End of life care matters.
Matthew Graham-Brown BSc, MBChB, MRCP
An 86 year old male was admitted acutely unwell on the medical take with pneumonia and signs consistent with sepsis. His initial observations and examination findings showed:
The admitting medical team initiated entirely appropriate immediate management, including blood and sputum cultures and administration of IV antibiotics for presumed left lower lobe pneumonia (which was later confirmed on CxR). They resuscitated with IV fluid challenges of 250ml boluses of 0.9% sodium chloride. A urethral catheter was inserted and fluid balance chart was started. They sent blood tests including atypical pneumonia screen and appropriately followed the steps outlined by the ‘sepsis-six’.
After 4 hours of careful IV fluid administration and reassessment of the patient his blood pressure started to consistently improve and he was deemed euvolaemic – he was however oliguric having passed only 12ml urine since the catheter was inserted. With the patient stabilized, the admitting medical SHO gathered other relevant parts of the patients history:
- CKD stage 4/5 secondary to presumed renovascular disease (baseline eGFR 15)
- Severe aortic stenosis, not for deemed fit for any intervention
- Ischaemic Heart Disease (2x previous MI’s + CABG in 2001)
- Type 2 Diabetes
- BisoprololClopidogrel (intolerant of aspirin)
Nursing home resident, where he lived with his wife. He required help with washing and dressing, but was usually able to transfer to chair with assistance of one. One son and one daughter both of whom lived abroad.
The patients blood test results were phoned through to the ward:
An ECG was carried out, which showed no signs associated with hyperkalaemia, and the patient was given 50ml of 50% Dextrose with 10 Units of fasting acting insulin with a plan for repeat U&E’s in 6 hours.
They also contacted the renal team for advise about patient management and any background information related to the patient. The patient was well known to the renal team and the on-call renal registrar was able to access the patients most recent clinic letters and care plans from the renal patient database. The patient had decided six months prior to his admission that he did not want renal replacement therapy under any circumstances and that should the need arrive his preference was for maximal conservative therapy. This had been further discussed and ratified with the patient and his wife by the home care team on their most recent visit. The renal registrar advised that the patient should be moved to the renal ward for his care and medical management.
On arrival on the renal ward, the patient was haemodynamically stable with improved vital parameters, and although tired was more lucid than on admission. He was reviewed by the renal team who agreed with the diagnosis and management plan initiated. All nephrotoxic medications had been discontinued and he was on appropriate antibiotic therapy. He was deemed to be euvolaemic and because he remained oliguric he was not written up for more IV fluid. USS of the renal tract was arranged to ensure there wasn’t an obstructive element to the patients acute on chronic kidney impairment and the scan revealed 2 small, asymmetrical, unobstructed kidneys with an empty bladder.
The renal consultant had an honest and frank discussion with the patient about his current medical state and his prognosis. It was explained that he had pneumonia, and was very unwell, and this had led his kidneys to fail at the present time. The consultant explained that the toxins which the kidneys usually clear had accumulated to the extent that they were potentially becoming harmful to his life and that this would be a point in other cases that they would proceed with haemodialysis. It was then confirmed with the patient that he had previously decided he would not want dialysis, which he acknowledged. The consultant then asked whether this was still the case, and the patient confirmed it was. Finally the consultant checked the patients understanding that without dialysis there was significant risk to the patients life and that in this case there was a potentially reversible cause for his renal failure and went so far as to say that he would advise the patient consider allowing the team to support him with haemodialysis until it was clear whether his kidney function would recover. The patient understood all of this, but calmly and politely declined. He was completely sure that he did not want renal replacement therapy and preferred to be managed conservatively. With the patients agreement a DNAR order was completed and it was documented that the patients care was not to be escalated above ward based management. His family were contacted and by chance his son was flying in the following day and a meeting was set with the son and wife to discuss the patients care plans.
The patient remained oliguric overnight despite optimization of fluid state, treatment of underlying cause and discontinuation of nephrotoxic medications and repeat biochemistry the following morning showed a further deterioration in renal function, with rebound of the previously treated hyperkalaemia:
When the patients family arrived and they had been to see the patient, the ward registrar and the ward Sister (with the agreement of the patient) discussed the patients condition and care plans with the family. Whilst his wife understood and agreed with the decisions he had made, his son was not happy and felt these were decisions imposed on his father by the medical team that were ‘ageist’ and not fair. The medical team listened to the son’s concerns and along with the patients wife explained these were decisions his father had made in advance of becoming ill, and despite being given the option of changing his mind, he was very clear about the types of care he would want, and those which he did not want. They explained he was consistent in his decision making and was competent to make the decisions, despite being unwell. The son asked if there was anyway the medical team could just do dialysis until his sister could arrange a flight home to see her father. Whilst the registrar and the ward sister understood the reasons behind this request, they explained this would be a direct violation of the patients wishes, and that their duty of care was to the patient not to his family, and that respecting his wishes and maintaining his dignity were the priorities in his care.
Over the following 48 hours the patients renal function failed to improve, despite best supportive care and although his conscious levels had initially improved, he became increasingly somnolent and uraemic and the decision was made with his wife and son to give him full palliative care support, and he passed away peacefully in hospital.
These sorts of discussions with patients and families are never easy, regardless of how much planning goes into personalized advanced care plans. Whilst in this case the patient stood by the plans he had made, in many cases when faced with the prospect of dying patients change their minds – and they are entitled to do so. The job of Doctors and nurses is not to decide which patients should and should not have renal replacement therapy, it is to arm them with the facts about dialysis therapies and offer them advise about the realities of dialysis for them as individuals. Whilst we might be able to predict to a certain extent who will and who won’t do well on dialysis, based on age, functional status and medical co-morbidity, it is impossible to predict with total accuracy, and patients decisions and wishes should be respected.
It is obviously important that family members are involved in decisions about their relatives care, and whilst no-one would want to cause the family of a sick patient any more distress, it is the patients wishes that are to be maintained above all else.