Abstract
Dear Editor:
It has been 40 years since physicians in our field began a professional association. It has been 20 years since our field was formally recognized as a subspecialty. How can a case like this happen in 2022?
Case
A 71-year-old Armenian woman with past medical history of hypertension, hyperlipidemia, and nicotine dependence presented to the hospital on July 21, 2022 with substernal chest pain. A code ST-Elevation Myocardial Infarction (STEMI) was called and cardiology was consulted. Her cardiac catheterization revealed severe 3-vessel disease and on hospital day 5, she underwent coronary artery bypass grafting × 4.
On day 13 and postoperative day 8, a CODE BLUE was called with initial rhythm of pulseless ventricular tachycardia. Advanced cardiovascular life support protocol was initiated, followed by intubation. She was extubated two days later.
On day 16, the patient was in cardiogenic shock with shock liver and acute kidney injury. Dobutamine was started. Echocardiogram showed an ejection fraction of 20%. She underwent a thoracocentesis for right pleural effusion. She was also found to have multiple right upper arm deep vein thromboses in the internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins. Heparin drip was started.
On day 20, she developed acute respiratory arrest requiring bilevel positive airway pressure with her left lung whited out. She also had metabolic acidosis with Blood Urea Nitrogen to Creatinine (BUN/Cr) ratio of 39/2.20 with estimated glomerular filtration rate (eGFR) of 20. A nontunneled central venous catheter was placed for possible dialysis. Acute kidney injury was treated with Lasix and Venofer (iron sucrose).
On day 21, a bronchoscopy was performed for mucus plugging.
Repeat echocardiogram showed severe global hypokinesia with ejection fraction of 30%–35%. Automatic implantable cardioverter-defibrillator placement was held due to multiple complications including persistent leukocytosis. Surgery was consulted for possible gallbladder pathology. Hepatobiliary iminodiacetic acid scan was negative; no intervention indicated.
On day 22, arterial ultrasound of upper extremities showed no right or left radial artery flow.
On day 23, repeat bronchoscopy was done and again found mucus plugging.
On day 24, dobutamine was weaned off. Bloody vomitus and hematochezia were reported. Heparin was discontinued.
On day 25, gastroenterology was consulted. No intervention recommended.
On day 26, she was transfused 1 unit of packed red blood cells.
On day 27, laboratories showed hemoglobin of 8.4, BUN/Cr ratio of 94/2.59 with eGFR of 17 and phosphorus (PO4) elevated at 5.0 mg/dL. Her need for oxygen increased and she was placed on high flow nasal cannula (HFNC) therapy due to worsening right pleural effusion. The senior resident in the intensive care unit (ICU) spoke with patient's daughter (her durable power of attorney) over the phone about goals of care. Code status changed to do-not-resuscitate order (DNR), but okay to intubate. Patient noted to be increasingly depressed, refusing to eat, and verbalizing her wishes for comfort care.
On day 28, palliative care was consulted for goals of care. On examination, patient was gaunt and ill-appearing. She was notably tachypneic on HFNC therapy. She had a depressed affect. When asked about her goals of care, she stated not wanting to continue with aggressive treatment any longer as it is like “torture” to her. To her family, she verbalized wishes for comfort care and to pass peacefully, stating that they would honor her wishes.
When we met her later that morning, she was seated in a geriatric chair with her son visiting. She was visibly tachypneic and apologized for not wanting to talk and proceeded to have a heated exchange in Armenian with her son. He felt that his mom was intentionally not eating and was acting up because he was there. After a brief pause, she suddenly cried out in a loud guttural tone, “STOP TORTURING ME”! As we stepped out of the room with her harrowing words still echoing in our ears, her son followed us into the hallway's alcove to speak privately. He shared that after the death of his dad less than six months ago from COVID, his mom's heart was severely broken. He also suspected that she had signs of heart problems all along, but never mentioned. When going over code status, he referenced his sister as the durable power of attorney and shared that his mom would not have wanted life-sustaining treatments, including a breathing tube. He planned to talk to his sister again about what would be best considering his mom's wishes.
We were made aware that the ICU primary team had requested a psychiatry consult to evaluate patient's decision-making capacity due to concerns about her depressed mental state, refusal to eat, and request to stop treatment.
On day 29, the medical resident spoke with daughter over the phone that morning. She would be traveling from California and planned to arrive to the hospital in the early evening to see her mom and meet with the medical team.
The primary doctor's evening note stated that family was present including her daughter to revisit goals of care and were agreeable to hospice. Code status was changed to Do Not Intubate (DNI) to accompany DNR order.
On day 30, she refused all her afternoon medications from a total of 20 daily medications. Later that afternoon, she was discharged to a hospice inpatient unit. Less than three days later, she was discharged home.
The senior medical director of palliative medicine in our hospital said little has changed over the past four decades; this case was no different from those he saw then. The only difference is consults come later now, after even more tests and procedures, extending the patient's time to suffer.
Discussion
This case evoked many strong and unsettled emotions within us when we first became involved in the patient's care on hospital day 28. We observed strong emotions in the patient's son. We infer the ICU team also had strong emotions. Yet throughout my medical training, we have not paid enough attention to the crucial role emotions play in making treatment decisions. How can we incorporate this often overlooked aspect of whole person care into our routine practices such that treatment decisions can be made more thoughtfully and collaboratively? Might that have changed the hospital course of our patient? We would argue, “Yes.”
The purpose of the ICU is to save lives. Yet, the industrialization of medicine with a focus on technology, care paths, and reduction in variation prevents busy clinicians to take the time needed to tease out the individual, the unique, the distinctive about each patient. We speculate the providers were treating STEM1 with multiple complications. They were not treating a whole person who disintegrated piece by piece. Out of the 20 medications that she was on, the only comfort-focused medicine available to her was oxycodone/acetaminophen as needed.
It seems to us that future research should look at the value of early palliative care referrals and the harm of the “late referral.” It seems we need to move the field from heroic efforts at the last minute to changing the norm of practice of all providers. Can we unite medicine behind the goal to relieve suffering and not contribute to it? We would say, “Yes” as our patients and families depend on us to do just that.