My Father's Hospitalization and Our Choices: The Conflict Between Life-Prolonging Treatment and ACP

Ever since my father was hospitalized, I have spent my days feeling unsettled.
On the third day of his hospitalization, the attending physician explained his medical condition.

Explanation of Medical Condition

• Left cerebral infarction (likely due to atrial fibrillation)
• The infarction is extensive, and inflammation has also caused a cerebral hemorrhage
• Cerebral edema will continue for about two weeks, peaking around one week
• If the edema compresses the brainstem, breathing will stop and blood pressure will drop, leading to a critical state
• Due to left brain damage, there is a possibility of right-sided paralysis, cognitive impairment, and aphasia

The doctor continued.

"There is a surgical option to relieve the edema, but what would you like to do?
I understand you do not wish for life-prolonging measures.
As it stands, he cannot take in nutrition.
The options for nutrition are as follows."

• Central venous nutrition (high-calorie IV)
• Gastrostomy
• Enteral nutrition (tube through the nose)
――――――
• Intravenous drip only
• None

"First, please choose from above or below the line. This is for the current situation."

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Family Choices and Conflict

We answered that we would not proceed with surgery for the cerebral edema.
However, regarding nutrition, I was bewildered by having to decide immediately despite it being the acute phase.

No life-prolonging measures = no aggressive treatment.
But this is the acute phase. Do we really have to decide on nutrition this quickly...?

My mother was confused and didn't know what to do.
As a nurse, I had the knowledge, and if I considered my father's ACP (Advance Care Planning), I could reach an answer, but
I questioned whether a family member with absolutely no general knowledge could make this decision.

I answered, "Below the line."
(*Selected intravenous drip only)

I had to face the harsh reality, and the doctor told us, "The next 10 days will be the turning point."

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Moving to a General Ward for Visitation

Visits were not allowed in the HCU, and feeling that I might reach the end without seeing my father again,
I asked the attending physician, "Please move him to a general ward so we can visit him."

Since we were not opting for life-prolonging measures, the doctor agreed, and we were able to move him to a general ward.
When I visited my father for the first time, unlike when he was admitted, he was unconscious and connected to IVs and monitors.
A different kind of frustration welled up compared to when he was rushed to the hospital by ambulance.

After that, my days of visiting every day after work began.
For two weeks, I spent every day feeling unsettled, wondering when the hospital would call.

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About Cerebral Edema After Cerebral Infarction

After a cerebral infarction, **cerebral edema (brain swelling)** occurs around the area where blood flow was cut off.
• It begins immediately after onset and peaks on the 3rd to 5th day
• It generally improves over about two weeks thereafter

💡 When the left brain is damaged
• Right-sided paralysis
• Cognitive impairment (difficulty with understanding and judgment)
• Aphasia (difficulty speaking or understanding language)

If the edema becomes severe, it compresses the brain, further worsening blood flow, and in severe cases, it can cause brain herniation, which is life-threatening.

Treatment involves using osmotic diuretics such as Glycerol or Mannitol to suppress the swelling.

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The Importance of ACP (Advance Care Planning)

What I keenly felt through this experience is the importance of sharing the person's wishes with family and medical staff in case of an emergency.

By doing ACP, you can respond in accordance with the person's wishes even when forced to make sudden decisions.

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Summary

• Cerebral edema peaks 3 to 5 days after a cerebral infarction
• Right-sided paralysis, aphasia, and cognitive impairment are common with left brain damage
• Decisions on whether to perform life-prolonging treatment may be necessary regardless of whether it is the acute or chronic phase
• Discussing ACP as a family is a tremendous source of support

I wrote this in the hope that it might serve as a reference for those who are similarly facing the illness of a family member or choices regarding life-prolonging treatment.
Thank you for reading.

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