Below is a series of e-communications between myself and a long time friend. The exchange is concerning this woman’s dying father and she wanted some information to help her understand what was happening. Unfortunately the local physicians seemed to not be providing information and the family and loved ones were feeling somewhat abandoned by the local medical system.

I’m reproducing this here with permission to show that the whole health care community can and should be engaged in educating families about what is happening to their loved ones. Following the exchange of letters below I summarize a few things and explain some of my thinking in what I said to her.

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Hi Joe

Please pardon my question to you about this as I’m sure you get many off the cuff type of neurology questions ……. but my father is dying so I was curious…

Last night my mother found him ‘shaking’ on the bed seemingly having a seizure. 911 was called and EMTs came (5 of them!) they were not able to resuscitate him on the bed (no pulse/breathing) so moved him to the ambulance to do further compressions/CPR. He was then brought to the hospital where they did more CPR. He was ‘stabilized” but his BP was VERY low until lots of meds given (do not know what kinds). Pulse was low as well.

Today he is on a vent, totally unresponsive except for some slight reaction to pain stimuli as the day wore on. BP doesn’t seem to maintain itself on its own and continues to drop unless on meds.

CT scan revealed no evidence of a stroke or embolism, no swelling or brain shifting – just normal aging signs and signs of Alzheimer’s.

We’ve not gotten a good picture from a doctor about what happened. Cardiac enzymes are up but indicated that could have been from all of the resuscitation work.

Could a heart attack cause a seizure? Can the brain NOT show any signs of stroke/embolism but still be damaged?

We have discussed and feel we’ll take him off life support tomorrow but I’m still left with the what happened question.

Might you have any thoughts?

Thanks so much!
T.

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Hi T.,
My sincerest sympathies to you and your family at this difficult time. I do not at all mind friends asking me questions. My life’s work is to try to help people and families during such difficult times so any small help I can be I’m glad to offer.

It is absolutely possible to be unable to see on imaging ischemic stroke or damage post seizure event such as you describe. It is also possible for a heart attack to cause a seizure. Even low blood pressure could cause a seizure especially with a brain that has pre-existing pathology such as Alzheimer’s.

I personally would not dismiss the low blood pressure or heart attack scenario especially with low blood pressure persisting. So without all the medical data please let me speculate. If his heart went through an episode of low blood pressure with or without low heart rate the brain might reach a point where not enough blood was getting to the brain. The brain, being fragile from other pathology, loses homeostasis which leads to the seizure. The shaking makes the heart work harder, but maybe it can’t. The seizure also makes the brain need more blood flow. Yes, it is complicated, but the result is a battle between the brain and heart, sadly both end up losing.

The cause of the original episode (heart attack, low blood pressure) could be hard to determine but might be a brief period of low blood glucose, a sneeze or several things that a person with normal control systems is able to respond to but a person with pre-existing pathology cannot respond to normally and a series of runaway events occur.

Everything you said above says to me that your father’s body is losing or has lost the ability to respond to cardiovascular changes that a normal healthy person is ready to deal with. I do not think anyone will be able to predict if that is something that could be changed or treated but (excuse me for being indelicate) the human body cannot live long without the control systems working.

I know what I am saying may be hard to take considering what you, your father and family are experiencing. The human body has many back up systems but as we age they begin to fail and other’s take over. We (patients, family and physicians) may not know that control systems are becoming less effective until an event such as you describe above occurs. Now, we are left with trying to preserve life and hoping that the control systems (control of blood pressure, heart rate, heart work, blood flow etc) can get back on line.

If you have any other questions, feel free to ask. All I have done, and all I am able to do, is speculated on some things that might have happened to your father.

Best wishes.

Joe

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HI Joe

Thank you SO much for your explanation. It does make very good sense to me and helps me understand a bit better about some of the events that have led up to the state he is currently in. I just couldn’t grasp the seizure activity with the lack of findings from the CT.

We’ll be having conversations with the Neurologist and Cardiologist today about his current state in order to make ‘the’ decision. But we all know what we’ll do. Sadly if he did suffer brain damage and could recover from the heart ‘issues’ he currently has – we don’t think he’d function well between that and the Alzheimer’s – he was already really struggling with the Alz.

My mom is his caretaker and has advanced COPD (Oxygen 24/7 etc) so her capabilities are limited. The cost for a GOOD nursing home is ridiculous and ‘they’ wont pay for the cost via Medicare unless you are pretty much broke – which would leave my mom without anything to live on (she is very independent and won’t do a nursing home herself)

Anyways….. I ramble.

All of us know what today will bring. There is a lot of dread and anxiety over it and in some ways a desire to have ‘it’ be over. But all in all – he is 80+ years old and has led a great life, and the practical side of me understand that this is life. Death is a part of life. Hard part is going thru it.

Thank you for helping me understand some of the physical aspects of what may have happened – we can all only speculate but I’d guess that you are very accurate in what could have occurred.

I’m grateful for your expertise and willingness to help me understand.

T.

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Please note, I waited a respectable period of time before asking T. for permission to post this exchange to my blog. Obviously I have taken out personal and patient identifiers. She was happy to allow me to share this on my blog because I think she understood the goal was to help patients and clinicians see how some information, even speculative is important to share. T. and I exchanged a few additional communications, which I will keep private.

 T.’s father died less than 48 hours after the episode above. The family made what they considered informed decisions concerning pain management and resuscitation choices and in their eyes he died peacefully with dignity.

I understand that physicians often are hesitant to speculate on events that have transpired with failing patients. Especially when it may never be known what happened as is the case with T.’s father. This hesitance may come from a fear of being sued or fear of being wrong, but the goal for all of us is to help patients and their families. This family, T. especially, needed information. I understand that it may be easier for her to ask an old friend some of these questions, but many people do not have that option. The physicians are the only source of information or comfort.

I also acknowledge that what I said may be wrong but what I tried to do in my answer was to not artificially raise her hopes but provide her with some relevant information that she and her family might need should they choose to withdraw care or make him D.N.R (do not resuscitate). Please look closely at the last two paragraphs in her response to my information; her goal was to try to “understand” what was happening. Clinically, we may NOT KNOW what is happening, but there is an understanding of multi-organ-failure that needs to be conveyed to the patients and their families.