Problem Based Learning Case Study in End-of-Life Care

1. Problem Based Learning Case Study in End-of-Life Care

2. Mrs. Gill Mrs. G is a 84 year old woman with a history of insulin-dependent diabetes mellitus and coronary artery disease who presents to the ER with a 2 day history of severe pain in her right calf and foot. Prior to this she would get a cramping in her right calf when she walked 1-2 blocks, relieved with rest. She is writhing in pain when she comes in.

3. Pain History? O = other sxs: No swelling, no redness, but rt. foot pale and cold P = palliative/provocative factors: worse when she puts any pressure but even keeps her up at night Q = quality: throbbing ache R = region: from rt knee down all the way around leg S = severity: 10 on a 0 to 10 scale T = timing: constant for last 2 days U = untoward effects on QOL: cannot do anything anymore, very overwhelming at this point

4. Further History? PMH: • Diabetic for 5 yrs, NPH insulin shot 20u just at bedtime; blood sugars staying in the 100s; regular check-ups every 3 mos fine including eye exam • Small MI 5 yrs ago, needing 3 vessel CABG, recovered well and did cardiac rehab for 6mos after. ROS: • No fevers, appetite good, no weight loss • No chest pain, no shortness of breath • No skin breakdowns, no areas of inflammation • No numbness, no weakness, no back pain

5. Physical Exam • Severe distress, cannot keep still • VS: afeb, HR – 124, BP 186/96, RR – 22 • Lungs clear to ausculation • CV: Nml S1S2, 1/6 SEM LUSB, no JVD, carotids nml, pulses 2+ except to pulses palpable in Rt foot or Rt popliteal, Rt femoral pulse nml • Abd: soft, non-tender, no HSM, no pulsatile masses • Extr: Rt foot pale and cool to touch, no edema, joints all nml • Neuro: non-focal

6. Acute pain control? • With this severe of pain, IV/SQ opioids treatment of choice and no contra-indication. • Remember, start low and advance as needed • Options – Morphine 1-2mg IVP q10min prn, Dilaudid 0.2-0.5mg IVP q10min prn

7. What side effects would you acutely worry about? • Sedation – common, as long as arousable, not a worry • Nausea/vomiting – can give reglan/compazine if occur, or change the med

8. What are you thoughts of what is causing this pain? Differential: * Acute ischemic limb pain Others: • Reflex sympathetic dystrophy – a neuropathic burning pain seen after trauma, with autonomic dysfunction – pale, no sweating, maybe with swelling, usually with dystrophic changes – thin skin, atrophic weak muscles, tight joints • Musculoskeletal pain (like torn muscle, arthritis, ruptured Baker’s cyst) usually with more focal swelling, redness, warmth • Acute neuropathy usually dermatomal with back pain for sciatica, more neurologic changes and usually more diffuse stocking-glove pattern for diabetic

9. What tests would you get and why? • Basic metabolic panel mainly for renal function: BUN 42, creatinine 4.2 • Muscle enzyme tests for degeneration: CPK – 4400, Myoglobin – too high • Arterial blood flow tests – show occlusion in the femoral artery on rt, no popliteal, dorsalis pedis, or post tib wave forms • Angiogram – acute occlusion of rt common femoral artery

10. What treatment options? • Anti-coagulation – IV heparin started • Embolectomy – attempted emergently but failed • Surgical by-pass/amputation

11. Mrs. Gill in charge? The vascular surgeons feel surgery is the only option. In fact her renal function is rapidly deteriorating, and unless she gets an emergent amputation, she will likely die in 1-2 weeks. In fact, they bluntly told Mrs. Gill this and she adamantly refused, greatly upsetting the surgeons who immediately want a psych consult.

12. How do you decide Mrs. Gill is capable of making this decision? • Does she understand what is the nature of her problem and the decision at hand? • Does she know the options available and the consequences of each option, along with the risks? • Is she able to rationally give you reasons for her decision? • Does this decision-making ability wax and wane, change over time? • Do close family members concur with her abilities?

13. Is that your final answer? On talking with Mrs. Gill, she does realize she will die without an amputation, but cannot give reasons why she does not want it, saying that God works miracles all the time and there must be other ways because she does not trust the surgeons. Her mental status does fluctuate during the day. Her only close relative is a daughter who was present at this discussion. The daughter states that her mom has become increasingly confused over the last few months and that she feels her mom is not capable of this decision. She never filled out advanced directives. You all agree Mrs. Gill is not able to make this decision.

14. Who’s decision is it now? • State of Illinois has a Health Care Surrogate Act which goes through a chain of command of who can make the decisions – from power of attorney, to spouse, to children, to parents, to siblings… to friend. If no one is available, it needs to go through the courts for a court-appointed guardian. • REMEMBER – this surrogate decision-maker needs to base this decision on what they believe the patient would actually want if they themselves could choose.

15. Daughter’s decision Based on what the daughter knows about her mom, the fact that her mom never wanted to undergo any other surgeries after her by-pass and that her mom just wants to be able to stay at home comfortably, the daughter agrees to not have her mom go through the surgery.

16. Your personal beliefs lead you to feel this is a wrong decision • How can you effectively and ethically respond to this discrepancy in beliefs? • Realize whose decision it is • Realize your limitations • Communicate in a way not to coerce • Responding in this way will help you personally in tough decisions for the future so you will not have guilt, anger • If to hard, recommend other physicians

17. So there’s nothing more we can do for Mrs. Gill? • NEVER nothing more we can do – focus just shifts on palliation • Define her goals; discuss advanced directives if you can. • Discuss options to keep her comfortable, especially hospice care at home

18. Mrs. Gill’s course: For the first 2 days in the hospital, Mrs. Gill needed to take 2mg of IVP morphine every 1-2 hrs, about 20 doses in a day, to stay comfortable, getting her pain down to a 2 on the pain scale, where she wanted it. At first she was drowsy, but gradually woke up, wanting to go home. Home hospice was agreed upon, though she wanted the IVs stopped. She had no nausea or other side effects.

19. What pain regimen would you put her on? • 2mg x 20 doses = 40mg IV/d x 3 = 120mg of morphine PO equivalent per day. • Long acting options – • MS contin 60mg q12hrs po • Oxy contin 40mg q12hrs po • Fentanyl patch 50 ug/hr q72hrs • Break-through options – • MSIR 15-20mg q2-4 hrs. prn • OxyIR 10-15mg q2-4 hrs. prn

20. What long-term side effects would you want to address? • Constipation – add stimulant to prevent it – Senokot, Pericolace • Nausea may occur with switch to PO regimen • Sedation usually continues to get better, though with her renal failure may worsen as a natural course

21. Mrs. Gill’s course She got home the next day, pain very well controlled, with home hospice. She had moments of lucidity where she was able to resolve issues with daughter and say good-byes. She needed a hospital bed and commode, along with nursing aide visits daily to help the daughter care for her at home. She gradually slipped off into a coma and died peacefully within 1 week of discharge. The daughter, though sad, was very grateful in how her mother passed away. The hospice bereavement team is following the daughter.