Reference no: EM133398049

Case: Your facility has received a patient, 57 y/o male, with history of hypertension, End Stage Renal Disease on HemoDialysis three times a week, paraplegia, Decubitus wounds on every pressure point of patient's skin including bilateral ischemia, bilateral hips, sacrum and BKA knee. All have fibrinous exudate, mild odor, and some necrotic tissue noted. Patient presents to with hypotension and altered mental status. Patient reportedly lives at home with a sister who cares for him and he is normally somewhat communicative, but was nonverbal this morning and seemed confused prompting presentation to your facility. He is found to be hypotensive to the 60s over 30s.

Initially, the following are labs drawn on this patient: WBC count of 11.5. Hemoglobin 6 and hematocrit of 20.2. Platelets were 242, UA with too numerous to count WBC and 4+ bacteria concerning for infection. Sodium 135. Influenza and covid screening were negative. CXR show left subclavian tip in place, as well as patchy right perihilar and right lower lobe airspace opacities concerning for pneumonia. Patient receives dialysis through access in the groin. He was given a dose of vancomycin and zosyn at 8am. He was started on levophed with current rate of 15.

Source of infection appears to be from multiple decubitus ulcers and or urinary tract infection.

Patient has no known allergies

Other past Medical History includes: Diabetes mellitus (on insulin); Stroke with persistent altered mental status, atrial fibrillation, hypertension, history of reoccuring Bacteremia; Chronic anemia; Seizures; LFT elevations; DVT with hemorrhage on heparin, status post IVC filter; Colostomy; PEG tube for feeding/nutrition; Left below knee amputation.

Palliative consulted: prognosis, poor, likely less than 6 months. Reviewed daughter's understanding of his current situation. Reporting understanding that he has a bad UTI and the wounds are infected with a potential infected toe. Explained that patient is septic, has pneumonia although not currently needing oxygen.

Pt does not have a living will or Durable Power Of Attorney for healthcare. Daughter confirms that she is the surrogate decision maker. Discussed code status, full code interventions (CPR/vent/no guarantees for a positive outcome) versus allowing a natural death. She states that she has been through this situation a few times with him in the past, and have had the conversation with her father in the past. He has always said he wanted everything done. She reports wishes for full code interventions. She states others talked to her about hospice 2 years ago, and that he has since rebounded. Her dad is a fighter and hoping he can regain his cognitive function with treatment of these infections. Does not want her dad to suffer but that she does not want to give up if he can potentially recover. Recommended DNR however after confirming daughter understands what that means, she confirms wishes for full code.

The first few days of the patient, determined that patient may also have a possibility of osteomyelitis which is likely due to multiple wound sites. His PEG tube is plugged and attempts to clear with Creon was successful.

Day 4 Patient had a Code blue due respiratory failure, with CPR and was felt to be due to aspiration. Pt code status changed to DNR after conversations with daughter after the patient had a successful code. Daughter shares that patient did this about 3 months ago and survived. The daughter feels this is just another episode and is hoping for a miracle.

Two days later, the daughter changed code status from DNR to full code. General Surgery was consulted and determined patient is not a candidate for operative debridement of wounds due to odds of him ever being healthy as well as recent respiratory code of less than 96 hours ago.

Patient seems to maintain and the next few days, pt is noted to be nodding and shakes head to questions today appropriately; responds to some questions and follow some commands although movement is somewhat limited. Family states patient is back to neurological function; patient is extubated from the ventilator after six days on the vent.

Two days later, although still nodded to questions; patient is not able to cough and unable to clear secretions. Due to this patient, became hypoxemic and oxygen sats dipped into the 70s, and had to be reintubated. Although, he was intubated , Code Blue was called after intubation likely due to hypoxemia and hypotension.

After 7 days on the vent (second episode), further discussions with family needed due to direction of care. Various reasons were given for family not able to commit to talks. A patient can not remain on the vent long term through the mouth. A trach is usually recommended for long term ventilation anywhere from 7-14 days.

Day 11 of intubation, Family meeting requested to further discuss goals of care. Encouraged family to consider patient's bedbound status with multiple wounds, dialysis dependent, intubated, and inability to communicate would be an acceptable quality of life for him. Decision to be made in the near future regarding continued aggressive medical management including potential tracheostomy placement versus focusing on patient's comfort. Daughter aware that her father is critically ill.

A few more days pass without family communication occurring either via phone or presence. Further direction of care is needed.

YOU are the Director of Clinical Ethics. You have been contacted by the floor and providers as they are starting to have conflict with this patient. Your assignment is take the above information and apply the Medical Indications box to this case. Use the first chapter of the book and research to understand her medical issues.

Question 1. Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?

Question 2. Are there parties, other than clinicians and patients, such as family members, who have an interest in clinical decisions?

Question 3. What are the limits imposed on patient confidentiality by the legitimate interests of third parties?

Question 4. Are there financial factors that create conflicts of interest in clinical decisions?

Question 5. Are there problems of allocations of scarce health resources that might affect clinical decisions?

Question 6. Are there religious issues that might influence clinical decisions?

Question 7. What are the legal issues that might effect clinical decisions?

Question 8. Are there considerations of clinical research and education that might affect clinical decisions?

Question 9. Are there issues of public health and safety that affect clinical decisions?

Question 10. Are there conflicts of interest within institutions and organization (e.g. hospitals) that may affect clinical decisions and patient welfare?