Do I trick my dad into surgery?

I would respect his wishes. He wants no more cutting. He’s already experienced it and he doesn’t want any more.

I know you want what's best for your dad but sometimes doing nothing might be what's best.

You're dad was clear prior to the onset of dementia that he doesn't want anything to do with doctor's. Were it not for the dementia would he agree to this procedure?

Although he's incapable of making this decision on his own, his wants and needs should still be considered. If it comes down to drugging him in order to get him this surgery step back a bit and examine if it's really worth it. Giving someone a tranquilizer in order to get that person to do what we think is best for them strips that person of their dignity and autonomy and despite dementia we're all entitled to dignity and autonomy especially when we're unable to express ourselves.

There is nothing like reading of a worse more heartbreaking situation to make someone else feel grateful...my eyes filled with tears as I read about your situation. Others have responded wisely...you are blessed with knowing of your dad's wishes and thoughts re medical care. So I would agree with those who think not about the surgery, but I would find the best hospice program and consult with them, if only to be in your back pocket if things progress to a point where their services would be a blessing. Sending hugs and prayers...

May I ask you a question? If you have concerns of being uncomfortable about answering, PLEASE feel free to disregard what I’m going to ask you.
Are you presently able to deal with the fact that your father is becoming more and more and more vulnerable, and that you or someone else will soon need to take charge of hi and become responsible for being sure that he is safe, as comfortable as possible and that his basic needs are being met?
Here’s the reason for my asking- you (and all of us who are caregivers) have known someone and (loved, tolerated, supported, helped, etc.) them for a period of time that has included ups and downs.
You have conservatorship, and you are aware of some important facts that are currently involved in your father’s care.
Your situation with managing his care is complicated/compromised by the fact that you live an inconvenient distance from him, and although you keep up to date with his status, and get the best possible services to him, you have become aware that there are some issues that don’t have an immediately discernible solution.
So the question- have you reached the point at which you are willing/able to consider the fact that his attitudes and opinions regarding his day to day life can no longer be considered as important as his safety, comfort and actual welfare? Then, are you comfortable with developing the awareness that you are now the “parent” and he has become the “child”?

With “no ability to comprehend”, and I absolutely take your word for this, it would seem that your father would fall into the hardest type health management category of all. You will need to consider all of the ugly unpleasant choices that face him, actually make a list of them, and prioritize them in order of the least awful or most likely to be achievable choices first.

Then, what is his most desperate need, and how can it be achieved? Would you consider administering a sedative in food? Would you consider hiring a large powerful person who could physically intimidate him to bathe?

How aware is the surgeon of his mental status? Do you have a document describing a diagnosis of dementia? If not, can you arrange to have an assessment done of his status by a geriatric trained psychiatrist, psychologist, MSW?

I have been a part or full time caregiver of several dearly loved relatives during my entire, decades long life. I am amazed at the progress the field of psychopharmacology has made in increasing the comfort of the elderly who deal daily with the torment of a broken brain. No more “drugged off his butt”, but perhaps more manageable, comfortable, peaceful.

Over the years I’ve become far too aware of being in the “sick to my stomach......overwhelmed” place, and I feel your anguish come off the paper as I read.

If your dad were mine, I’d seek a resource for some behavioral intervention FIRST. His physical needs are so numerous, and he’s constantly working against himself with his management issues. The head injury, the dementia, personality, habit.....if his caregivers aren’t able to manage him, and his behaviors will render him too difficult for many types of residential care, then isn’t it worth considering to give behavior intervention a chance as his best shot? Try hard to consider shifting your thinking from “things that won’t work” to “things that can be tried”.

Please get a list together for yourself containing ways for you to comfort and encourage and support yourself as well. You deserve it.

Basal cell rarely kills people. It can spread - usually very, very slowly - and can destroy tissue and bone.

Your father has more severe problems than skin cancer. You are correct that, without proper hygiene, the wound will not get cleaned and then what? Drug him again because he's septic and has to go into the hospital?

"I know he wants the least medical intervention as possible." That's what would guide me in this difficult decision. Respect his wishes.

I believe the best approach is to explain to him the consequences of not having the surgery. If he understands that the cancer could metastasize and ultimately kill him, he might say he's tired of living anyway. Of course having to deal with the widespread cancer would not be pleasant, but perhaps he would agree to be "drugged up" if it were to become too painful. At 80, he presumably could be capable of living many more years, but with dementia the quality of life would be considerably diminished. If the cancer takes a long time to spread, his dementia and increasing age (with the latter resulting in a potential co-morbidity) eventually may make him eligible for hospice. As CM said, none of the options are really acceptable, but between his dementia and stubborn personality he is unlikely to cooperate with any medical intervention unless motivated to do so by pain or until some other condition ends his life. Sorry I can't offer anything more optimistic, but the only realistic (and perhaps easiest for all concerned) approach may be to let nature takes its course.

The comment that your father can't be held in rehab if he doesn't want to be there is puzzling, because it seems - do you agree? - that your father is long past there being any question about his ability to make decisions. He can't, and you are his conservator.

The prognosis is crucial. If this cancer will not kill him, and he is generally well and likely to live for a long time, then not doing the surgery will severely impact on his quality of life for a sustained period. His hygiene is already poor, he is combative - what kind of condition is he going to be in when you add the complications of not being able to retain saliva, food or drink?

You are right to take your father's wishes into account; especially as he has undergone this procedure twice in the past, which means that his wishes are rooted in experience and to that extent well-founded. What's changed is that he is not able to understand the consequences of refusing the surgery now.

Is there anybody he does communicate with well, and trusts? The ideal would be to explain the problem better and win his agreement. I'd keep trying for that before you turn to drastic measures. I don't know if anybody has talked about the PRE-operative period: it might be an idea to have your father admitted to a memory care unit in advance so that everything possible can be done to stabilise him mentally and improve his physical state before the surgery.

You do also have the option of complying with his known, originally well-founded wants, but the consequences of doing that could be terrible for him and possibly very long-term - hard to align that with his best interests.

I should worry less about the detail of how the surgery and recovery would be handled. There are ways. They're not nice to think about, but they work and they will be carried out in the safest and least traumatic way possible by people who know what they're doing.

You have the impossible bit: deciding what to do when all of the options look unacceptable. Have your father's doctors given you any idea of how long you have to think this through?

Very very hard. Even if you presented say, photos of a real person with this 'hole' could he choose? "This Dad? Or surgery?" Even if he DID agree, he may not on the day of surgery.

You know him best & have already flagged the problems in the hospital setting. Being in an unfamiliar place mixed with anatheasia causes more confusion which often leads to a cascade of events: not taking pain pills, not eating or drinking, pulling out IV fluids & catheter, dyhydration, UTIs, falls, bruises, even fractures or head injury.

Many dementia patients I meet post hip surgery (so quite different) are too confused to eat, drink, keep IV fluid cannula in. It's very individual who will recover & who will deteriorate. Some require huge support from family - staying night & day if need be in shifts & do recover but often not back to their 'before'.

Would the hospital try to discharge your Dad home if rehab is not a viable option? I imagine he would have to be transferred directly to a SNF where he may become even more confused or even agressive.

Yes he probably needs the surgery. But can it be done? And what burden to him? And what burden to you?

Anesthesia is very difficult for elders. Often these cancers can be extensive, and surgeries the same with removal of bone, and other problems. The surgeons cannot predict when this "hole" will occur, and as someone who has, as a nurse, dealt with people with about one half of a face left, I can tell you that they can become quite good at learning to eat and swallow past a "hole". Either way this is a very difficult decision. I personally would not have my father, given these circumstances, do this against his will. Nature will take its course either way you go.

If your father refuses surgery, what happens next with the cancer? Has it metastasised? What is his probable length of life? Have you talked to him about death, and his wishes for end of life? His quality of life doesn’t sound good, and perhaps bringing it an end is what he wants. Doctors sometimes talk about the obvious issue which is presenting, in this case the BCC. Widen the discussion to look at the bigger picture. My sympathy to you both in a difficult situation.