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The Patient's Story

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Mrs J is a 77-year-old woman who presented to the emergency department after several days of worsening shortness of breath. On evaluation, she was in hypercapnic respiratory failure thought to be due to an exacerbation of chronic obstructive pulmonary disease. Chronic radiographic changes made it difficult to exclude a concomitant pneumonia, so she was treated with ceftriaxone and doxycycline in addition to corticosteroids and nebulized bronchodilators. After Mrs J became agitated during a trial of noninvasive ventilation (biphasic positive airway pressure [BiPAP]), she was sedated, intubated, and transferred to the intensive care unit (ICU). Several days later, the medical team learned that the patient carried the diagnosis of pulmonary fibrosis and that previous pulmonary function test results documented a significant restrictive ventilatory deficit. Her lack of improvement and this historical information made it likely that the patient would be slow to wean from mechanical ventilation. The inpatient attending physician (hospitalist), in discussion with the patient's primary care physician and the ICU team, initiated discussions with the patient's 2 sons and daughter regarding appropriate goals of care and potential limitations to therapy. One of the sons, Mr G, held the durable power of attorney for health care.

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The family reported that the patient's overall quality of life had been declining. Mrs J's eyesight was failing, and she became dyspneic with minimal activity. She had told her children that she did not wish prolonged life support. The family decided to withdraw ventilatory support but first wanted to see if Mrs J could wake up to speak with them. Once sedation was lightened, the patient was aware of her family's presence. She was able to interact with them but not to speak or to participate in decisions regarding her care. She was subsequently extubated. Small doses of morphine were administered to treat dyspnea. She appeared comfortable before gradually becoming somnolent and then unarousable. She was transferred from the ICU to the hospital's inpatient palliative care unit, where she died peacefully the following day.

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The family was appreciative of the clinicians' efforts and grateful that their mother was able to awaken before her death even while they remained conflicted over their decision-making role.

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Perspectives

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A Perspectives editor interviewed Mrs J's son, Mr G, and the hospitalist, Dr M, 1 month after Mrs J's death and the intensivist, Dr K, 3 months later.

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MR G: She had been at home and had been living there for the last 22, 25 years with my sister, who's slightly mentally retarded. [Over] the last couple of years when my mother's eyesight was failing, she couldn't walk too well, she got very dizzy. During those last couple of years she relied on my sister to help her a lot. You know, to buy groceries. My mother also had Meals-on-Wheels to help her. So, she was living at home. Her primary ...

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