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I am his medical and durable POA. He is retaining 1500cc of urine in his bladder after voiding, and it will soon cause kidney damage. He is "with it" enough to understand this but he finds the indweling catheter intolerable and threatened to pull it out when he had one placed, and stated "it is better just to die than wear this".

So I went back to the hospital and had the nurse deflate the balloon and remove it properly, and she told me to get medical POA (which I already have). I am wondering about this nurse's comment: even though I can legally enforce that he wear a catheter, he may do some serious physical damage pulling it back out again if he doesn't want to wear it. And guardianship is obviously not an option because he is competent although moderately demented. He is living in a locked memory care unit with a 24/7 charge nurse so catheter maintenance is not at issue here.

More details: This catheter is meant to be worn only one month while the urologist assesses if he is a candidate for surgery (cystometrogram, cystoscopy, kidney imaging) and to prevent kidney damage.

This blockage is caused by prostate enlargement (BPH) which has been medically treated with 5mg finasteride and 2 flomax for 3 months to no avail. He was diagnosed with BPH years ago and was taking 1 flomax daily the whole time. This is probably more detail than anyone wants to read but just in case anyone is thinking there it can be medically treated.

So the family doctor was following the BPH for years. My Dad finally complained of bedwetting (really out of character for him because he is embarrassed by it) so I immediately took him in for a workup and he got referred out to a urologist.

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I should add that my Dad is fully aware that this catheter will penetrate the abdominal wall and he wasn't crazy about that part but was ultimately OK with it given the other options. Everything was explained to him.
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We had a followup appointment with the surgeon. What was discouraging was that he must have forgotten that my Dad has dementia, because at a prior appointment he thought that my Dad would not do well with self-catheterization but now he was suggesting that as an alternative to the Foley. My Dad was adamantly against it though (whew), so I suggested the suprapubic catheter and the surgeon said fine, but maybe you want to get a second opinion before you decide to go through with that.

My Dad seemed fine with the suprapubic but was kind of deferring to me. I said with a lower risk of infection and better comfort it seemed like a good choice and my Dad agreed and the surgeon agreed. The surgeon still didn't seem enthusiastic about this choice though, surprisingly. What's bugging me is I'm wondering why. It seemed like the best choice.

Then when I went back to my Dad's assisted living to debrief the charge nurse, the nurse was incredulous and right in front of my Dad said, "Did he agree to that?" I said yes, why not, it has lower risk of infection and is more comfortable. Then the nurse then informed me that my Dad would probably have to move out, because they couldn't handle the care for a suprapubic catheter, only Foleys.

I was so upset. I later got a call from the director of nursing at the ALF and he said he wasn't sure they could handle suprapubic catheters, but that they'd look into it. Later he called again and said that my Dad wouldn't have to move, that they could handle suprapubic fine.

It's like, what is the deal with this suprapubic catheter if there's LESS chance of infection and it's more comfortable? I mean, the TURP didn't work so the only other options seem like self-catheterization 3-4x/day (r/o because of dementia) or possibly permanent kidney damage.

I am thinking now...I should get another opinion. These doctors and nurses are worrying me about something that I thought was a good option.
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Wow Veronica thanks for that information about the balloon! He is fortunately on a memory care unit with 24/7 charge nurse coverage and they have at least 3 other residents with catheters, so they are great with the catheter care. I think he's in good hands.

I think the patient picking up on anxiety is a big factor with catheter care especially. Fortunately I do not have to play this role but my Dad listens to me (for now) anyway, which is huge.

What I try to do is listen to him and make things as easy as possible for him. In this case it was scheduling the surgery as soon as possible, explaining to him whatever needed explaining (over and over), and honoring my Dad's request for male nurses (to the extent that this was feasible).
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Jem it sounds as though things are going as well as can be expected for your Dad. I agree that the supra pubic may have to be the final answer. Foleys are often uncomfortable for some people. I had one through two surgeries but I am not male and it was only in for two days each time. I did not even feel it there. Whether it is painful or not a patient will continue to pull it out if they hate it. FYI if anyone needs to remove a Foley in an emergency you just need to cut off the 'tail" at the end of the catheter to deflate the baloonand when the water has run out gently pull it out. Remember for a male the part inside will be about 9 inches long and a female about three inches. Stop if it hurts have the patient take few deep breaths to relax and do the same thing yourself and then continue. Remember the patient picks up on the caregivers anxiety.
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Just an update: My father finally accepted that he was going to have to wear a catheter for a while leading up to the surgery. In fact, he went through several tests (cystometrogram, cystoscopy) that were required preoperatively, and eventually had a TURP procedure performed and everything.

However, the TURP procedure did not stop the urinary retention because his bladder muscles are too far gone. He's still wearing the Foley catheter, changes to a "night bag" himself at night (with prompting) and a "day bag" every morning (with prompting), and I take him to the doctor to have the whole catheter changed monthly. It's miraculous considering he was refusing the catheter early on.

I think he's going to need the suprapubic catheter eventually, because the Foley is very uncomfortable, and the urologist feels that self catheterization is not an option because of the dementia (I agree).

So that's where we're at. I'm interested if anyone knows of any options we haven't considered. But, I am thankful that his kidney function was spared any further damage. His lab values for BUN, creatinine, and therefore GFR are much better than prior to catheterization.

I also have to make a plug for Kaiser Permanente Southern CA. The whole experience was really good despite the disappointing outcome. I really feel like they did their best by my Dad. Very thorough and professional urology team that saw my Dad through a myriad of appointments and an overnight hospital stay, personable surgeon that got his MD at Columbia University, you really couldn't ask for better.

It was known from the cystometrogram results that my Dad's bladder function was not great prior to surgery but the procedure is minor enough that the surgeon thought it was a good risk to try just so my Dad might have the best quality of life. Not every doctor feels that way when the patient is 85 yo so I'm thankful.
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Thank you so much Veronica you've been very helpful. I feel like I know a lot more now and can speak with the surgeon about options!

With my Dad, of course since he is so adamantly against the catheter I feel it's not an option right now. But I am going to start discussing some unplreasant things with him like dialysis, funeral arrangments and we will get a will executed and signed. These are necessary conversations anyway but I will tie them into his decision so that he's aware that what he's doing has serious consequences. It's hard for him to get worried about kidney damage since he can't feel it happening until its too late. You can explain that to him but I think the dementia lessens the impact of consequences somehow.
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jem you are correct the supra pubic would be a permanent solution. do you think dad would accept that. depending on his general health that could be the best solution and the least dangerous for him. there is still the danger of infection but with skilled nursing care available the risk is probably ledd that self cathing several times a day which you said he would never consider. I would continue to allow him to make his own decisions anything you try to inforce will only make him uncooperative.if he says he'd rather die that have a catheter so be it but it won't be a pleasant death. Anyway see what the sugeon recommends then do your own research on the options presented.
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*SNF
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Veronica91 I hope you are right. I am hoping my Dad can get some kind of procedure done without a complete workup. Certainly a suprapubic catheter would be a possible alternative if surgery is not an option, however I would think that would only be considered as a permanent or longterm solution, not just for a workup. I will be talking with the surgeon next week.

My Dad like I said does have memory problems BUT he is extremely intelligent. He knows more than average. He will remove the bag, cut the catheter, yank on the thing, and complain loudly to the point that he will get transferred to a SFN, even if he can't pull it out.

Just out of curiosity I read up on Guardianship in California and even for a temporary emergency order you have to file a full petition for "Conservatorship of the Person" (aka guardianship in other states) and the conservatee has to attend the court proceedings. Only lasts 30 days with no extension. Yeah, probably not going to be the most expeditious way to get things done.
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Jem I don't quite understand why the bladder function has to be assessed before a prostatectomy can be performed. There is now a lazer proceedure that basically vaporizes the prostate from the inside using a cystoscope. Ask the urologist if he is a candidate for a green light lazer proceedure. The recover is very fast and he could go home same day or next morning. He would probably only need the catheter till he is discharged. There may be some discomfort urinating and leakage for some time after any of these proceedure. Light anesthesia only and far less risk to the general health of an 84 year old.
he definitely would be able to pull out a foley if he puts his mind to it. It might hurt but it still can be done with a good tug. he may even figure out that if he cuts the end off the little side tube he can drain the water out of the balloon then it's easy to get out. Would Dad accept a supra pubic catheter.. A small incision is made just above the pubic bone and a catheter inserted into the bladder where it remains permanently. A supra pubic catheter could be put in without anything else being done. I would not try to enforce any treatment against Dad's will. it really isn't worth it. hope all this works out for you and Dad. Let us know what happens.
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My Dad's also been known to exit a moving car when not getting his way so the drive home from the urologist's would be...interesting.
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OK this is good to know, that it's hard to pull out. But I have heard pts pulling out their catheters and my Dad would definitely try. Also, I am a bit worried about my Dad "firing" me as his POA, which would be a disaster, although he tends to place total trust in me...he is very verbal and intelligent and will start requesting a lawyer etc.
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A urethal catheter is very hard to pull out because there is outer layer to it that has a balloon that retains it in the neck of the bladder. My husband was told that the alternative to the TURP was a suprapubic where they remove the prostate from the outside rather than the inside, which is more drastic surgery. We did have one horrible night when he wound up at the ER with a totally closed uretha which is very very painful. Kidney damage is a slower, long-range problem, but a total blockage is an immediate and painful emergency. It does help the patient be more willing to go along with some sort of treatment!.
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I'm not sure exactly what that will do. Couldn't he still pull out his catheter at the first opportunity, even if I can legally have it replaced?
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He is not willing to have a catheter period. This catheter was only meant to be for 1 month. (I say "only" but I know that indwelling catheters must be uncomfortable; it's just to clarify that it is not and was never meant to be permanent). He would not be willing to have a catheter inserted and removed every 6 hrs. I can tell you that with certainty.

Reminders are not an issue as he is in a locked memory care facility with 24/7 nursing staff; the issue is that he absolutely refuses the catheter.

Basically, I am worried because apparently without it the surgeon will not be able to even assess his bladder function and his candidacy for TURP. The surgeon is not going to perform a TURP if his bladder is not functioning well enough on its own. So I am thinking, the surgeon is not going to perform a TURP if my Dad absolutely refuses any catheterization with retention this pronounced.

Clearly, any procedure is risky in a 84-yr old even with local anesthesia, so add to that noncompliance and no assessment of bladder function. I don't think TURP is going to happen.
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Ask about a Transurethral Urethral Resection of the Prostate (TURP), which can be done under local anesthesia with a sedative. If you can avoid general anesthesia, there is less risk to the patient.
Nobody wants to wear a catheter all the time, but would he be willing to have one inserted and removed every 6 hours? Could he do this himself with a reminder from the nurse? For example: 6am, noon, 6pm and midnight?
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