Case Study 3 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. 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. Questions 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? _____________________________________________________________________________________________ Determining prognosis
● Karnofsky Performance Scale 32 ● National Hospice Organization Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases 33
Deciding whether a patient has a life expectancy < 6 months is an unavoidably imprecise exercise, however the following scales or tools provide clinicians with some quasi-objective criteria to help guide decisions: Referral patterns Continuity of care and multigenerational relationships allow a family physician to guide a patient and family through the hospice referral process with a unique knowledge of the patient’s values, family issues, and communication style. (In general, most hospice referrals come from physicians, although social workers, nurses, and patients’ families can also make a hospice referral.) The majority of caregivers and families of patients who have received hospice care report that they would have welcomed more information about hospice from their primary care physician at the time the diagnosis was labeled terminal. Most hospices expect the referring physician to remain in charge of the patient’s care and to be available by phone or other means for consultation, although expectations for availability vary by hospice. In some cases, the local hospice medical director may be
● Palliative Performance Scale 34 ● Palliative Prognosis Score 35
willing to cover the attending physician on weekends and during vacations. 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.
Book Code: CA23CME
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