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care at the end of life phil byth and simon pont

Mr AC21 year old male TAFE studentNon-smoker and non-drinkerLived with mother and brother. Visited father.Presentation5 days abdominal pain, vomiting, hiccups and burping. Abdominal distension and weight loss over last month. Examination Unwell, pale, distended abdomen, hepatomegaly.Past HistoryAge 10 repair of VSD, partial anomalous venous drainage with RV outflow tract obstruction satisfactory progressNo family history of bowel cancer.

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care at the end of life phil byth and simon pont

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    1. CARE AT THE END OF LIFEPhil Byth and Simon Pont ICU PRESENTATION

    2. Mr AC 21 year old male TAFE student Non-smoker and non-drinker Lived with mother and brother. Visited father. Presentation 5 days abdominal pain, vomiting, hiccups and burping. Abdominal distension and weight loss over last month. Examination Unwell, pale, distended abdomen, hepatomegaly. Past History Age 10 repair of VSD, partial anomalous venous drainage with RV outflow tract obstruction satisfactory progress No family history of bowel cancer

    3. Findings: CT Scan Massive hepatomegaly, multiple metastases in the liver and lung, ascites. Lymphadenopathy. Annular constricting colonic lesion. OT No evidence of polyposis. Transverse colon primary. Omental and liver metastases. Colonic anastomosis

    4. Day 6 – Post op 7/2 Tachycardia, oliguria , fever and tachypnoea. Theatre for probable anastomotic leak. Findings Pinhole in anastomosis No peritoneal soiling Ascites ++ Hypotensive intra-op Retrospective: liver failure

    5. ICU Admission

    6. Day 1 IPPV 45 % FiO2 Oliguria, fluid resuscitation lactate 7 Abdo distended Blood to molec genetics for DNA extraction and storage, (request of father).

    8. Process of decision making10 steps Interprofessional team consensus Communication Documentation Negotiation Second opinion Trial of therapy Mediation Arbitration/adjudication Notice of intention to Withholding/withdrawal of life-sustaining treatment

    9. Day 2 Family meetings with: Mother Brother Maternal grand parents Father/ Step Mother Registered Nurses ICU Social Worker Surgeon Catholic Chaplain PLB

    10. Clinical Assessment Documented metastatic moderately differentiated adenocarcinoma with extensive peritoneal and hepatic involvement Progressive biochemical and clinical hepatic and renal failure secondary to colonic tumour load Pulmonary function is deteriorating

    11. Meeting 1 Advice received from colleague regarding mother and her parents views regarding End Of Life Decision Making Medical recommendation put after explanation of current situation Extubation declined by mother and her parents on basis that “we want xxxx to live as long as possible”: said to represent patient’s choice. Plan to reconvene in the afternoon

    14. Day 3 Meeting 3 Attendees: As previously Medical recommendation reaffirmed after further surgical and oncological explanation Likely to die in next few days, 2? to worsening renal, hepatic and pulmonary function Prognosis from liver mets alone < 3 months Mother wishes treatment to continue regardless

    15. Plan Continue supportive care until day 4 1300 meeting “Second opinion” (ICU Acting Director)- Progressive hepatic and renal failure secondary to abdominal tumour load. Pulmonary function is deteriorating. No prospect of reversing multi system failure. Advise Area Executive that medical recommendation re withdrawal of treatment refused by mother and her parents . Accepted by xxxx father and his wife. Area subsequently agreed that if an agreed care plan not achieved at next meeting we recommend treatment be withdrawn in 48hrs. Mother advised she may seek order from Supreme Court to prevent such action.

    17. Day 4 Further deterioration in lung function (increasing congestion and FiO2) Cr 230, UO 0.5ml/kg/hr Triple antibiotics, WCC 60,000

    19. Plan agreed- negotiated by Solicitor Priority is xxxx’s comfort at all times; significant distress is not acceptable whether intubated or extubated. Aim for therapeutic extubation at 1100 on day 6 Diurese to reduce pulmonary congestion Reduce sedation, continue analgesia If not suitable for therapeutic extubation, terminal extubation to occur at same time. Mother agreed that re-intubation will not be requested Ordinary measures to maintain xxxx’s condition until day 6 will be provided at discretion of ICU SMP and AMO. No legal documentation of agreement required by the family

    20. Day 5 Request from Grandmother regarding dialysis and improving pulmonary function. Good response to frusemide infusion Day 6 Hb 6.6 Sedation off, lungs “dried out” Extubated in presence of family after meeting with Surgeon and ICU Fellow Moans only, Fentanyl increased for comfort

    21. Day 7 Patient died peacefully RIP Follow up

    22. Lessons Learned – a self audit Reference: Guidelines for end of life care and decision making. Released by: NSW Department Health 2005

    23. Lessons Learned“I will leave you with the Social Worker …..”

    24. 1. Consensus building approach

    25. 2. Developing a management plan

    26. 3. Cyclic Process

    27. 4. Resolving disagreements

    28. 5. Focus on the patient

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