A 78-Year-Old Woman with a History of Metastatic Colon Cancer

A 78-year-old woman with a history of metastatic colon cancer, malignant ascites, and congestive heart failure collapses at her son's home.  She is escorted by ambulance to the hospital, where she is admitted to the intensive care unit.  In the days leading up to her admission she had complained of fever, productive cough, shortness of breath, and malaise.  Shortly after admission she develops respiratory distress that requires sedation, intubation, and ventilatory support.  Wide-spectrum intravenous antibiotics are begun to treat suspected pneumonia, and her diuretic dosage is increased.  Responsible for her care are a number of specialists, including an oncologist, pulmonologist, cardiologist, and critical care hospitalist.  Each physician meets separately with the patient's adult children every day to discuss his or her assessment and treatment recommendations.  The patient's condition moderately improves, but all attempts to wean her from the ventilator fail.  As each day passes, the family members become increasingly irritable when discussing their mother's health problems, and finally accuse you of suggesting unnecessary procedures and treatments.  Which of the following is most likely responsible for the family's negative attitude?

A) Inadequate pain management
B) Violation of patient's living will directive against intubation
C) Poor nursing care
D) Concern that health care insurance will not cover cost of hospital admission
E) Lack of communication between physicians involved in patient care