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The hospitalization
Bob became ill with a chest infection and was treated as an outpatient. After treatment, he was admitted to the hospital in a confused state.
“I see spiders,” he said to Glyn as he picked at the air from his hospital bed.
Glyn told Bob’s doctors he had been a perfectly coherent, a spry 88-year-old before his hospital admission. The doctors seemed indifferent.
As often happens with old people, after his acute hospitalization, Bob was transferred to a nursing home. When he arrived, the staff immediately returned him to the hospital, saying he was too sick to be in a nursing home and suggested further evaluation and treatment.
I flew from Denver to California to be with Bob and his family and see what I could do to sort out Bob’s medical care. He died before I got to his bedside.
On the surface, this might seem to be just another death of an elderly man. Often when elderly spouses are separated, one will die. As I sat with the family the day after Bob died, with his granddaughter Ann, in her final year of medical school, she and I reconstructed the details of Bob’s final days.
Bob’s physicians had started him on antibiotics a few weeks before his death. As we listened to the course of his illness and the timing of events, Ann and I began asking questions.
“Tell me again how he was acting,” I asked.
“Bob was seeing people who weren’t there and talking nonsense,” Glyn said.
I recalled the spiders. These hallucinations sounded like liver failure, usually caused by chronic alcohol use, but also caused by certain medications with a similar effect on the liver, especially in the elderly. Bob wasn’t a drinker.
“Was he yellow?,” I asked.
“Yes, at the end.”
Another sign of liver failure.
“Do you remember what antibiotics he was taking?,” I asked.
“No.”
“Was he getting regular blood tests while on the antibiotics?”
“I don’t know. He had blood drawn when he was in the hospital.”
Too few facts, but Ann and I looked at each other. I mentioned medication-induced liver failure.
Ann nodded her head and said, “That’s what I’ve been thinking.”
As near as we could tell from the limited facts, it appeared the antibiotics had damaged Bob’s liver, leading to his confusion, jaundice, and death. In general, medications are processed by the liver or the kidneys before being excreted. Some medications have well-known side effects on the organs. Specific antibiotics are notorious for this, especially in the elderly. The standard of care is to check the liver enzymes in the blood. If the levels are up, it means the liver cells are being damaged. It was not clear to me Bob’s liver enzymes had been regularly checked.
It appeared to me his physicians paid no attention to Glyn and considered Bob to be a confused old man who was grieving over separation from his wife, perhaps even thinking him an old geezer not worth saving.
A couple of days before Bob died, his physicians recognized he was jaundiced — yellow because of liver failure. Bob was confused because of the build-up of ammonia from his liver’s inability to process it. Bob probably died of the side effects of medications toxic to his liver.
Had Bob been cared for by clinicians who remembered to check his liver enzymes, he might have lived through his illness.
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