Mrs Smith
Mrs Smith is a 90-year-old woman with a history of heart failure, chronic renal insufficiency, hypertension, type 2 diabetes, atrial fibrillation, and arthritis. Her husband died in the hospital 10 years ago after he had a myocardial infarction. Mrs Smith has 3 adult children. After her husband's death, she sold the family home and moved into a small apartment. Two years ago, her oldest daughter, Karen, who was divorced and had no children, moved in with her. Mrs Smith was hospitalized several times over the last 2 years, and her functional status has progressively declined. Karen kept her own home, so has been maintaining both her mother's apartment and her home, working full-time, and helping her mother. Mrs Smith's middle son, Bob, lives in the area with his wife and 4 children. He comes to see his mother occasionally so that Karen can get a break. Mrs Smith's youngest child, Susan, lives more than 1000 miles away with her husband and 2 children. She visits her mother a couple of times a year.
Mrs Smith is frail, yet is cognitively intact and continues to participate in all decisions regarding her medical care. Her wish at her last hospitalization was to not have CPR if her heart were to stop. She also did not want to be intubated. She has an advance directive that says she would want comfort care should she suffer a devastating neurological injury or be in a terminal medical condition. Her advance directive lists all 3 children as her health care proxies and names Karen first. She has separately told her children she would not want to be ''kept alive on machines'' and recently told them and her primary care provider that she would not want to be on hemodialysis if her kidneys were to fail.
Mrs Smith awoke in the middle of the night struggling to catch her breath. She called out to Karen, who connected her home oxygen for her. Karen gradually increased the oxygen from 2 L/min to 6 L/min per nasal cannula. When her mother's breathing problems worsened, she called 911. The paramedics arrived and placed a 100% nonrebreather mask on Mrs Smith, started an intravenous line, and transported her to the hospital. The physician in the emergency department informed Karen that her mother was having an acute exacerbation of her heart failure and that intubation may be necessary. The physician thought that her mother would only need to be intubated for a few days. After discussing the pros and cons of intubation, Karen gave her consent. Mrs Smith was intubated, mechanical ventilation was started, and she was transferred to the ICU. Her fluid status was very tenuous, and her kidney function was poor. Her ICU team managed her care, using intravenous diuretics, a dobutamine infusion, and an insulin infusion.
Mrs Smith's creatinine level increased, and her team expressed concern that Mrs Smith might need renal dialysis. Mrs Smith could not participate in decision making during this hospitalization because of being intubated and occasionally sedated. Karen stayed at the hospital every day and provided informed consent for her mother's various procedures. Susan called the hospital daily and verbalized her concerns about the treatments that her mother was receiving as she felt that her mother would not want them. She had been expecting her mother's decline and was not surprised to hear how critically ill she now was. She was angry that her mother was intubated and told her mother's primary critical care nurse, Carl, that her mother would not want all of these treatments done. Bob was somewhere in the middle; he was able to see both of his sisters' view points, but was personally unclear what the next steps should be. Karen, Bob, and the team met on hospital day 7, and everyone agreed that ICU care and treatments would continue. During the meeting, the attending physician (intensivist) recommended that if Mrs Smith's heart should stop he did not feel that CPR should be started. He wanted to change her code status from ''attempt CPR'' to ''do not resuscitate.'' Karen would not agree to this, and Bob was unsure what to do. The physician decided not to change Mrs Smith's code status.
Mrs Smith's critical care nurse, Carl, is concerned because several times Mrs Smith tried to pull out her endotracheal tube. Soft wrist restraints were ordered, but he and the other nurses tried not to use them unless it was absolutely necessary. Instead, the nurses administered small amounts of sedation, as prescribed, to keep Mrs Smith from becoming restless. The attending physician did not want to use a lot of sedation as then Mrs Smith became too drowsy and was unable to participate in spontaneous breathing trials. Carl feels that Mrs Smith is suffering by being awake enough to know she is both intubated and restrained. He tried to advocate for better sedation from the attending physician, but the physician felt that additional sedation was not needed. Carl also shared his concerns with Mrs Smith's daughter, Karen, but she did not have a problem with the restraints. Karen feels that the restraints are needed so that her mother will not pull any of the tubes out and that she needs all of the tubes as they are going to help her mother to get better. Carl also verbalized his concerns that Mrs Smith's previously stated wishes are not being honored. The team listened to Carl, but feels that because her family is not in agreement, all treatments should be continued.
Ten days after Mrs Smith was admitted to the hospital, the attending physician and medical team rotated off service, and a new medical team was in charge of Mrs Smith's care. The ICU nurse, Carl, approached the new attending physician, Dr Shaw, and shared his concerns with her. Carl expressed his concern that Mrs Smith's condition was not improving and that Mrs Smith would not want the treatments continued. Carl feels Mrs Smith's daughter, Karen, has been making decisions based on what Karen wants, not based on the decisions her mother would make. Dr Shaw listened carefully to Carl's concerns and asked Carl if he would work with the social worker to set up a family meeting.
The social worker called Karen and Bob and asked them if they would come in for a family meeting. Karen said that she would like to delay the meeting for a couple of days as her sister, Susan, would be in town then. The meeting was set up for 3 days later, which was hospital day 14. All of Mrs Smith's children attended. Mrs Smith's critical care nurse, social worker, and the chaplain also attended the meeting, and Dr Shaw led the meeting. Dr Shaw asked everyone to introduce themselves. She discussed her concerns regarding Mrs Smith's medical history, current weakened cardiac status, dependency on mechanical ventilation, declining kidney function, and her professional prediction of a poor prognosis. Dr Shaw provided several care options and gave the rationale for the option that she felt was best, which was to transition care to a palliative care approach. She then asked the family members to share their perspectives. Susan and Bob said that they were supportive of a palliative approach. Karen, on the other hand, adamantly disagreed. Karen did acknowledge that mechanical ventilation and dialysis were things that her mother never wanted, but might be something her mother would be willing to try for a temporary period of time. Dr Shaw discussed her concerns that she did not believe that extubation would be possible. She did not think a decision to begin dialysis was needed today but that it would more than likely be needed within the next several days. Carl also verbalized that he was concerned as he knew that Mrs Smith had said in the past that she did not want CPR, intubation, or dialysis. He asked the family to seriously consider what decision Mrs Smith would make if she were in the room and could speak for herself. After some discussion, the family members were able to agree that CPR should not be started if their mother's heart stopped. Karen was reluctant, but eventually agreed. However, the siblings were not able to agree on anything else. Because they could not decide, the team agreed to continue all current care. The team also asked Mrs Smith's family if it would be OK to call the palliative care service to see if they could help to support the patient, family, and the team further. The family agreed that involving palliative care would be all right.
The next day, the advanced practice nurse (APN) from the palliative care service talked with the team and then met Mrs Smith's children. She encouraged each of them to talk about what their mother would want. Bob and Susan feel that their mother would not want dialysis and would not want to be on the ventilator this long. They feel that everything should be stopped. Karen said that she would not give up on her mother and feels that all treatments should be continued and that a dialysis catheter should be placed so that dialysis could be started. Karen said that she would feel too much guilt if she had to make a decision about stopping treatments. The palliative care nurse asked the social worker and the hospital chaplain to continue to support the family during the decision-making process. The palliative care nurse also worked with the team to ensure that Mrs Smith was not anxious and more comfortable in between the breathing trials by using short-acting opioids.
The family was provided with daily updates. Several days later, Karen told the palliative care nurse that she was now comfortable making a decision not to start dialysis, but that she could not make a decision to stop other treatments. Two days later, Mrs Smith developed sepsis, septic shock, and multisystem organ failure. Another family meeting was held, and the palliative care nurse was part of this meeting. The team supported the family as they were told that Mrs Smith was dying, despite all their efforts. Dr Shaw recommended stopping all aggressive interventions, including infusions (diuretics, insulin, dobutamine) and mechanical ventilation. Susan and Bob supported this recommendation. Karen was distraught and would not agree. She said she wanted to go home and think about it. Late that evening (hospital day 20), Mrs Smith took a turn for the worse; her blood pressure dropped suddenly and continued to drop despite attempts at administering fluid boluses and increasing Mrs Smith's vasopressor infusions. Her family was called in and made it to her bedside before she died. Morphine was infusing at 5 mg/h. Mrs Smith was unconscious and showed no signs of distress.