Case Studies: Could This Happen At Our Hospital?
Rosemary Flanigan, PhD
The Patient Is Dying, and the Physicians and Family Did What?
A 79-year old white female with advanced ovarian cancer, severe back and abdominal pain, COPD, depression and anxiety disorder, and asthma was admitted to the hospital from Happy Valley Nursing Home through the emergency room. She had had difficulty breathing and the ambulance was called. All the records of her case history accompanied her.
The ER staff intubated her and after a short time, she was weaned from the respirator and sent to the medical floor. It was agreed that she was unable to withstand surgery, but she still was suffering from back and abdominal pain. She could breathe on her own, so she was sent back to the nursing home after being put on xanax and neurontin.
Within 24 hours she was returned to the hospital in abdominal and back pain, nausea, and emesis. She received some relief from darvocet and dilaudid (q8h). The oncologist was called; the patient was made comfortable within a few hours.
From her first admission, her family requested comfort care only; a DNR was signed. The patient’s status continues to decline, the prognosis is grave, the patient is dying, her respirations shallow, and the attending physician discontinues morphine.
The patient becomes unresponsive. At this point the family panics and rescinds the DNR. The patient is intubated and sent to ICU. There is no indication on the chart that anyone recognizes the patient is in the dying process.
What physicians saw the patient? Cardiologist, pulmonologist, dermatologist, oncologist, onc/surgeon, thoracic surgeon, 3 psychiatrists, neurologist, neurosurgeon, anesthesiologist, infectious disease specialist, GI specialist, hospitalist.
What was she given? Massive diarrhea, rashes and excoriations, decubiti, generalized edema, c-diff. . . pseudomembranous colitis, ventilator dependency, nubain for pain.
On day 51 of her hospital stay, her family signed a DNR again. She died the next day in ICU.
Questions for discussion
1. What is going on here, and how ought this case have been handled?
2. Was there a plan of care for this patient?
3. Why do you think the family rescinded the DNR order?
4. Would trying to convince the family to agree to a DNR be “playing God”?
5. Did the physicians treating this patient coordinate the patient’s care? 6. If you answered no to question
6, why did they act so unilaterally, and how would the care have been different if they had met as a team?
7. When should this case be brought to the ethics committee? How can such cases be brought to our committee? How would an ethics consult affect the case?
8. Where was palliative care in this case?