Palliative Care Session Case
Phase 1:
Mrs. R is 75 year old African American who presents to a primary care office with her daughter. She reports having a fall last night while getting up to use the restroom. She reports feeling weak and more tired but denies any injuries from her fall. She reports she has been having some pain with urinating, but otherwise has been feeling well. She denies recent fever, chills, cough, nausea, diarrhea or episodes of dizziness.
Mrs. R reports her medical problems as diabetes, high blood pressure, gout, and chronic kidney disease. For these problems, she takes lisinopril, Lantus, metoprolol, aspirin, Lasix and allopurinol. She denies any recent changes to her medications.
Mrs. R reports that she lives alone in a senior-housing apartment. She eatsher evening meal in the dining room, but prefers to prepare her own breakfast and lunch. She doesn’t require any assistance with walking, dressing or with personal hygiene. She pays her own bills and drives herself to the grocery store and church. She has two daughters who live in town who are supportive of her.
Her daughter who accompanies her to the visit reports that she has been increasingly concerned. She notes that when she calls in the evenings she has intermittently been confused. Also, her cable service was disconnected last week because she failed to pay the bill. This was very upsetting to daughter because she previously paid her bills on time. When her daughter called the cable company they reported that she had not paid her bill for three months.
Examination:
Mrs. R is frail appearing. Her blood pressure is slightly elevated at 150/85 but her vital signs are otherwise normal. Her heart, lung, abdominal, and extremity exams are normal. Her neurologic exam is notable for mild peripheral neuropathy. Her MMSE (Mini Mental State Exam) score was 22/30, consistent with milddementia. A urine sample was obtained and it revealed a urinary tract infection.
Assessment:
Mrs. R has a new diagnosis of mild dementia. She also has a urinary tract infection.
Plan:
Mrs. R. was treated with an antibiotic for her urinary tract infection. Blood work was obtained for evaluation of a new diagnosis of dementia. These labs came back unremarkable except for her chronic renal disease which was stable. Her daughter stayed with her for two days until she felt better and appeared safe to stay by herself, and a brief course of home health care was ordered
Follow-up:
Mrs. R and her daughter returned in one week for a follow-up appointment. Her fatigue and weakness were improved and her fall risk seemed resolved. She appeared less confused. An MMSE was repeated and her score was 25/30.
Phase 2:
Mrs. R presents to her primary care provider for evaluation of a five day history of fevers and chills, increased confusion, fatigue and weakness. Her daughter comes with her to the appointment and is particularly concerned about the sudden decline in her mother’s health.
The evaluation performed in the office, including urine and blood tests, is consistent with a significant worsening of her kidney function and also a new diagnosis of urosepsis (significant infection in the blood that results from a urinary tract infection). Her primary care provider recommends Mrs. R is transferred to the hospital for further evaluation and treatment. Mrs. R is agreeable to going to the hospital and an ambulance is called. While waiting for transport to arrive, her primary care provider asks Mrs. R what is important to her. Mrs. R states “I want to be around for my family as long as possible, but I don’t want to be a lump on a log. I only want to do things that allow me to be active with my family.” She states she would like to remain a “Full Code”
Upon arriving at the hospital, Mrs. R is admitted to the intensive care unit. Because of the degree of her renal failure, the inpatient team recommends dialysis. After discussion with her daughter, Mrs. R agreed to dialysis but states “when it no longer works well or isn’t worth it, I want to stop.” Mrs. R is started on dialysis and remains in the ICU for three days before being transferred to the general floor. She remained in the hospital for a total of 10 days. At the time of discharge from the hospital she remained weak and more confused from her previous baseline. Recommendations were given for admission to a skilled nursing facility for physical therapy and occupational therapy as well as medication management. Due to the difficulties of caring for herself at home, she agrees to move to long term care facility at the completion of her skilled therapy.
Phase 3:
Mrs. R has continued with dialysis three days per week. Since her last hospitalization, she has had four additional hospitalizations, each of these for symptomatic hypotension after dialysis. She also has been diagnosed with congestive heart failure and it has become increasingly difficult to sustain her blood pressure during dialysis and while also keeping her from becoming fluid overloaded.
Mrs. R is no longer able to walk and she remains in the bed or wheelchair at all times. She is so exhausted after dialysis treatments that she is unable to participate in the facility activities that she previously enjoyed and she is becoming increasingly withdrawn and depressed. She is now dependent on the staff for all of her activities of daily living (ADLs) including bathing, dressing, and toileting.
The staff at her long-term care facility have become concerned with the changes in her health, mood and function and have requested a care conference to discuss goals of care. The daughter is contacted to notify her of the meeting and she “insists on continuing aggressive care,” but she is agreeable to attending the meeting.
This case was presented and moderated by Karli Urban, MD at the 25th Annual Caring for the Frail Elderly Conference on August 14, 2015 with facilitators Kevin Craig, MD, MSPH, Debbie Parker-Oliver, PhD, MSW, Lori Popejoy, PhD, APRN, GCNS-BC from the University of Missouri.
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