CEP SESSION Ethics 4
BASICS OF ADVANCED CARE PLANNING By Dr Norhisham
Friday, 20 March 2015
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A 34 year old Chinese man with a history of substance abuse and alcoholic dependence is admitted for breathlessness. He has had past admissions for similar episodes of breathlessness due to fluid overload attributable to alcoholic cardiomyopathy. He claims to have stopped drinking and no longer abuses substances. He is single and lives with his parents. He used to work in the past but has since stopped for more than a year due to his frequent admissions. Investigations have revealed that he has a dilated cardiomyopathy. His last echocardiogram shows an ejection fraction of less than 30%. His liver function tests have been abnormal for several months. He claims compliance to fluid restrictions and to his medications. He is keen to improve his health status and is willing to consider other treatment options including surgical options. He is aware that there are interventions available. The cardiologists involved in his care have optimized him medically. The cardiothoracic surgeons have also reviewed him and do not recommend heart transplant surgery in view of his co-morbidities. Since admission, he has been noted to have tachycardia and low blood pressure.
Questions: How should management plans be explored with him? What are the important issues that must be discussed with him?
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An 80 year old former school teacher presents at the Accident and Emergency Department with breathlessness and fever. He is hypotensive and has low oxygen saturations. Initial clinical and radiological findings are consistent with a right middle and lower lobe pneumonia. After oxygen supplementation and fluid resuscitation, his clinical parameters improved and he was stable to be transferred to the general ward. Antibiotics have been started and culture results are pending. It is noted that the high-sensitive troponin is raised and there is a mildly elevated creatinine kinase. The next night, the nurses report that the patient is complaining of right sided chest pain and is more breathless. He still has an ongoing fever. He is conscious and appears more lethargic. The nurses report that he is anxious and worried about his condition. He has told the nurses that he is already old and does not want to suffer in his old age.
Questions: With whom should discussions on treatment plans be initiated? What should be discussed in those plans? How would you respond to the reported patient’s statements?
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A 78 year old woman with advanced dementia is admitted from the nursing home with poor oral feeding. The nursing home memo reports that she requires assistance in her activities of daily living and is mostly chair-bound. She appears thin and her weight is 35 kg. There are grade 1 pressure wounds on her sacral area and the bony areas of her lower limbs. The blood results on admission show electrolyte abnormalities and an elevated urea consistent with biochemical features of dehydration. She is rehydrated with an intravenous hydration of 1.5 litres of fluids. Her hydration improves clinically and biochemically. On the second night after admission, she desaturates to 80%. Supplemental oxygen is started and the oxygen saturation improves to 94%. The electrocardiogram does not show any acute changes. An urgent chest X-ray shows increased infiltrates in both lung bases. A septic work-up was done and the patient was started on intravenous antibiotics. The nurses are instructed to inform the nursing home of the “dangerously ill� status of the patient. The patient becomes restless and delirious later that night. Physical limb restraints are required as she became more aggressive. The doctor on call decides to give the patient an antipsychotic to calm the patient.
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The next morning the patient is sleeping peacefully during the rounds. She continues to remain quiet and lethargic the rest of the day such that she hardly eats. The sleep-wake cycle reversal continues and her intake remains dismal. Recognising that without adequate nutrition, the patient will not improve, the team deliberates on the insertion of a feeding tube. The final decision was to insert a feeding tube. On the fourth day of admission, the patient’s niece shows up in the ward. She is upset that a feeding tube was inserted without consulting her. She has with her, the patient’s lasting power of attorney that names her as a donee. She asks if the patient is terminally ill and informs that the patient has an Advance Medical Directive.
Questions: What are the concerns of the niece? How would you address her concerns? What care/treatment plan will you formulate with her for the patient?
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A 74 year old man has recently been transferred from the ICU to the general ward. He had presented with a fever, an altered mental state and a fall. He was found to have a subdural hematoma with midline shift that required burr hole drainage. Post-operatively he was kept mechanically ventilated. In the ICU, he had other issues like pneumonia with hypotension requiring inotropic support. He was eventually weaned off inotropes and ventilatory support. He appeared stable in the first few days after transfer. Rehabilitation is in progress with the physiotherapist and occupational therapist engaging him daily. He desaturated in the afternoon one day and the chest x-ray showed a multilobar pneumonia. He had difficulty maintaining his oxygen saturations despite supplemental oxygen. The respiratory physician reviewed him and recommended non-invasive ventilation. The same night he developed atrial fibrillation with a rapid ventricular rate. He desaturated again and became more breathless. Increased non-invasive ventilation support was needed. A repeat X-ray showed worsening pneumonia with increased pulmonary congestion. The next morning he appears more ill and is drowsy. The arterial blood gas revealed worsening acidosis and carbon dioxide retention. His oxygen saturation fluctuated between 86-92%. His blood pressure is also on a downward trend. The patient’s family are distressed and worried.
Questions: How will you update the family? What are the important points that must be discussed?
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