Borderline mother refuses to drink following stroke

[blue-eyed bonnie]

Hi, I haven't posted in several years but I really need some help now.  My 87-year old undiagnosed BPD mother has lived with me (sole caregiver and NofK) since a serious car accident in 2016. With therapy and SSRIs for me, we have managed to live together relatively well.  About 6 weeks ago, Mother suffered an ischemic stroke in left carotid artery.  They saved her life by stinting the artery but I don't think she is really going to allow herself any quality of life now.  After refusing food for 10 days in the hospital, they sent her home to my care because she refused to go to rehab facility. Now home, she needs constant watching (I installed monitor in room) and she refuses to drink adequate water (or any other liquid) to stay hydrated.  She has already been to ER once for dehydration induces hypotension; they refused to admit her and told me I would need to start eviction proceedings in order to send her against her will to any type of care facility.  I have arranged for home NP services to administer IV fluids twice weekly, but now she is refusing them.  I have explained to her that dehydration explains all of her symptoms (low BP, indigestion after eating, constipation, abdominal pain, etc.) but trying to reason with someone that has BPD is nearly impossible as you all know.  I have explained that she is making a choice of suicide, but she vehemently says she wants to live and refuses a DNR order if she is hospitalized again.  I am really at my wits end.  Should I just go ahead and let her kill herself by not calling for medical intervention as her dehydration symptoms become dangerous to her life support?  If anyone out there has dealt with this already, I would really appreciate hearing your story.

[Notwendy]

This is really tough, I am sorry.

The struggle seems to be between the two of you.

There is only one boundary here that I can think of:

"Mom, I love you and want to see you stay as healthy as possible. You have indicated you don't want a DNR and want full medical support. Since you won't let me help you do this, I will need to have you in a facility where you will get full medical support from the medical staff so that you can receive it. 

I would prefer that you stay here, but for you to stay here, you will need to drink enough liquids and allow home health to supplement that. If you are not able to sustain your fluids here, then I need to have you go somewhere where they can give you the best possible care"

This takes YOU out of the conflict. pW BPD often seem to have the most dysfunction with their immediate family members. She may cooperate better with the medical staff than with you. It's not personal to you. It's the nature of BPD.

But this gives her the choice and sets the boundary:

"I want you to get the care you have indicated you want. I can not provide this here if you don't drink fluids and allow the home nurse. If my home is not the best medical care for you, then you need to be where you can get that care".

Basically - drink fluids here and have assistance from the nurse or you can not stay. Put nicely.

I imagine she doesn't want to go to skilled nursing. This puts the responsibility for her own health on her.


It takes it off you. You can't make her drink. You are not responsible for her choice to drink liquids or not. She has to choose that. When you are the one concerned about this, it takes the responsibility off her, and becomes a power struggle.

My BPD mother also does this. If I ask her to do something, she wants control and so she resists it. As the disorder goes, she is more cooperative with other people than her own family members. So I think taking YOU out of the conflict puts the responsibility to accept fluids on her.

[Notwendy]

Another suggestion ( consider all choices before you give her the choice to drink or not be at home ) is to consult Hospice ( if you are in the US or other equivalent if there is one in your country).

People assume Hospice is for the very end stage of life, but recent changes have included some care for eligible elderly within a certain life span- I am not sure exactly. It may also include some emotional support for patients ( and families ) at this time of life.

I have heard of elderly people losing interest in eating and drinking as they approach the last part of their lives. Even if your mother says she wants full medical support, her body, her emotional state may be signaling otherwise.  She may have lost  the urge to drink - either from age or stroke - and need to be prompted. ( maybe by someone besides you). She may also be depressed after it and need additional mental health support.

While people think that Hospice means the end, in some cases, Hospice care might even extend a person's time for a while by supporting their health care and emotional needs for the time they have left.

It may be that an alternative to skilled nursing placement or you being the one to struggle with your mother about her fluid intake might be to involve Hospice's support for both of you. I don't know if you have contacted them, but if not, and this is available, asking what they may assist you with might help.

[Methuen]

I am sorry for what you are going through.  This is horrible. Refusing to eat and drink is classic end of life behavior.  Telling you  she wants to live despite that behavior sounds classic borderline. Just classic.

Great advice has already been given.  I have a couple of thoughts to add, including the need to protect yourself.

She has put you in an impossible situation.  If she is refusing to drink to the point of it being life threatening (which it sounds like it is if she cancelled IV’s ordered by a doctor), If it were me I would call an ambulance.  That way there is objective evidence you tried to help her.  If she goes in an ambulance, they would have to treat her dehydration.  

When she was in hospital after the stroke, was a social worker involved?  This person could help you navigate these issues.

I think it would be wise to do this, because if she “passes”  under your roof, there could be an investigation on you.  

I don’t know about the legality of slowly observing someone commit suicide, and not taking the necessary action  to stop it.  I would worry about the optics of that.

Like NW said, communicate to her that she must drink if she wants to live.  If she can’t or won’t do that, but maintains that she wants to live, advise her you will need to seek help for this.  Drops of water don’t count.  Measure it, because even at this end stage she will likely need to be in control.  Ask her doctor how much water she needs daily, so its objective.  

Of course if she indicates she is ready to let go, then that is different.  Personally I would record the conversation.  My mom has given  me every reason not to trust her.

If you let her communicate suicide under your roof, I don’t know if it’s possible where you live that some authority could investigate you for not taking appropriate medical action, especially if she’s told anyone else she wants to live.  

Hospice or hospital care, it sounds like she needs something.  If she chooses not to eat or drink with hospice or hospital care, that’s a normal choice with end of life, but at least it cannot be interpreted by investigating authorities that you didn’t take appropriate action.  

I can’t believe the ER refused to admit her.  If eviction proceedings is what you need to do , then as painful as it is, I would start the process.  Your mom should not be doing  this to you, and putting you in this position.  But she has.  So do what you need to do and react accordingly.

Also, are you navigating this alone, or with a partner or sibling or anyone?  I’m hoping you have local  support…for you.

Whatever you decide, it’s on her.  

[zachira]

So sad about what you are dealing with. In many places, having a person die at home can lead to an investigation. I know a person whose husband died in the ambulance on the way to the hospital and the wife was threatened with an investigation unless a certain official signed off on the paperwork. This is in spite of the husband being elderly, having diabetes, and morbidly obese which was all medically well documented. Do follow Methuen's advice, and find what you need to do to protect yourself from being accused of contributing to the death of your mother, in spite of the fact you are dong everything you can to get her to drink fluids. Calling an ambulance is a good idea and then refusing to take your mother back home and insisting she go to an institution that can provide her with the care she needs, will protect you from unfounded accusations of elder abuse, and get your mother the care she needs for end of life care.

[Notwendy]

This is excellent advice and something I haven't considered since my BPD mother is not living with me.

When she speaks of her helpers, she has made the accusation of "elder abuse". Once she complained that a nurse at the hospital "pushed her down on the bed". The more likely situation is that she was uncooperative and tried to get off the bed by herself and the nurse had to keep her from having a fall.

I would be concerned if she were in my home that she'd accuse me of that. She still is in charge of her money and care but has poor judgement. Still, she qualifies as legally competent. We ( her kids) have power of attorney in the case she is not able to make decisions. A social worker has advised us that if we try to assume this now, a judge would side against us and think we were taking advantage of her.

Once we went to the bank with her to try to help her organize her finances. When we got there, she refused to allow us to see her accounts. She started to get agitated. The bank personnel were staring at us. We left. I realized had this escalated they would have called security and we might have been taken to jail. If she dysregulated, she might accuse us of bad intentions.

We know now to not go to the bank with her.

While your mother herself may not ever accuse you of doing harm to her - I agree with getting medical personal involved in her care plan. If you call 911 they have to assess her in the ER. Hospitals have social workers to help. Get as much help that you can.

Hospice seems like a good resource if you have it. Should she decide to not eat or drink, they can still be supportive in terms of pain control and a care plan and support for you. This way, there will not be a false assumption of your care for her.

[blue-eyed bonnie]

Thanks everyone for your support and some great suggestions.  I didn't realize that hospice would help with elderly conditions that were not necessarily end of life.  I will find out what she might qualify for in terms of in house care.  She definitely is more compliant with others than with me.  I will also contact a lawyer that specializes in elder law.  Several other people have mentioned that I might be liable for her death here at home.  As for the ER, they were NOT helpful.  They gave her a liter of fluid and called and told me to come get her.  They questioned me about my care, which leads me to believe she probably told them I didn't give her any food or water!  Sigh...  I didn't go with her to the ER, I was hoping they would admit her to the hospital and then I could work on doctor's order to rehab facility, but since she refused to consider rehab, they didn't admit her.  Once she was rehydrated, of course she was not in any serious health crisis for hospital admission.  The ER social worker called and said I had to come get her, since my house was her legal residence.  Otherwise they would put her in a cab.  So not much help there.  I live in a small, rural community. Anyway, I appreciate everyone's help and suggestions.  This group is always such a lifeline!

[zachira]

You have learned a valuable lesson about advocating for yourself and your mother. The people in the ER will most of the time tell you to come and get your mother, unless you say you can not care for her at home, and a long term placement has to be found right now.

[GaGrl]

Your mother's physician can order home health care and hospice care, whichever is appropriate. As I found with my mother last year, hospice is no longer bound by th ex six month estimate of end of life. It is more focused on palliative care and quality of life. I found it invaluable.

Also, the home health and hospice care companies also have social workers, physical therapists, speech therapists, personal care assistants, and chaplains on staff. The social worker, especially, can guide you in obtaining help in some of the elder care legal issues (including competency issues).

[Turkish]

Is there Adult Protective Services where you are? Every county in the USA has one, and I bet Canada has similar.

The response of the ER isn't surprising. This exceeded their mission. I would call APS ASAP to get a social worker involved. You aren't equipped to deal with this and a situation like zachira described is what I would fear if your mother flat out refuses to take care of herself.

At least it can be documented, and she and you will get support. If hospice is the answer then that it good. My friend's mother got to a point that she refused to eat or drink. While sad, she was an independent entity, and being under hospice care, all that could have been done was done.