Case 1: Sepsis
A 72-year-old, 90-kg (198-lb) woman who lives in an assisted living facility is evaluated after 10 days in the intensive care unit. She was admitted with severe urosepsis. She was in shock requiring pressors for several days and developed severe acute respiratory distress syndrome (ARDS) and acute renal failure requiring continuous venovenous hemoperfusion. She was persistently febrile until two days ago and is still being given piperacillin–tazobactam.
She remains intubated and is receiving ventilatory support with an oxygen saturation of 94% on Fio2 of 0.60, a positive end-expiratory pressure of 8 cm H2O and a plateau pressure of 30 cm H2O. The heart rate is 102 beats/min, blood pressure is 140/90 mm Hg off pressors and secretions are minimal.
The patient is still oliguric and receiving hemodialysis. She has been off sedation for three days, but remains lethargic and confused. She cannot cooperate with the neurologic examination, but nurses have noted that she seems very weak and coughs minimally when suction is applied. Measurement of arterial blood gases on the current ventilator settings show a Po2 of 68 mm Hg, a Pco2 of 36 mm Hg and a pH of 7.42.
The patient has a living will and has expressed the desire not to be kept on life support if there is no hope for recovery. There is no health care proxy, and family members cannot be located.
Which of the following is most likely to minimize ventilator duration, facilitate discharge from intensive care and be in accord with the patient's desires?
A. Schedule a tracheostomy and plan on transfer to a long-term acute care facility when
she is sufficiently stable
B. Begin corticosteroid therapy
C. Begin spontaneous weaning trials and plan extubation if she succeeds for at least 30 minutes
D. Extubate and begin noninvasive positive-pressure ventilation and proceed with pressure support wean
E. Proceed with “terminal” wean because of medical futility
Case 2: Severe pain
A 67-year-old man with newly diagnosed, widely metastatic prostate cancer is hospitalized for severe hip, chest wall and shoulder pain. Acetaminophen, ibuprofen and oxycodone–acetaminophen have not relieved his pain. Administration of intravenous morphine sulfate, 1 mg/h, is initiated, with a breakthrough dose of 2 mg/h, intravenously, as needed. His pain is well controlled after two days.
Which of the following is the most appropriate drug regimen for this patient after hospital discharge to the home?
A. Controlled-release morphine sulfate twice daily and immediate-release morphine sulfate
B. Oxycodone–acetaminophen as needed
C. Hydrocodone–acetaminophen as needed
D. Controlled-release morphine sulfate twice daily and oxycodone as needed
Case 3: Comorbidities
An 86-year-old woman with a history of type 2 diabetes mellitus and chronic kidney disease is brought to the emergency department for shortness of breath. She has a history of multi-infarct dementia, left parietal stroke and ischemic cardiomyopathy with an estimated ejection fraction of 20%. She has resided in a nursing home for two years after falling several times at home and sustaining a right hip fracture. Since that time, her functional status has declined and she has been confined to bed. A stage II sacral decubitus ulcer has developed. Her family notes that her appetite has declined over the past two months.
On physical examination, respiratory rate is 26 breaths/min and blood pressure is 180/70 mm Hg. BMI is 17 kg/m2. On cardiac examination, a grade 2/6 holosystolic murmur is present and is heard best at the apex. Jugular venous pressure is 10 cm H2O. There are crackles halfway up both lung fields posteriorly. There is 2+ edema.
Laboratory values are as follows: hemoglobin, 9.6 g/dL (96 g/L); leukocyte count, 5,600 cells/µL (5.6 × 109 cells/L); platelet count, 343,000 cells/µL (343 × 109 cells/L); blood urea nitrogen, 50 mg/dL (17.85 mmol/L); creatinine, 5.2 mg/dL (459.78 µmol/L); sodium, 130 mEq/L (130 mmol/L); potassium, 6.3 mEq/L (6.3 mmol/L); chloride, 107 mEq/L (107 mmol/L); bicarbonate, 16 mEq/L (16 mmol/L); calcium, 7.4 mg/dL (1.85 mmol/L); and phosphorus, 6.7 mg/dL (2.16 mmol/L). Urinalysis showed a pH of 5.3, specific gravity of 1.011, 3+ protein, trace hemoglobin and broad waxy casts. Renal ultrasound shows echogenic kidneys measuring 10 cm with thin cortices.
Which of the following is the most appropriate treatment for this patient?
B. Peritoneal dialysis
C. Low-protein diet
D. Palliative care
Case 4: Colorectal cancer
A 78-year-old woman is evaluated for worsening symptoms of metastatic colorectal cancer. At diagnosis five months ago, she had an 11-cm liver lesion, extensive large pulmonary nodules and a 5-cm sigmoid mass. She underwent resection of the primary tumor to relieve obstructive symptoms but developed multiple pulmonary emboli postoperatively. Her initial treatment regimen consisted of 5-fluorouracil and oxaliplatin but resulted in disease progression after eight weeks of therapy. Currently, she cannot care for herself because of cancer-related symptoms and is mostly bedbound.
Which of the following is the most appropriate next step in management?
A. Irinotecan chemotherapy
B. Palliative care
Answers and commentary
Correct answer: A. Schedule a tracheostomy and plan on transfer to a long-term acute care facility when she is sufficiently stable.
This patient had severe sepsis complicated by shock and multiorgan dysfunction. The normothermia is encouraging with regard to clearing of sepsis, but she remains in kidney failure, may have a critical illness neuropathy and has not yet recovered from ARDS. Use of corticosteroids for late-stage ARDS is supported by a small randomized trial but has not been convincingly shown to be beneficial. The patient does not meet “wean screen” criteria; she is receiving too much oxygen supplementation (Pao2 = 60 mm Hg or Sao2 > 88% on Fio2 = 60%). Thus, a spontaneous breathing trial would be premature.
The patient is a poor candidate for noninvasive positive-pressure ventilation because of her delirium and weak cough, and she has not demonstrated that she can sustain ventilation on settings that would be used noninvasively. Withdrawing support would be the most efficient way to minimize ventilator duration and intensive care unit stay, but it is not clear yet that her situation is futile and there is no health care proxy. Although her prospect for returning to her previous state of functioning is not good, withdrawing support at this time would conflict with the patient's stated wishes.
Defining medical futility is a matter of debate, because of different kinds of futility—inability to restore the previous quality of life, for example, as opposed to physiologic futility, the inability to sustain vital functions. Also, patients differ on the level of futility at which they would go along with withdrawing care. Many would stop if the likelihood of success is less than 10%, others only if less than one in a million. Since this patient cannot respond to these issues, the withdrawal of support cannot be supported yet. The timing of tracheostomy is also a matter of debate currently, but the most commonly held view is that patients should receive a tracheostomy as soon as they are deemed unlikely to wean within 21 days and should be prepared for transfer to a chronic facility as soon as medically appropriate.
- Intubated patients should receive a tracheostomy as soon as it is deemed unlikely that they will wean from mechanical ventilation within 21 days.
Correct answer: A. Controlled-release morphine sulfate twice daily and immediate-release morphine sulfate as needed.
Because of the severity of this patient's pain, morphine, or other strong opioids such as hydromorphone or fentanyl, is the therapy of choice. The patient's chronic and breakthrough pain was controlled in the hospital with intravenous morphine sulfate; therefore, morphine should continue to be used in the palliative care of this patient. The transition from parenteral doses to oral morphine doses is simple and eliminates the need to perform equianalgesic dosage conversions in order to use other narcotic agents.
Combined agents, such as oxycodone–acetaminophen, codeine–acetaminophen, and hydrocodone–acetaminophen, are used to treat moderate pain and therefore would not be appropriate for this patient's severe pain. In addition, drugs containing acetaminophen have a limiting ceiling effect of 4 g daily because of the risk for hepatotoxicity and, therefore, place a limit on the amount of narcotic that can be prescribed.
- Patients whose pain is controlled with morphine in the hospital can be easily converted to an oral morphine program for home management.
- Acetaminophen–narcotic combinations have a ceiling dose effect due to the toxicity of acetaminophen.
Correct answer: D. Palliative care.
Palliative care is the most appropriate treatment for this patient. A study on outcomes of octogenarians on dialysis demonstrated poor outcomes in patients with poor functional status (defined as a Karnofsky score <40, particularly for those patients with poor nutrition and BMIs <18 kg/m2). In these patients, the probability of survival at six months was only 50%. Therefore, palliative care and supportive measures are most appropriate in this patient.
Median survival on hemodialysis was 28.9 months in carefully selected octogenarians who were functionally independent, compared with 8.9 months in patients treated conservatively. A Karnofsky score greater than 40, early referral and improved nutritional status assessed by a BMI greater than 22 kg/m2 correlated with improved outcomes. Outcomes on peritoneal dialysis are generally equivalent to hemodialysis in all populations except for women with diabetes who are older than 65 years of age, in whom mortality is increased.
Poor nutritional status is not a contraindication to dialysis but has been demonstrated to be an independent predictor of poor survival on dialysis. Health-related quality of life is unlikely to be significantly affected by initiation of dialysis in patients with poor functional status but has been shown to improve in the first year of dialysis therapy in carefully selected octogenarians with functional independence. A low-protein diet may be useful in alleviating uremic symptoms but is relatively contraindicated in the setting of a decubitus ulcer.
- Octogenarians with poor functional status are unlikely to experience improvement or benefit from dialysis.
Correct answer: B. Palliative care.
Although there are now many active agents for treating colorectal cancer, including 5-fluorouracil, oxaliplatin, irinotecan, bevacizumab and cetuximab, none of these has been significantly effective as second-line treatment in bedbound patients. The risks of chemotherapy outweigh its benefits in patients with a poor performance status (a measure of the functional status of the patient) because these patients are much less likely to respond to chemotherapy and are more likely to experience therapy-induced toxicity.
Irinotecan therapy can be effective in treating colorectal cancer; however, its toxicity in this setting would likely outweigh any potential benefits. Although cryotherapy to the liver can potentially slow the growth of hepatic disease, it would not be effective in treating the extent of disease outside the liver in this patient or in improving her survival. If the patient had significant pain localized to a hepatic lesion, cryotherapy might be more reasonable. Repeated CT scans should only be done if the repeated results would change the patient's therapy, which is unlikely in this setting. Adjuvant radiation therapy can be successfully applied for palliation, especially for pain control of metastases to bone, brain and the presacral area. This patient does not currently require treatment for these conditions, and radiation therapy is therefore not indicated.
- The risks of chemotherapy in bedbound patients with colorectal cancer who have a poor performance status outweigh its benefits because of poor likelihood for response and therapy-induced toxicity.