Instructions: Spend 5 minutes reviewing the case below and considering the questions that follow. Note: This is an excerpt from an article by Yoojin Na, an emergency room physician at a hospital in metropolitan New York, which appeared in the New York Times. Case Study 3 A woman held her grandfather’s hand as he lay in intensive care. The patient in question was in his 90s with progressive dementia and multiple chronic conditions. Since December, he hadn’t been able to make it more than a few weeks without a fall. The palliative-care assessment from his last admission gave him an estimated life expectancy of “weeks to months.” Everything I saw on examining him told me it was now days. Soon he wouldn’t be able to breathe on his own. I described to his granddaughter the discomfort of having a ventilator pump air into one’s lungs. I explained that such measures would only prolong his suffering. Still, she insisted that her grandfather be kept “full code” and have “everything done.” Three days later, the patient went into respiratory distress. Since he was full code, his sudden decline activated a rapid response, which meant all nearby personnel — doctors, nurses, respiratory therapists and techs — rushed to the room to resuscitate him. The inpatient doctor called the family again. This time, they agreed to make his code status D.N.R., for do not resuscitate. But the patient had turned out to have Covid-19, and the family’s DNR decision came only after many staff members were exposed reviving him. He died the next morning. The whole ordeal made me wonder why people insist on futile care even when it comes at a risk to others.
1. Why do you think the family initially insisted on having doctors use “full code” procedures for their grandfather?
2. How would you have handled the conversations with family members when communication was limited to telephones?
3. If the patient had a POLST, stating they were DNR/DNI, would that have been able to be used to refuse the insistence of full code status by the family, assuming the patient had made the decisions for the POLST? What if it was an advance directive?
In general, the attending physician is expected to be the primary physician of record, be available by telephone or have coverage arranged, write admission orders, and handle the routine decisions for patient care. Some hospices provide attending physicians with standing orders that have broad parameters for the control of common symptoms, such as pain and dyspnea. The attending physician and the hospice medical director are expected to provide certification to Medicare that the patient continues to meet hospice eligibility criteria on a regular basis. The attending physician is also expected to provide medication refills when needed. Essential drugs for quality care in dying patients Effective management of symptoms at the end of life is challenging but often can be achieved with fewer than for six key medications. Clinicians can help support patients and family by using these medications judiciously with the assurance that it will provide a death that is as safe, dignified, and comfortable as medically possible. Table 5 summarizes the most common EOL medication classes. Later sections of this activity will explore some of these options in greater detail. Pain Management at the End of Life The following is an overview of the treatment of pain as it applies to the end of life. More detailed information regarding pain management in general will be covered in later sections.
Table 5. Common medications in a “hospice comfort kit” 36
Medication class
Example medications
Common indications
Antipsychotics
Haloperidol or risperidone Acetaminophen (oral or suppository) Lorazepam, alprazolam, diazepam Morphine, oxycodone, hydrocodone
Delirium, agitation
Antipyretics
Fever
Benzodiazepines
Anxiety, nausea
Opioids
Dyspnea, Nociceptive pain (not generally effective for neuropathic pain) Excessive oropharyngeal secretions
Secretion medications Hyoscyamine, atropine
Laxatives
Docusate, lactulose, senna with docusate
Constipation
Although pain relief is often considered— and may sometimes be—an end unto itself, it is particularly important for clinicians to recognize that, at the end of life, pain management and control of symptoms may be more appropriately viewed as means of achieving the more primary goal of improving or maintaining a patient’s overall quality of life. The meaning of “quality of life” varies, not just from patient to patient, but even between the phases of an illness experienced by a single patient. A focus on quality of life is important because sometimes a patient may have priorities that compete with, or supersede, the relief of pain. For example, the end of life can be an extremely important and meaningful time. 37 For some patients, mental alertness sufficient to allow maximal interactions with loved ones may be more important than physical comfort.
Optimal pain management, in such cases, may mean lower doses of an analgesic and the experience, by the patient, of higher levels of pain. The point is that, at the end of life, decisions about pain relief must be more than usually balanced with a mindful consideration of the patient’s own values and desires. The types of pain syndromes arising at the end of life include most of the acute and chronic pain syndromes clinicians confront in other patients, and many of the same diagnostic and therapeutic strategies and skills are the same or similar. But pain management at the end of life does raise some unique clinical and ethical issues and, hence, these issues are appropriate for a focused consideration. In addition, the prospect of severe, unrelieved pain at the end of life ranks very high among patient fears.
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