A 74-year-old woman is brought to the emergency department by ambulance due to confusion. Her son reports that the patient has had chills and poor appetite for 3 days and became difficult to arouse today. She was ambulatory before this episode and does not use a walker or cane. The patient has no chronic medical conditions except for mild urinary incontinence. Temperature is 39 C (102.2 F), blood pressure is 74/33 mm Hg, pulse is 134/min, and respirations are 24/min. She is lethargic but opens her eyes with verbal stimuli. Examination reveals erythema, warmth, and swelling of the left anterior leg and foot without fluctuance and a strong dorsalis pedis pulse. The patient is given antibiotics and an intravenous fluid bolus but remains hypotensive. The physician thinks she will benefit from vasopressor therapy. The son, who is the patient's power of attorney, presents copies of her advance directive with a signed do-not-resuscitate (DNR) form. He asks the physician to respect the patient's wishes and hold off any resuscitation efforts. Which of the following is the best next step in management?

Question

A 74-year-old woman is brought to the emergency department by ambulance due to confusion.  Her son reports that the patient has had chills and poor appetite for 3 days and became difficult to arouse today.  She was ambulatory before this episode and does not use a walker or cane.  The patient has no chronic medical conditions except for mild urinary incontinence.  Temperature is 39 C (102.2 F), blood pressure is 74/33 mm Hg, pulse is 134/min, and respirations are 24/min.  She is lethargic but opens her eyes with verbal stimuli.  Examination reveals erythema, warmth, and swelling of the left anterior leg and foot without fluctuance and a strong dorsalis pedis pulse.  The patient is given antibiotics and an intravenous fluid bolus but remains hypotensive.  The physician thinks she will benefit from vasopressor therapy.  The son, who is the patient's power of attorney, presents copies of her advance directive with a signed do-not-resuscitate (DNR) form.  He asks the physician to respect the patient's wishes and hold off any resuscitation efforts.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

Explanation: This previously healthy and ambulatory patient has cellulitis with septic shock (ie, fever, tachycardia, hypotension). Vasopressor therapy (eg, norepinephrine) is indicated and should be instituted promptly. However, the patient has executed an advance directive including a do-not-resuscitate (DNR) order, and her son, who is her designated proxy decision maker, is interpreting it to exclude all resuscitative measures, including pressor support. DNR orders are most commonly intended to avoid ventilator dependency and prolongation of terminal illness. However, many patients who have signed DNR orders are willing to receive care for temporary or correctable conditions (eg, acute infection). In addition, although DNR orders typically apply to implementation of advanced cardiac life support (ACLS) algorithms for terminal arrhythmias, they generally are not intended as a refusal of supportive care (including vasopressors) (Choice E). As this patient's proxy decision maker, the son is responsible for making decisions consistent with what the patient would have wanted (ie, substituted judgment). Therefore, the next step in this patient's care is to explain to her son the acute and likely reversible nature of her condition and discuss what the patient intended when she signed the DNR form. (Choice B) Medical neglect is failure to provide appropriate care for a vulnerable dependent person, usually due to malice or indifference. This patient's son has refused consent for vasopressor therapy because he believes that is most consistent with the patient's documented wishes. His actions do not constitute neglect. (Choices C and D) A court proceeding or ethics committee referral would be appropriate if there were reason to believe the son is deliberately acting in conflict with the patient's wishes. However, he appears to be attempting to represent the patient in good faith, and these steps would not be appropriate. Educational objective: Patients typically execute advance directives to avoid prolonged care for terminal illness but usually do not intend to refuse care for temporary conditions. When an incapacitated patient's proxy decision maker refuses consent for treatment of correctable conditions, the physician should discuss the illness and treatment further to ensure that refusal is truly consistent with the patient's wishes.

A 74-Year-Old Woman Is Brought to the Emergency Department by Ambulance