vomiting, hypotension, and anemia. The most serious adverse reactions were thromboembolic events, including stroke, pulmonary embolism and deep vein thrombosis."
One can get into possible trouble using plasma and avoiding PCC because of the volumes required and the risk of volume overload in that age group.
There was a lot of discussion on this thread about the reversal of anticoagulation in preventing hemorrhagic complications but none about the complications associated with thrombosis of such reversal. Whether it was an ischemic (bleeding) or thrombotic (clotting) are both associated with the risk of instituting anticoagulants.
The human mind tries to rationalize death but can't get a handle on it and eventually it tries to compensate with rational explanations in order to minimize the fear and ease of confronting our own mortality.
We are all going to die and so does it really matter what we die of? That only matters for the living.
There is risk to being put on blood thinners ie anticoagulants and having a bleeding episode with significant morbidity and mortality and we also know and knew that there is serious risk associated with clotting episodes with quick reversal of anticoagulation with both anticoagulants. One can not stop abruptly the use of Xarelto because one can get clots. It has to be tapped off.
Clinical decisions are made with the known facts one is presented with and one does not know enough about any situation to be able to predict who will form clots and who won't especially if they don't have a history of a blood clot.
The warning on PCC's to reverse anticoagulation are clear.
"Important Safety Information
WARNING: ARTERIAL AND VENOUS THROMBOEMBOLIC COMPLICATIONS
Patients being treated with Vitamin K antagonist therapy have underlying disease states that predispose them to thromboembolic events. Potential benefits of reversing VKA should be weighed against the risk of thromboembolic events, especially in patients with history of such events. Resumption of anticoagulation therapy should be carefully considered once the risk of thromboembolic events outweighs the risk of acute bleeding. Both fatal and nonfatal arterial and venous thromboembolic complications have been reported in clinical trials and postmarketing surveillance. Monitor patients receiving Kcentra, and inform them of signs and symptoms of thromboembolic events. Kcentra was not studied in subjects who had a thromboembolic event, myocardial infarction, disseminated intravascular coagulation, cerebral vascular accident, transient ischemic attack, unstable angina pectoris, or severe peripheral vascular disease within the prior 3 months. Kcentra might not be suitable for patients with thromboembolic events in the prior 3 months.
Kcentra is contraindicated in patients with known anaphylactic or severe systemic reactions to Kcentra or any of its components (including heparin, Factors II, VII, IX, X, Proteins C and S, Antithrombin III and human albumin). Kcentra is also contraindicated in patients with disseminated intravascular coagulation. Because Kcentra contains heparin, it is contraindicated in patients with heparin-induced thrombocytopenia (HIT).
Hypersensitivity reactions to Kcentra may occur. If patient experiences severe allergic or anaphylactic type reactions, discontinue administration and institute appropriate treatment.
In clinical trials, the most frequent (≥2.8%) adverse reactions observed in subjects receiving Kcentra were headache, nausea/vomiting, hypotension, and anemia. The most serious adverse reactions were thromboembolic events, including stroke, pulmonary embolism and deep vein thrombosis."
One can get into possible trouble using plasma and avoiding PCC because of the volumes required and the risk of volume overload in that age group.
There was a lot of discussion on this thread about the reversal of anticoagulation in preventing hemorrhagic complications but none about the complications associated with thrombosis of such reversal. Whether it was an ischemic (bleeding) or thrombotic (clotting) are both associated with the risk of instituting anticoagulants.
The human mind tries to rationalize death but can't get a handle on it and eventually it tries to compensate with rational explanations in order to minimize the fear and ease of confronting our own mortality.
We are all going to die and so does it really matter what we die of? That only matters for the living.
Great post will good info, I didn't know mom was in danger of stroke with Vitamin K reversal. Maybe the docs figured taking a chance that my mom would get a mild stroke was better than leaving her bleeding.
Unfortunately they said her clot is taking up a big area in the carotid artery. Today the hospital chaplain came in explaining to me how complicated these blood cases are and the doctors try to do their best with the difficult decisions they have to make. I kind of feel guilty now, I took her to the hospital to get better but they ended her life instead, even though it was unintentional, because she trusted me to protect her.
One thing that bothers me about mom's case is if they knew the warfarin reversal drug could cause a blood clot, why did they do the reversal on Wednesday, want her to go home on Thanksgiving at INR-1, then change their minds so a cardiologist could look at her on Friday, and then let her lay in bed on Friday and Saturday morning not giving her a CT scan for a stroke at INR-1 until she had symptoms late Saturday morning. The thought crossed my mine since she had a stroke at INR-1 in 2012, maybe she should be checked on Thursday or Friday (wouldn't the scan show her blood coagulating even if the stroke didn't happen yet), but then I figured they must know what they are doing so I didn't say anything. If there was a chance to save her a few hours after the stroke, why did they let her lay so long before testing her? On Saturday the nurses let her sleep until 11:00 a.m. until the cardiologist saw her and was alarmed she wouldn't wake up and ordered the scan.
One thing that bothers me about mom's case is if they knew the warfarin reversal drug could cause a blood clot, why did they do the reversal on Wednesday, want her to go home on Thanksgiving at INR-1, then change their minds so a cardiologist could look at her on Friday, and then let her lay in bed on Friday and Saturday morning not giving her a CT scan for a stroke at INR-1 until she had symptoms late Saturday morning. The thought crossed my mine since she had a stroke at INR-1 in 2012, maybe she should be checked on Thursday or Friday (wouldn't the scan show her blood coagulating even if the stroke didn't happen yet), but then I figured they must know what they are doing so I didn't say anything. If there was a chance to save her a few hours after the stroke, why did they let her lay so long before testing her? On Saturday the nurses let her sleep until 11:00 a.m. until the cardiologist saw her and was alarmed she wouldn't wake up and ordered the scan.
I'm so sorry to read that your moms life is coming to an end. You've been a wonderful daughter to her. You've done all you can to care for her so that she can have a quality of life for whatever time she had left. I know it is an event just to get her out of your apartment, transported to an appointment. I know COVID has thrown a huge wrench into everything. Both of your lives have changed since COVID.
I looked to see if you put her age in this thread, am not seeing it. I went back to your other thread about the horrible pain your mother suffers, doctors didn't want to give her anything for pain because they were worried about addiction, which is a joke since she was 92 then!
I don't recall if I told you about my elderly neighbor from my last house. All he had was a niece and I. He was my unofficial grandfather, I never had one. When we moved in 2008, he ended up losing his lady friend to heart issues. Her daughter kicked him out of her house. He was moving his stuff back in his house, he fell. He ended up in the hospital, they didn't think he would live alone again.
They found he had a heart issue where his heart stops for a few moments. He was in his 80's, at his age, he did not want a pace maker put in. He was discharged, stayed with us for a month because his niece refused to take him. There's a vet home up the road from me, my hub and I toured it, got the app, he was going to start the application to see if he could get in it. I told the social worker he needed assisted living because he was showing dementia signs. He also used to fall asleep while he was talking. They let him go home. It was the beginning of the end.
He went home and in the next 2 years, totaled 3 cars. My guess is he fell asleep while driving. Thankfully he didn't hit anyone, he did not get hurt. He also OD'd on cumadin. He woke up one morning, almost bled to death. They somehow convinced him to do the pace maker that he was against.
He was discharged, brought back to the hospital a few weeks later. He had a hernia that he used to wear a binder to hold it in. In all of the time he was admitted, not one doctor checked out his hernia and in the end, it is what killed him. It was not a peaceful death either. He was in so much pain, pain killers did not help. His elderly niece called me after he passed away. He was 87.
You said your mom was at the best hospital. I know you're in NYC. I don't know why they were not on top of it since they knew what could happen. Maybe they're having a labor shortage due to COVID? I know things are bad all over.
The consequence is that your mother suffered a clot that she will not recover from. The positive is that your mom is sleeping, she is not in pain like my elderly neighbor was.
Please do not beat yourself up. As I said, you've been a wonderful daughter with all that you did to get her to now at 92. Your mom is not going to pass from getting COVID because of all of the precautions you've taken. I know that was a huge fear of yours.
I hope she continues to sleep, pain free, having a peaceful death when it's her time.
Quote:
Originally Posted by wp169
The doctor said the bleeding only stopped with the reversal agent but then started clotting. I was thinking about asking them to give her a CT scan for stroke when they thought everything seemed ok at INR-1, but they didn't give her the test until stroke symptoms started. I don't think it would have made a difference if they found the stroke early enough to give her the clot busting drug because it would have made her bleed again. If she has to die from this bleeding episode, it's better the problem is the blood clot causing her no pain and peaceful sleep, than painfully bleeding to death from her bleeding muscle injury and clot stopping drugs. The doctor said her reaction to the procedure was bad luck and unpredictable, but maybe it was good luck that it went the non-painful way for her.
It seems to me staying on warfarin with all the inconveniences only because there is an easily available reversal agent isn't a good enough reason when the agent comes with stroke risk. The doctors made the reversal procedure sound so simple and never told me about the stroke risk, so I went from expecting her to be ok and coming home to planning her death in four days.
I was worried about bringing her home (when I thought she was ok) because I was wondering if her pelvic muscle would tear again with any stress like coughing or toilet straining and that's exactly what the doctor told me yesterday, if she survived, this would happen over and over again.
Anyway, I'm posting this info not to dwell on it, but hopefully what happened to my mom will help someone else in her situation.
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