Practice Management and Administration: Ethics |

End of Life Care: A Dilemma FREE TO VIEW

Asad Omar, MD
Author and Funding Information

St John Providence Hospital, West Bloomfield, MI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A420. doi:10.1016/j.chest.2016.02.437
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SESSION TYPE: Original Investigation Slide

PRESENTED ON: Saturday, April 16, 2016 at 04:00 PM - 05:00 PM

PURPOSE: Medicine in 2015 is characterized by progress in technological, pharmaceutical, and interventional advancements that can prolong physiological function and human life. As a result, patients and their families have a different outlook and more options with respect to resources used. However, the expansion of options for medical intervention requires accompanying education about measures taken, the consequences, intended and unintended, and the moral implications behind them, so an informed decision can me made.

METHODS: The patient is a 93 year old debilitated female, with dementia, and a recent diagnosis of a necrotic colorectal cancer with metastases to the liver who was brought to the emergency room (ER) for increasing lethargy. The patient was recently deemed inappropriate for surgery, radiation or chemotherapy. In the ER, her blood pressure was 68/48 and hemoglobin was 6.1g/L with guaiac positive stool. Blood transfusion was ordered. A lengthy discussion was had with the patient’s sons, one physician and the other a lawyer, that the patient’s anemia was due to her underlying malignancy and represented an irreversible disease process. The sons remained adamant that all aggressive measures be taken to prolong and sustain life. The patient was transferred to the ICU.

RESULTS: She had a prolonged ICU stay requiring transfusions for ongoing bleeding and was evaluated by the ICU team, oncology and palliative care team. Futility of care and poor prognosis was discussed with the family everyday with them failing to grasp the depth or gravity of the patient’s illness. Hospice care was reiterated daily with no success. Over the prolonged stay, the bleeding stabilized and she was transferred to the medical floor. The discussions about goals of care continued with no success. Ethics committee was involved with their recommendation being hospice care. A month into her admission, she was intubated for worsening respiratory symptoms and was transferred back to the ICU where she remains at the writing of this report. Discussions with the family are also ongoing.

CONCLUSIONS: In a time of expanding options for medical intervention to sustain life, the duty of caregivers involves educating individuals not only about the interventions that can be made but also whether or not the intervention will actually improve the quality of life, which is the goal.

CLINICAL IMPLICATIONS: It is often an ongoing struggle between the family’s wishes for patient care and what true expectations we as physicians have in providing that care.

DISCLOSURE: The following authors have nothing to disclose: Asad Omar

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