Clinician Challenges in Providing Health Care for a Morbidly Obese Family Member: A Bariatric Case Study
Morbid obesity is a chronic disease affecting millions of Americans. The disorder is likely to increase in prevalence because currently one third of the American population is obese.
Many factors are associated with morbid obesity, including psychological (eg, depression), physiological (eg, hypothyroidism) mechanisms, sleep disorders (eg, sleep apnea), drug therapy (antidepressants, antidiabetic agents, steroids), and genetics. Increasing numbers of morbidly obese patients are requiring critical care, presenting major challenges to professional staff across the disciplines. This manuscript presents a case study describing the experiences of a morbidly obese woman in the final years of her life from the perspective of her health professional relative. The patient typifies many of the major risk factors for morbid obesity; her story reveals many of the issues faced as she revolved in and out of the critical care and acute care system. Her substantive health problems affected multiple body systems and included hypothyroidism, congestive heart failure, hyperlipidemia, and subclinical Cushing’s Syndrome, likely related to previous medical therapy (cortisone) for rheumatic fever in childhood. The case description addresses many integumentary system issues the patient experienced; skin injuries and infections that can pose serious life-threatening situations for the morbidly obese patient must be prevented or treated efficiently. Health professionals can learn a great deal and improve the care they provide by listening to morbidly obese patients.
Potential Conflicts of Interest: This is a first-hand report of providing care for a close relative.
Bariatric Surgery: Patient Incision Care and Discharge Concerns
Providing Quality Skin and Wound Care for the Bariatric Patient: An Overview of Clinical Challenges
The number of people with morbid obesity, defined as a body mass index (BMI) >40,1 is rising quickly in the United States population. The prevalence of obesity (BMI >30)1 in American adults is approximately 35%.2
Caring for morbidly obese patients is a substantial and increasingly necessary challenge for today’s health care providers. This challenge is particularly acute for critical care areas where morbidly obese patients may require emergency interventions to stay alive. The practicalities of intervening with and moving these patients are daunting. Reviews of the literature have shown the morbidly obese are more difficult to intubate and that it is harder to maintain a patent airway due to differences in size of neck structures.3 These persons are also at greater risk for thromboembolic events.4 Some diagnostic tests (eg, computerized tomography scanning and magnetic resonance imaging) may be difficult to obtain because a morbidly obese patient may not fit in the scanner machines.5
The special care needs of morbidly obese (sometimes referred to as bariatric) patients have been well described in the literature.6-8 These needs are magnified when morbidly obese patients are critically ill.9,10 The specific challenges of skin and wound care in this population recently have been described.11
Because of their weight, morbidly obese patients are at great risk for a variety of cutaneous conditions and related disorders. In addition, they are challenged by cardiovascular dysfunction, hypertension, and pulmonary disorders such as respiratory failure and hypoventilation. Even pharmacological care is difficult, because drug pharmacokinetics are altered by excess adiposity.12
Although I was well acquainted with the clinical challenges presented by morbidly obese patients from my own ICU and wound ostomy continence (WOC) nursing experience, the full breadth and depth of the problem repeatedly was “in my face” when helping a morbidly obese older sister in the final years of her life. The series of care events could have been called “the Good, the Bad, and the Well-Intentioned but Ugly.” Health care professionals who care for their own family may find, as I did, it is far harder than anticipated. In a recent study,13 16 health care professionals were surveyed regarding their experiences as geriatric specialists and simultaneous geriatric family caregivers. Similar to my own situation, they found the family member/health professional dual role caregiving experience creates emotional struggle. Caring for a family member can generate frustration not only with the patient, but also with the health care system and its providers, as well as within one’s self. As a family, you may have to learn that good self-care cannot be imposed on another person, and that ongoing loving counseling and advice may not prevent ultimate poor outcomes.
This case study addresses several care conundrums of morbid obesity and discusses specific skin and wound care issues — my clinical specialty — that actually were incurred by the case study patient.
A 62-year-old white morbidly obese female (Ms. T) was admitted to a cardiac critical care unit suffering from severe congestive heart failure (CHF). She weighed at least 400 pounds but would not reveal her exact weight to family members. Her story was provided by her younger sisters to the admitting medical and nursing staff because they had much practice accompanying her to the hospital. She was a “frequent flyer” with repeated acute care admissions.
Past medical history. Ms. T was born in 1948, a healthy child until 3 years of age when she contracted rheumatic fever. She was hospitalized in a pediatric acute care hospital for the better part of a year. Notably, when she was in the grips of the worst of the rheumatic fever in the acute care hospital, she deteriorated to the point where she received Roman Catholic Last Rites and was expected to succumb to myocarditis-related heart failure. One cardiology physician approached her parents and asked if they were willing to pay for an experimental drug that might save her life. Her parents agreed, and the little girl received intravenous adrenocorticotropic hormone (ACTH), one of the first steroids to be used clinically in the 1950s. She responded immediately to its anti-inflammatory effects on the heart14 and improved markedly.
Ms. T was hospitalized in a children’s rehabilitation hospital prophylactically for 3 years to keep her quarantined from her 3 siblings at home. At the time, streptococcal infections were rampant in the community. During that rehabilitation period, Ms. T received special recognition as the “National Heart Girl” from the American Heart Association. She was a skinny, beautiful little girl with big dark eyes and a sweet smile. She was placed on daily penicillin, and in 1955, was sent home at age 7 to be with her family. From the disease process, she developed mitral insufficiency and eventually developed mitral stenosis in the fifth decade of her life.
By the time she was 9, Ms. T was showing signs of a weight problem. Whether it was due to the daily penicillin or the ACTH effects was unknown. However, later physicians suspected she had developed a form of subclinical Cushing’s Syndrome because she had truncal obesity, relatively thin extremities, oily skin and hair, and striae on her abdomen.15,16 In her second and third decades, she worked as a secretary and teacher (after finishing college), and eventually worked for the federal government in the computer security division of a federal agency.
In her fourth decade, Ms. T developed type 2, insulin-dependent diabetes mellitus (IDDM), hypertension, and high cholesterol. She also was a heavy smoker. In her fifth decade, she developed clinical depression, hypothyroidism, and sleep apnea (for which she wore a continuous positive airway pressure ([CPAP]) mask at night), and she became morbidly obese (see Table 1). It was uncertain whether her depression was related to her hypothyroidism, sleep apnea, or genetic heritage. She responded well to antidepressants until her weight increased to morbid obesity levels. In her fifth and sixth decades, she developed worsening CHF complications, increased blood pressure, venous stasis ulcers that were frequently infected related to peripheral edema and opening of the skin, urinary incontinence related to her excessive weight, and severe insulin resistance related to morbid obesity. She had multiple hospitalizations for CHF and infected leg ulcers (usually methicillin-resistant Staphylococcus aureus [MRSA]). She was placed on U-500 insulin to control her blood sugar. A uterine growth was noted on an abdominal scan; she had a hysterectomy at age 59. Postoperatively, she developed a surgical site infection (MRSA) in the pannus that resolved over 4 months’ time with use of negative pressure wound therapy, broad-spectrum antibiotics, and excellent wound care. Despite multiple requests from physicians and family members, she refused to consider bariatric surgery. In the last 18 months of her life, she was hospitalized 5 times for CHF and sent to several different nursing homes for brief periods to recuperate. Ms. T lived alone.
Problems noted in the hospitalizations and nursing home stays included: CHF, severe insulin resistance, all previously mentioned comorbidities, and multiple ongoing integumentary system issues including pressure ulcers (acquired and reacquired in acute care), irritant dermatitis (related to urinary incontinence), cellulitis related to chronically nonhealing venous leg ulcers, and intertrigo of her groin and under her large abdominal pannus and breasts.
Patient’s surgical history. Ms. T underwent a tonsillectomy (age 9), thyroidectomy (age 54); hysterectomy (age 59), and multiple colonoscopies for screening.
Family history. Ms. T’s father (deceased at 75 years of age) was obese and his medical history included colon cancer (diagnosed when he was 62 years old), type 2 diabetes mellitus (DM), and cerebrovascular accident (CVA). Her mother’s history (deceased at 93 years of age) included CVA and hypertension (HTN). Her oldest sister, deceased at age 68 years old, also was obese and had depression, type 2 DM, and CHF. Her 2 other sisters are overweight and alive and well. Ms. T’s brother died in infancy from congenital heart disease.
Lifestyle. Ms. T was a smoker (20 pack years). She did not consume alcohol or use drugs. She was an excessive eater who loved food buffets.
Medications. Ms. T was prescribed regular insulin (U-500), furosemide, metoprolol, levothyroxine sodium, escitalopram, atorvastatin calcium, and an ACE inhibitor. Medication allergies included penicillin (developed in her fifth decade), sulfa, cephalosporins, and quinolones.
Final care. In her next-to-last hospital critical care admission, Ms. T responded well to expert, aggressive cardiopulmonary care with good diuresis and improved breathing. She was transferred to a medical floor and then eventually discharged to a local nursing home. After 5 days at the nursing home, she developed marked CHF with increased generalized edema, weight gain, and poor oxygenation. She was transferred to an acute care hospital’s cardiac care unit, where she was intubated and placed on a ventilator and received strong inotropic drugs intravenously (phenylephrine and norepinephrine). Her family visited her on the last evening of life and asked for her to be anointed. Her cardiac ejection fraction was 22%. Despite valiant efforts by the critical care staff, Ms. T succumbed. She was only 62 years old.
Reviews of the literature17 support that morbid obesity is a multifaceted condition and considered a chronic disease. This complex disease process involves gender, lifestyle, dietary habits, sleep deprivation, genetics, and ethnic factors. Certain drugs can be associated with weight gain and include antipsychotics, antidepressants, antiseizure drugs, diabetic drugs, and glucocorticoids.17
Neuroendocrine disorders also are associated with morbid obesity and obesity and include hypothalamic syndrome, hypothyroidism, polycystic ovarian syndrome, and Cushing’s Syndrome. Psychological factors (eg, depression) also can be associated with substantive weight gain. Although it is easy to say “lose weight” to patients, the complexity of etiological factors makes treatment of morbid obesity difficult.6,17 Bariatric surgery has been supported as an effective management strategy.10,18
When morbidly obese persons are hospitalized in critical care, health care providers are confronted with numerous problems. The overall management of patients with morbid obesity involves good clinician understanding of the “multifaceted interplay between respiratory stabilization, compromised cardiac function, increased circumferential adipose tissue, fatty liver, predisposed risk of infection, skin integrity, vascular issues, and nutritional needs.”19 For example, ICU personnel have developed “high risk” protocols to maintain skin integrity.20 Conversely, some care issues (eg, pharmacological therapy adjustments for weight) have no definitive answer; the available treatments are not entirely evidence-based, but rather empirical.21,22 Because critical care of obese patients is a daily occurrence for most clinicians caring for adult clients given its prevalence in the population,23 full understanding of the effects of morbid obesity on all aspects of care is essential. The integumentary system, in particular, can be profoundly affected. Morbidly obese patients can be viewed in 2 ways: either 1) as a focus of dread, resentment, and neglect because their care is definitely harder than those with normal weight, or 2) as an opportunity to demonstrate the very best of clinician expertise, caring, and ingenuity. In the last years of Ms. T’s life, I sadly observed the former but also rejoiced in the latter.
Watching and participating in my family member’s care taught me several lessons. I think clinicians would benefit from putting themselves in the place of morbidly obese patients and looking at their history. Nobody asks to become that heavy (although some clinicians demonstrated that attitude to the patient and family). Psychological issues (depression, internalized anger, apathy, obsessive compulsive disorder, and so on) can be contributing factors. Physiologic derangements (endocrine disorders, sleep apnea, drug effects) also can cause morbid obesity.17,24 Cognizance of the disease from this perspective may change attitudes. Of course, body image is strongly negatively affected. Having to move a 75-lb pannus or lift hip tissue “saddle bags” is not ideal living, issues these patients have to deal with every day. Clinicians need to reflect on the patient’s quality of life, even as they function in the frenetic pace of critical care.
Understandably, critical physiological issues (eg, airway, circulation) have to take precedence, but basic care cannot be ignored in the ICU milieu of alarms and machines. Bariatric patients need help with good body hygiene. Like everybody else, they want to feel clean. To place a basin in front of a patient or to offer cleansing wipes without assistance is ineffective. Importantly, it can be perceived as uncaring by patient and family. Asking the patient how he or she manages hygiene is helpful and enlightening. In chronic care settings, long-handled brushes, showers with hoses to rinse off cleansers, and other such devices are mandatory for optimal care and to encourage patient participation.
Skin and wound care is a serious challenge in the morbidly obese. As a WOC nursing specialist, I anticipated vigilance for skin integrity in the critical care areas would be better than other care units, but sadly that was not always true. In the worst example of this neglect, Ms. T told critical care nursing staff she could feel she had a sacral pressure ulcer because she was in pain. The nurse superficially examined the area and did not fully turn the patient. Upon hearing this from the patient, I asked for a WOC nurse consult, who upon thorough assessment found a hospital-acquired Stage III pressure ulcer exactly where the patient indicated. The CCU staff nurse who performed the cursory assessment shrugged her shoulders and never apologized. Staff need to know morbidly obese patients are at risk for pressure damage and that ulcers can occur in “atypical” spots (eg, in deep skin folds).8 When I share this story with nursing students, I emphasize the critical nature of listening to the patient.
Critical care clinicians are trying to change the mobility paradigm for intensive care patients.25 Surviving acute illness is important and involves preventing persistent profound impairments such as pressure ulcers, necrotizing infections, and other negative outcomes. This paradigm shift is critical for morbidly obese patients. Traditionally, intubated patients were kept on bed rest to avoid complications. However, intubated, mechanically ventilated patients with light sedation can sit in a chair or walk short distances with good outcomes physiologically for all body systems, including the skin.25
Appropriate equipment. Specialized equipment is a basic requisite for organizations caring for morbidly obese patients. The hospitals involved in Ms. T’s care had wide bariatric beds with special pressure-redistribution surfaces; the nursing homes where she was treated did not. Morbidly obese patients have to be able to move safely and not have adipose tissue pressed against side rails. This does not just involve provision of wide beds; bariatric support surfaces have to be used if skin breakdown is present. Nursing homes without the correct equipment should not accept these patients or be sanctioned for providing inadequate care.
Moving morbidly obese patients in a safe manner requires the correct equipment. One nursing home in particular had no bariatric stretchers, old bariatric-sized wheelchairs, and lifts that did not accommodate the weight of bariatric patients. One of Ms. T’s transfers left her with major bruising and a skin tear of her forearm. The nursing director was apologetic but no new equipment appeared. It took many days to get a support surface adequate for her weight. I was advised not to “upset” the unit nursing staff with the patient’s care needs. When I went to the pertinent administrators, I revealed my clinical expertise, formal education, and the fact that I frequently served as an expert witness. The climate of receptivity and respectful treatment changed markedly. Sadly, confrontation was necessary to get what was required for needed treatment. As a side note, Ms. T had excellent insurance, so treatment was not a matter of money; clinical inertia and ignorance thwarted proper care. I knew skin injuries and infections can pose serious life-threatening care situations for the morbidly obese patient; I learned I had to teach this fact to professional caregivers.
Odor management. Odor management for obese and morbidly obese patients is also important. Because of physiological changes in glandular function, the presence of diabetes, and difficulty in keeping clean, morbidly obese patients need strategic attention. Commercially available skin cleansers with clean scents can make a difference in the patient’s self-esteem when combined with cleansing wipes or cloths or other approaches. Using dry abrasive soaps can actually hinder good skin hygiene by compromising an effective skin barrier.26 Conversely, drying products that decrease moisture (eg, Interdry, Coloplast Inc, Minneapolis, MN) can help lessen odor. One positive I discovered is many organizations are eager to hear about innovative products and acquire them for better patient care.
Attention to skin. Deep skin folds and the perigenital area require special attention in morbidly obese patients. Soft tissue infections, especially necrotizing fasciitis (NF), are a threat to the patient. Perineal NF infections are called Fournier’s gangrene. Diligent clinicians check hidden skin areas and keep them as clean and dry as possible. One nursing home used a hair dryer on cool to dry the deep areas well. It worked quickly and very well. I learned that complimenting the staff for their creativity helped support better care.
Morbidly obese patients often have chronic venous disease and lower extremity lymphedema.27,28 These pathological changes markedly increase risk of skin breakdown and infection. Clinicians need to thoroughly inspect the extremities for the presence of cellulitis and arrange for elevation of the legs and devices to reduce edema (providing no signs of infection are present).
Humor. A sense of humor used therapeutically can be enormously helpful for morbidly obese patients. I remember one critical care unit where Ms. T was a CHF “frequent flyer.” She told us she really liked the staff because they made her laugh and approached her physical care in a humorous but respectful way. An exceptionally caring nurse amused Ms. T by saying she was from “rail to shining rail,” to which she replied, “And it’s true, too.”
Additional care providers that excelled in humorous caring include a professional specialty group Ms. T used chronically as an outpatient and who followed her in the hospital. The physicians, nurse practitioners, and support staff were solicitous and funny and provided prompt appropriate care. One physician always joked, “Here’s trouble” when he saw Ms. T. He always gave her a hug. The little gesture and the joyful spirited nature of the care group meant a great deal to a patient who had depression and multiple medical problems.
Education. Education is a key process for all parties involved. Morbidly obese patients benefit from education about self-care and encouragement to be actively involved.8,29 They need to be counseled to advocate for themselves if they believe their needs are ignored. I learned I had to encourage Ms. T to be assertive because she did not want to “cause trouble.” Staff clinicians from all disciplines also need education. Injury prevention for the patient and the caregiver is a paramount need: specific training, special equipment, and teamwork can make care more efficient and safe for morbidly obese patients. Staff members need to set limits and provide needed care when morbidly obese patients ignore suggestions or refuse to engage in needed care.
The role of the family. Families need caring, too. My other sister and I, both health care professionals, had assisted Ms. T for years and had begged her to consider bariatric surgery and to stop smoking and overeating. Consequently, we were well aware of the multiple challenges facing the patient. In acute or chronic care site units where good care was provided, personnel were professional and empathetic and kept us informed. They allowed us to vent our frustration and feelings of inevitability. The last 2 CCU admissions were particularly stressful, and the critical care staff members were superb. I remember telling a diminutive CCU nurse to “watch his back.” I meant it literally for him in the safe handling of my dying sister.
Morbid obesity is a difficult disease state, one that is often ultimately fatal. It demands the best of clinician providers. Understanding the needs and perspectives of patients, their families, and care providers can make care more streamlined and effective. Lessons learned from the experience of caring for the morbidly obese can be used to avoid substandard approaches and optimize opportunities to provide the best care available.
Theresa was a great teacher and wonderful writer. We talked about using her story as a case study sometime in the distant future after she died (never thinking the opportunity would occur so soon). She would be most pleased if this article helps health care professionals understand the special needs of morbidly obese patients from their perspective and that of their families. Theresa’s family is grateful to the many professionals who were caring in the fullest sense of the word.
Dr. Beitz is a Professor of Nursing, Rutgers University School of Nursing-Camden, Camden, NJ. Please address correspondence to: Janice M. Beitz, PhD, RN, 4 Coventry Court, Cherry Hill, NJ 08002; email: firstname.lastname@example.org.
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