What Would You Do (Part 2)?

Hi everyone:

We had a robust response to last week’s quiz, with input from many incoming interns. The clear favorite was...#3. As you recall, we posed the case of Mr. Brown, a man with severe COPD, admitted with an exacerbation. He told the team he didn’t want to be intubated for respiratory failure or resuscitated if his heart stopped. He also didn’t want BiPAP because it made him claustrophobic in the past. To honor his wishes, the team entered a DNR/DNI order and communicated that BiPAP would not be used. They signed out the plan to the night team.

That evening, Mr. Brown developed severe respiratory distress, unresponsive to treatment. The covering team was called to the bedside and considered these options:

1. Ask Mr. Brown if he wanted to reconsider his code status
2. Call Mr. Brown’s wife to see if she wanted to reconsider her husband’s code status
3. Start morphine and update Mr. Brown’s wife
4. Get an ABG and send Mr. Brown to the MICU
5. Persuade Mr. Brown to try BiPAP
6. Do something else.

#3 is correct (#6 is too, as discussed below). Mr. Brown is dying and uncomfortable. He clearly stated his wishes when he was admitted and the time has come to relieve his symptoms and let his family know the end is coming. Morphine and other narcotics treat dyspnea effectively and Mr. Brown should be comfortable soon.

Option #1 would be inappropriate for two reasons. First, given the acuity of the clinical situation and Mr. Brown’s clinical deterioration, it would be hard to envision having a thoughtful discussion that would reliably reflect his wishes. Second, and more importantly, Mr. Brown has already made his wishes clear. Although it may be reasonable to confirm a patient’s wishes if reasonable doubt is raised, there is no reason to doubt Mr. Brown’s preferences, which were clearly communicated and thought out. In fact, asking him to reconsider his wishes would likely exacerbate his distress just when he needs to be comforted.

Option #2 would be inappropriate for similar reasons. Mr. Brown’s wife is not in a position to make an emergency decision for her husband, nor would it be appropriate to ask her to override his wishes. She also needs to hear comforting words from the team as she faces losing her husband.

Option #4 would only worsen Mr. Brown’s suffering. ABGs are painful and wouldn’t provide any information to help care for him. Transferring him to the MICU wouldn’t help him and could increase his distress.

Option #5 is inappropriate given Mr. Brown’s past experience with BiPAP. Although BiPAP can help many patients with COPD flares, it should not be pushed on a patient who’s been traumatized by it in the past, particularly when he is actively dying. To be sure, as one of our incoming interns notes, though BiPAP can help in some palliative care settings, it would not help a dying patient who is struggling to clear secretions (Yiduo shared some helpful references, which I’ve listed below). Most importantly, Mr. Brown has clearly stated his wishes, which we must respect.

Many respondents chose option #6 and shared many wonderful ideas- no one said there was only one right answer! Here are some of their suggestions:

• Be sure to consider reversible causes of respiratory distress, such as PE. However, PE would be unlikely given the patient’s sputum production. Subjecting him to a CT pulmonary angiogram would be inappropriate.
• Consider adding lorazepam for anxiolysis
• Sit with the patient to comfort him.
• Discuss a palliative care plan with the patient in advance so an action plan could be implemented when deterioration occurs
• Remember to inform patient’s wife about her husband’s preferences, assuming she isn’t already aware, so she isn’t surprised later
• Ask the patient whom he’d like to have called when he deteriorates
• Start with a test dose of morphine and titrate it to his comfort, remembering that the purpose is to comfort the patient, not hasten his death
• Be sure to explain the situation to the patient as we focus on managing his symptoms
• Consider hospice transfer (which we can do at YNHH without moving the patient)
• Use a nasal cannula for comfort and avoid face masks, which are less comfortable and can make it hard for patients to communicate, drink, and expectorate
• If the patient wishes, call the chaplain for spiritual support
• Bring a fan into the room

It may come as no surprise that I posed this quiz because the right choices aren’t always made in these situations, leading to avoidable physical and emotional distress. I’m so impressed with your thoughtfulness and common sense. We can’t always cure, but we can always comfort, particularly when we apply our skills thoughtfully and compassionately.

Enjoy your Sunday everyone (I’m on my way to my niece’s bridal shower in Sturbridge, so time to hit the road)!

Mark

PS Suggested readings:

1. Quill and Quill, Palliative use of noninvasive ventilation: navigating murky waters. J Palliat Med. 2014;17(6):657-61
2. Chandra et al., Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998-2008. Am J Respir Crit Care Med. 2012;185(2):152-9.
3. Curtis et al., Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals of therapy. Crit Care Med. 2007;35(3):932-9.
4. Carlucci et al., Palliative care in COPD patients: is it only an end-of-life issue? Euro Resp Rev 2012; 21: 347-54