36

The patient, Gypsy Genes, is 89 y.o. Caucasian female with a history of recurrent urinary tract infections (UTIs) and a diagnosis of Alzheimer’s dementia x 10 years. Patient also suffer from L sided hemiparesis as a result of a stroke 5 years ago. She resides in a local nursing home where the staff reports she has had a “depressed” affect, confusion, and agitation x 5 days, since 5/1. It was reporteed by EMA that the nursing home staff was hesitant to transport to the hospital, as they believed the patient was exhibiting s/s associated with her dementia.

Upon arrival to ED, patient was treated as code sepsis. Vitals were BP 89/60, HR 120, Temperature 100.8 F, RR 22, O2 94% on room air. 2L supplemental O2 given via nasal cannula. Labs and Blood Cultures obtained at two different sites. Labs indicated a Lactate level of 3.0, WBC 21,000, BUN 69, serum creatinine 2.0.

Initiated sepsis one-hour bundle which included fluid Bolus at 30mL/kg, Vasopressors (norepinephrine) to maintain MAP >65 mm Hg (if patient is not responsive to fluid bolus), and Broad spectrum antibiotics (after cultures). The patient was stabilized with a BP of 110/75 and Intubated via ETT r/t la RR of 8 settings set at AC: Rate 20, FiO2 50%, PEEP: 5, Tidal Volume: 420, and ABGs showing Respiratory acidosis and then transferred to ICU due to acuity.Patient is currently on flagyl and levaquin, NS at 175ml/hr, One hour on ICU and the patient began to deteriorate, suspected MODS r/t Urine output: <30/hr, RR: 20, HR: 110, BP 75/54, 02 85% and Temperature 102. Patient assessment revealed generalized edema, cool skin and extremities, poor capillary refill (>4 seconds). Additional lab work up done revealed elevated BUN, creatinine, liver enzymes, and lactate level of 5 mmol/L. Initiated fluid bolus, hydrocortisone and vasopressors ( norepinephrine and vasopressin) with no improvement in fluid resuscitation and hemodynamic stability.

Patient is now in multiorgan failure and orders will be directed to comfort care. Now that the patient is in her end of life stage, physicians will follow the patient’s wishes from her physician’s orders for life sustaining treatment (POLST) form. Family has been contacted and updated on the status of patient’s condition. Gypsy’s daughter is now at bedside with a lot of questions for the whole healthcare team. Although the healthcare team is making it a priority to update the daughter, they have informed her that her mom already had a POLST indicating her wishes were to be DNR and provide treatments for comfort through symptom management. It is now the responsibility of the healthcare team to explain to the daughter that although she may want full treatment to treat her mom, they must respect her POLST. Gypsy is very religious and as a Roman Catholic, she was referred to the roman catholic sacrament of the sick. Antibiotics, IV fluids, and vasopressors have all been discontinued as they are no longer trying to treat her diagnosis. Gypsy’s medications directed for comfort measures will be a continuous infusion of 4mg/hour as well as lorazepam 2mg q6hr (Kuebler, 2014). The nurses are continuously assessing Gypsy to make sure she is comfortable and making sure the daughter is coping as well as possible.

DIscussion Questions:

1. Other than physiologic factors, what other variables would be fundamental at this moment in this patient’s care? What should the nurse assess in order to provide the best holistic end of life care he/she can?
2. What are different arrangements for patients who no longer have the capacity to make decisions regarding their healthcare?
3. If you were dying, what type of medical treatment would you want? (artificial nutrition?, intubation?, Resuscitation efforts(CPR)?) Who would make the decisions for you?

Reference:

Kuebler, K. M. (2014). Using morphine in end-of-life care. Nursing, 44(4), 69. doi:10.1097/01.nurse.0000444548.72595.ac