Do I trick my dad into surgery?

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.

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.

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?

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?

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.

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.

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.

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...

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.

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

You cannot legally trick or fool someone into surgery. Ask for an ethics committee conference.

If you are this Conservator, You have Dead On Rights Here, dear. Enfdangering the Welfare of an Elderly person is against the Law, And e'en if Dad don't Care because he is not Glued on Tight, You have no Fight. Get all you can to Intervene and Get him to even a Place where he is 24 Seven Care.

I don't see any answers here that really address it properly. You are in charge of doing what is best for your father, exactly like the role a parent has for their child. Now when a child isn't doing what is in their best interest you have to make a decision to force them to do it. Similarly, your dad wants to live. Now ignoring cancer is incompatabile with that goal. So the fact that he isn't in a right state of mind and is scared of pain doesn't matter in the bigger context of doing what he needs. So listen to the doctor and trick him.

This is complicated. You have to balance the possibility that the cancer could get worse and cause real difficulties with eating with his dislike of surgery. Is he in pain and could the pain get worse? For this one, treatment just to stop the progression of the disease may be warranted. He'd have to be anesthetized. That being said, if he hates doctors and surgery and is not in pain, perhaps it is kinder just to let him be. My mother with dementia also doesn't like to be in the hospital (she was biting the nurses), so we put her on hospice-type care where we just make her comfortable and she doesn't go to most of her doctor appointments any more, just the one that is in her assisted living facility. She has "no hospital" medical directives. She seems much happier this way.

Darlin, I’m late seeing your question but will relate our experience with this. My dad doesn’t have dementia as yet, but does have a dermatologist and his referring surgeon pal. I’d love my dad to break up with both. My dad has has surgeries twice in his old age for skin cancers. They were both much as you describe, but one was further along and required a skin graft to repair. Both turned into long, painful, and frustrating recoveries for my dad. He simply doesn’t heal quickly or well like he did as a young man. He comes out battered and bruised, weakened and tired. For us as a family, we found it cruel. And yes, the docs paint the dire picture of all the bad that can happen with not doing surgery, but when we actually researched it, we found these cancers grow so slowly our dad will die of something else far sooner than this, he most likely wouldn’t even get to the further effects like the hole you describe. The docs don’t see the recovery part, it’s not their problem. Now that it’s finally behind us, twice, even our dad agrees that it was a mistake, and that was with a dad who thinks clearly and has god hygiene. I can’t imagine the recovery with your dad’s situation. Blessings to you in this as you make this decision, often there aren’t any right answers just the best we can do

Your father's lack of hygiene and lack of co-operation sound like he needs more intervention than he is willing to accept. Does being his conservator give you legal power to force intervention for health and safety? Your father's general situation sounds more urgent than his basal cell cancer. The basal is slow growing but given that it is on a path to cause more difficult health and hygiene problems, it needs to be dealt with. It doesn't seem right to just let him wallow in filth and confusion no matter how much he protests any interference.

I understand your desire to get this "fixed" for your dad. Consider what the aftercare of his surgery will look like:
hating the pain and not taking pain meds?
fighting the staff to change his dressings?
trying to remove sutures or staples himself before wound is ready?
doctor or nurse having to do house call since he won't go to appointment?
possibility of eroding your dad's trust in you?
If you have a good plan in place to address these issues, go for it.

If you can't fathom how to manage the care after surgery, it might be time to admit that the time is coming near to "not do" anything except comfort measures. He might need a feeding tube inserted into his abdomen to get full nutrition if the cancer erodes a hole in his cheek. He is probably not comfortable with the cancer now and might be ok taking pain meds if explained these will help him to be more comfortable. There are skin patches that could be placed on his back - where he could not reach. He may allow massage - and somebody could also clean him at the same time. If this is more acceptable to you, talk with doctor about hospice services.

Gosh, it seems that he really needs that surgery. It should be taken care of and hopefully for the last time. It seems to be coming back to cause problems. I wouldn't want to let anyone live with that and in the long run will cause even more problems for him it sounds like. I hope that between you and his caregivers and doctors, you can come up with a plan. Prayers for strength in dealing with this for you.

I would call hospice. If your dad does not want the surgery, and you as his conservator want to respect his wishes, see if he qualifies. They will make him comfortable regardless of his condition.
This is a tough situation. Sorry you are going through it,

Another baffling question, if you are his conservator why is his hygiene and basic care not being addressed? How is he living alone with mental illness? I agree the skin cancer seems like down on the list of things that have to be addressed. I’m actually surprised APS hasn’t intervened.

The trouble with letting nature takes its course (which would normally be my default position too) is that in this case nature plans to gnaw the man's face off, potentially, before it gets round to killing him.

I really would plot the "what happens if we do do this?" versus "what happens if we don't do this?" charts in as much detail as possible before deciding. Make the surgeon sit down and concentrate on the questions.

Maybe consider hiring an elder law attorney, who can give you advice on what you as your dad's conservator can legally do to to him in the name of "intervention" versus what you are willing to do to him. How far are you willing to go as his conservator? Have you considered getting him a long term care bed in a psychiatric hospital so that his mental illness and dementia will be treated for the rest of his life?

As a first step, I would consider going to the doctor who diagnosed your father's dementia, and ask that doctor if your father still has the capacity to make medical decisions (and it doesn't sound like he does). Better yet, that doctor should state it in a letter so you can wave it in front of any of his doctors from now on. (I'm also thinking about end-of-life decisions here, like 'do-not-resucitate' orders, or treatment that could keep him alive, but leave him minimally functional, in which case a doctor's letter would be very helpful.)

If he no longer has the capacity to make medical decisions, then you can override her father's refusal to have the surgery, although getting his cooperation would still be preferable.

By the way, my mother is also very stubborn & very paranoid. The only time she agrees to bathe is if she's going to see a doctor, and she hasn't brushed her teeth in ages (even before going to the dentist). Even though more socialization would probably benefit her, I can't imagine most people would want to be near her because of her poor hygiene.

Darlin: I can't imagine what you're going through. I am so sorry for what your father's going through. You've been getting a lot of wonderful advice so I won't repeat it. Here's a perspective I came up with that has helped me almost instantly know the right answer to an ethical, moral, or emotional question:

A month from now, a year from now, five years, ten years, what action could you regret?

My questions that needed answering using this technique are WAY more simple than one you're facing, but looking at this dilemma from this perspective may help you figure out what's right for your dad, and you.

His neurologist can prescribe Seroquel which will calm him down. Skin cancer probably needs Mohs surgery & can be done as out patient in dr office. Good luck & hugs 🤗

Based upon your description, that 'sedative' would have to be a horse tranquilizer: )
By and large, I try to respect my dad's wishes unless they could harm someone else (like when we made him stop driving). He's also has mid-stage dementia and hasn't done even basic hygiene in years.
If you haven't already, press the doctor for an alternative (topical chemo, etc) that may keep the cancer from growing as aggressively.
Doctors can be incredibly obtuse about issues that the families of the demented elderly face. S/he clearly doesn't understand the degree to which your dad is resistant. Is there another doctor who could give a second opinion or at least be more realistic about options?

Don’t do it. You have done all you can do.

Are you an only Child? I would request FML leave if needed as it appears you investigate the quality of home care. If your father is resistant to his caregivers in the home it may be better to have him in an assistant living facility. the first thing I would do is make sure he gets proper hygiene then take him to the doctor and find someone to help support both you and your parent. God bless.

Basal Cell is typically slow growing and *generally* doesn't metastisize, but there are rare exceptions. As noted, your concern is not only how to get him to the surgery, but post-op care. Our mother, during early signs of dementia, had a spot on the edge of her lip. When pointed out, she dismissed it as a scab, hasn't been there long, etc. The only thing I would do is try to encourage seeing her dermo (she was religious about going and getting dad to go previously!) Nope, it's nothing. Even when another area on the side of her nose appeared. During one of her Mac Degen checks/treatments, THAT doctor told her she should have it looked at - then she went. Sure, don't listen to us!! By that time, the one on the nose required a little skin graft. For the most part her after-care went 'okay.' She needed prompting once in a while, but was still living alone with no care givers (we did try then at some point and within a short time she refused to let them in!)

Years later, after moving her to MC, another spot appeared on her cheek. The dermo doc suggested Mohs, which was how it was treated before, but when they said I couldn't be in the room with them, to ensure she was co-operative, they went with a "punch" biopsy instead. We did have to do it a second time, when the test results showed cells on the edge, but it was done in his office both times with just a local anesthetic. After care was handled by staff at the MC facility, but it was minimal. So far I have not seen any recurrence (2 years now?)

At her age, with dementia, I would not put her through the Mohs and told the doc that. I did want to try to nip it in the bud, so to speak, to at least delay any additional growth because of where it was on the upper cheek, about where her glasses would hit.

In your dad's case, getting him there, getting it done and treating it afterwards will be a monumental challenge. It does sound like he is on the cusp of getting facility care. You haven't indicated how long he has had dementia, what type it is or what stage he might be in. If he only has a few years left, I would focus on getting him into a facility and perhaps having at least one bath! Also, provided this is run of the mill (if there is such a thing!) dementia, not something like Lewy Body, would it be possible to get some anti-anxiety meds into him, even if the care-givers have to put it into his food? When mom had a UTI, we had to use this as she developed some serious sun-downing. Generally she is calm, fairly quiet, reads her paper, magazines, sales flyers, etc. With the UTI - off the rails! She only got the minimal dose (he might need a bit more), which was just enough to take the edge off. She was not doped up and it doesn't take time to build up in order to work. You should see results the first/every time, fairly quickly. This would be just to tone him down a bit, and perhaps make him a little more compliant with simple issues like a bath.

I would also have a frank discussion with these doctors. They clearly do not understand the whole dementia process. Gung-ho surgery away! Sure, dope someone up to come in, do the deed and then release him to himself, non-compliant? I would also be concerned about the fact that this has been 'excised' twice before - same place and same doctors? Why has it come back? Did they not do the job properly? None of mom's has reappeared.

I would also inquire about any alternative, less invasive treatments. I did find an NCBI review of the various treatments that are offered. Some have side effects, some have not been studied extensively enough to say how well the treatment works, but they have shown good results in many cases. If there is something they could offer that wouldn't require a lot of effort on his part/help from others, perhaps it could be considered (or seek second opinion.)

Focus on keeping him safe (and clean) first! We have to choose our battles!

Darlin. I, too, am my dad's conservator. The courts take the conservatorship very serious. You may want to consider moving your dad to a home or getting him closer to you. Drs can give rx to calm a person down. When my dad went through a combative stage with me, I had to crush pills & put them in his sandwich. If you are eating with him, just don't mix up the sandwiches. LOL.

Drs found basel cancer cells on my dad's back. I knew he would not allow anyone to hurt him. Surgery was discussed, but, biospy first. I warned the dr before she attempted to numb the area for the biospy. He threw her across the room. All the medical personnel left the room. The doctor, then, came back with a cream that could be used. It's Imiquimod usp, 5%. It comes in small packets that are applied every weekday morning, no weekends. The cream worked by taking off layers of skin without pain. It has been used several times now.