An 84-year-old man is admitted to the hospital with multilobar pneumonia and respiratory failure that required emergent intubation and mechanical ventilation in the emergency department. He is accompanied by his 2 daughters. Medical history is significant for poorly controlled type 2 diabetes mellitus, end-stage renal disease, moderate chronic obstructive pulmonary disease, and hypertension. The patient was recently diagnosed with hepatocellular carcinoma with bone and lung metastases.
The patient is started on broad-spectrum antibiotics and transferred to the intensive care unit for continued care. Shortly after arrival, his blood pressure is 76/54 mm Hg despite aggressive intravenous fluid hydration. The patient does not have a written advance directive, but his daughters say that he has made it clear that he "wants everything done" in the event of illness.
Which of the following is the most appropriate next step in management of this patient?

Question

An 84-year-old man is admitted to the hospital with multilobar pneumonia and respiratory failure that required emergent intubation and mechanical ventilation in the emergency department.  He is accompanied by his 2 daughters.  Medical history is significant for poorly controlled type 2 diabetes mellitus, end-stage renal disease, moderate chronic obstructive pulmonary disease, and hypertension.  The patient was recently diagnosed with hepatocellular carcinoma with bone and lung metastases.
The patient is started on broad-spectrum antibiotics and transferred to the intensive care unit for continued care.  Shortly after arrival, his blood pressure is 76/54 mm Hg despite aggressive intravenous fluid hydration.  The patient does not have a written advance directive, but his daughters say that he has made it clear that he "wants everything done" in the event of illness.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Critically ill patients in the intensive care unit (ICU) may be unable to communicate their wishes, placing the burden on family members who are often ill prepared and may have a limited understanding of interventions and the prognosis for recovery. In the absence of an advance directive, the physician should initiate aggressive life-sustaining treatment in accordance with the patient's wishes as communicated by his daughters. At the same time, the physician should educate the family about the patient's disease process, prognosis, and potential ICU interventions, including options for palliative comfort care as an alternative to aggressive management. Effective communication can often help align the goals of a patient and family with those of the ICU team, thereby promoting patient and family values, improving the quality of dying, and reducing family distress. ICU palliative care includes symptom management that prioritizes patient comfort and dignity and provides emotional and spiritual support for patients and families. (Choice A) The hospital ethics committee can be helpful in intractable situations in which there is irreconcilable disagreement among family members about the plan of care. In this case, the next step is to engage the family in a discussion of the patient's prognosis and palliative care options. (Choices B and C) It is essential for the clinician to respect the patient's reported wishes and to engage the family in discussion about treatment options. It would be inappropriate for the physician to make a unilateral decision regarding which, if any, life-sustaining measures should be withheld at this time. (Choice E) Although the family members' decision should be respected, it is important to engage them in further discussion of prognosis and treatment options, including palliative care. Educational objective: Physicians practicing in the intensive care unit must engage patients and families and provide an accurate picture of the disease process and prospects for recovery. In cases of severe illness and a high likelihood of death, patients and families should be made aware of palliative care treatment options that prioritize comfort and quality of life. __________ References: Meeting standards of high-quality intensive care unit palliative care: clinical performance and predictors. (http://www.ncbi.nlm.nih.gov/pubmed/22202706) Integration of palliative care in the context of rapid response: a report from the Improving Palliative Care in the ICU advisory board. (http://www.ncbi.nlm.nih.gov/pubmed/25644909) The changing role of palliative care in the ICU. (http://www.ncbi.nlm.nih.gov/pubmed/25167087)

An 84-Year-Old Man Is Admitted to the Hospital with Multilobar