case of advance directives
Introduction
A 69 yo man seen in clinic for routine followup. He is independent of all ADLs and iADLs. He continues to drive and reports no automobile accidents. Social history:
- never married PMHx:
- COPD diagnosed 10 years previously
- 35 pack year history of smoking, quit 10 years ago
- hypertension
- coronary artery disease
- diastolic heart failure
Dosage
Diagnostic procedures
- spirometry 1 year ago: FEV1 of 48%
- MMSE = 29/30, time & change test intact
Management
- yearly influenza vaccine
- PCV13 & Pneumovax received 2 years ago
- shingles vaccine received last year
- Tdap received 2 years ago
- advance directives
- Physician Orders for Life-Sustaining Treatment (POLST)
- living will or
- durable power of attorney for health care is appropriate.
* The patient completes a living will requesting a 'do not resuscitate' code status, (no defibrillation) that life-sustaining procedures be withheld or withdrawn if he cannot be weaned from a ventilator, if he is permanently unconscious or if life-expectancy is < 6 months. He specifically requests no tracheostomy for long-term ventilatory support if he cannot be weaned from the ventilator and he requests no feeding tube if he is not longer able to eat normally. He designates his sister as his surrogate decision maker.
Discussion:
* Later that year, he presents to the ED with 2 day history of fever, dyspnea, & increased production greenish-yellow sputum. He is severely dyspneic, intubated in the ED and admitted to the ICU. After 12 days of mechanical ventilation, prognosis is poor. Delirium, high oxygen requirements and excess secretions have hampered efforts to wean him from the ventilator. He has shown no improvement within the past 12 days. Based upon the patient's clinical status and his advance directives, the medical team recommends extubation, and comfort care. His sister objects. She requests all life-support measures to be continued and asks about a tracheostomy for long-term ventilation and PEG for long-term nutrition.
A family meeting is scheduled.