critical care for comfort only pt...

[EMEDPA]

So, 95 yr old demented pt with a variety of medical problems, including chf and afib(not anticoagulated beyond asa due to frequent falls) is put on naproxen bid by his pcp 6 weeks ago for arthritic pain. Today presents with melena, appears pale, and looks ill. Pt is dnr/dni. H+H 8/24 with evidence of new aki with new bun/cr ratio of 70. In afib, but not acutely in chf at time of presentation. First part is easy: stop asa and naproxen, gentle IV hydration, IV PPI and prepare for transfusion(anticipating IV hydration for AKI will knock h/h below 7/21 and applied WALLS criteria: https://emcrit.org/emcrit/lls-score/ )

Family member is a medical professional known to me and we both agree up front that transfer for egd/colonoscopy is not on the table, neither are pressors or heroic measures. Fine....until pt starts having projectile hematemesis in the hundreds of MLs. . BP 84/p down from presenting 130/86, sao2 down from 98% on RA to 89%. 

We both agreed fairly quickly that not drowning in one's own blood is part of comfort care. Suctioned, 3rd IV started,  PPI drip started. 2 units of uncrossmatched  blood given instead of one unit crossed. Octreotide and TXA considered, but quick lit review show no  benefits for nsaid induced gastric bleeding. exam and cxr show no overt chf or aspiration, so a bit more IV fluids given. admitted with some clinical improvement and stable bp.

typically I would write a critical care note for this level of care. Not going to do it. 

[LT_Oneal_PAC]

3 hours ago, EMEDPA said:

So, 95 yr old demented pt with a variety of medical problems, including chf and afib(not anticoagulated beyond asa due to frequent falls) is put on naproxen bid by his pcp 6 weeks ago for arthritic pain. Today presents with melena, appears pale, and looks ill. Pt is dnr/dni. H+H 8/24 with evidence of new aki with new bun/cr ratio of 70. In afib, but not acutely in chf at time of presentation. First part is easy: stop asa and naproxen, gentle IV hydration, IV PPI and prepare for transfusion(anticipating IV hydration for AKI will knock h/h below 7/21 and applied WALLS criteria: https://emcrit.org/emcrit/lls-score/ )

Family member is a medical professional known to me and we both agree up front that transfer for egd/colonoscopy is not on the table, neither are pressors or heroic measures. Fine....until pt starts having projectile hematemesis in the hundreds of MLs. . BP 84/p down from presenting 130/86, sao2 down from 98% on RA to 89%. 

We both agreed fairly quickly that not drowning in one's own blood is part of comfort care. Suctioned, 3rd IV started,  PPI drip started. 2 units of uncrossmatched  blood given instead of one unit crossed. Octreotide and TXA considered, but quick lit review show no  benefits for nsaid induced gastric bleeding. exam and cxr show no overt chf or aspiration, so a bit more IV fluids given. admitted with some clinical improvement and stable bp.

typically I would write a critical care note for this level of care. Not going to do it. 

Good job. Agreed that drowning on any fluid of your own is not comfort care. It’s a tough case balancing minimum comfort and heroic measures in this case. Glad family is medically knowledgeable. Makes it much easier. You did great.

did you consider some vasopressin for splanchic constriction? Not playing Monday morning QB, just curious your thoughts

[GetMeOuttaThisMess]

I was thinking of this from the perspective of my elderly parent who has clearly stated no heroic measures on her behalf.  Present day, enough mental deterioration to where she thinks the hospital knows her better than her facility physician.

All this being said, I know she has said that she is willing to die and if I substitute her in place of this patient, maybe an NG tube to avoid aspiration but otherwise I wouldn’t change anything, other than ask the PCP why would you put this person on an NSAID?

[EMEDPA]

1 hour ago, LT_Oneal_PAC said:

 

did you consider some vasopressin for splanchic constriction? Not playing Monday morning QB, just curious your thoughts

I didn't. I should have. We decided no vasopressors early on, so I didn't consider that indication.

next time. Thank you. 

[EMEDPA]

7 minutes ago, GetMeOuttaThisMess said:

I was thinking of this from the perspective of my elderly parent who has clearly stated no heroic measures on her behalf.  Present day, enough mental deterioration to where she thinks the hospital knows her better than her facility physician.

All this being said, I know she has said that she is willing to die and if I substitute her in place of this patient, maybe an NG tube to avoid aspiration but otherwise I wouldn’t change anything, other than ask the PCP why would you put this person on an NSAID?

We discussed an NG tube, but they kept pulling out IVs and taking off oxygen so we decided against. 

Apparently they started the naproxen because tylenol was not effective. My practice is no nsaids in the elderly. If you must, use something buffered FFS like mobic, salsalate, or trilisate at a low dose. 

[EMEDPA]

Did no one look at my link? That is some funny stuff people. 

[MediMike]

5 hours ago, EMEDPA said:

typically I would write a critical care note for this level of care. Not going to do it. 

All of what you did sounds completely appropriate, I'm curious though as to your decision to not write a critical care note? The patient is DNR/DNI not comfort are.  You provided critical care time to this patient regardless of the anticipated outcome, your time is valuable as is the equipment/material used.

If I didn't bill critical care time for patients who weren't going to make it my hospital would go under.

[MediMike]

2 hours ago, LT_Oneal_PAC said:

Good job. Agreed that drowning on any fluid of your own is not comfort care. It’s a tough case balancing minimum comfort and heroic measures in this case. Glad family is medically knowledgeable. Makes it much easier. You did great.

did you consider some vasopressin for splanchic constriction? Not playing Monday morning QB, just curious your thoughts

I've seen some info on vasopressin being utilized intra-arterially for LGIB and IV at high doses like 0.2-0.4 for variceal bleeds, do you have any data on it's utilization for other sources (gastritis etc.)? Wish I could get my hands on some terlipressin *salivates*

[EMEDPA]

41 minutes ago, MediMike said:

All of what you did sounds completely appropriate, I'm curious though as to your decision to not write a critical care note? The patient is DNR/DNI not comfort are.  You provided critical care time to this patient regardless of the anticipated outcome, your time is valuable as is the equipment/material used.

If I didn't bill critical care time for patients who weren't going to make it my hospital would go under.

They were dnr/dni/limited interventions/comfort care only. The last thing this family needs is a bill for critical care when they brought them in for comfort care. They are still inpt, so the hospital will be making ends meet. They pulled all their lines out(but not their foley) and it sounds  like they will be transitioned to hospice as the hgb continues to plummet and the renal function is not improving. 

[MediMike]

For any students following this thread, there is a big difference between all the items listed (DNR vs DNI vs Limited Interventions vs Comfort Care)

If they have a surviving spouse who'd be responsible for that bill I can kind of get it, or if they have an estate they are planning on leaving behind. Anyways, it's your time you're billing for!

The ethical argument behind medical billing can be left for another day. Glad you got the patient stabilized and upstairs.

[ohiovolffemtp]

Familiar with the link - referred to the LLS criteria in another post.  Certainly agree that you should be proud of how you helped the person.  Did you consider any kind of sedation to help prevent the patient pulling lines?

On the thought of not billing for critical care: I doubt that the incremental cost (better said, the actual payment) on the bill would be that high.  It's 4.5 RVU's for 30-74 minutes of critical care time.  At the current Medicare payment of $37.89/RVU - that's only $170.51.  I am presuming that given the patient's age they have Medicare.  You gave very skilled care that's definitely worth that.

[LT_Oneal_PAC]

3 hours ago, EMEDPA said:

I didn't. I should have. We decided no vasopressors early on, so I didn't consider that indication.

next time. Thank you. 

 

1 hour ago, MediMike said:

I've seen some info on vasopressin being utilized intra-arterially for LGIB and IV at high doses like 0.2-0.4 for variceal bleeds, do you have any data on it's utilization for other sources (gastritis etc.)? Wish I could get my hands on some terlipressin *salivates*

There’s not a lot of data for IV use. There is some for intra-arterial at the dose like Mike said and Ive heard some “expert opinion” on its use IV at the same dose.
 

personally I’m extrapolating a little from those studies, from physiology, retrospective studies showing vasopressin was the only pressors that didn’t have harm in hemorrhagic shock, and the AVERT trial. https://rebelem.com/avert-shock-vasopressin-for-acute-hemorrhage/
 

it’s not something I do regularly, but I’d rather use it than pump in tons of fluids that dilute factors and can worsen bleeding. My hospital also has no octreotide for variceal bleeding, limited supply of blood, no blakemore tube (though I have asked many times and considering a donation to get a kit) and certainly no ability for MTP. I may also use it in those that are refusing transfer for similar issues that Emed had. So I’ll use vasopressin “titrated to life” as a stop gap measure

[MediMike]

1 hour ago, LT_Oneal_PAC said:

 

There’s not a lot of data for IV use. There is some for intra-arterial at the dose like Mike said and Ive heard some “expert opinion” on its use IV at the same dose.
 

personally I’m extrapolating a little from those studies, from physiology, retrospective studies showing vasopressin was the only pressors that didn’t have harm in hemorrhagic shock, and the AVERT trial. https://rebelem.com/avert-shock-vasopressin-for-acute-hemorrhage/
 

it’s not something I do regularly, but I’d rather use it than pump in tons of fluids that dilute factors and can worsen bleeding. My hospital also has no octreotide for variceal bleeding, limited supply of blood, no blakemore tube (though I have asked many times and considering a donation to get a kit) and certainly no ability for MTP. I may also use it in those that are refusing transfer for similar issues that Emed had. So I’ll use vasopressin “titrated to life” as a stop gap measure

AVERT looked at folks who'd already received a couple units of pRBC is that right? I can't remember now.

You're kind of stuck in the setting of a ruptured varices huh? May as well just shove your arm down the esophagus and ride into the tertiary center...

Completely agree with you and your thought process, was curious if you'd found something I haven't. We don't have the most supportive GI service at times so managing these GIBs always throws a little stress my way.

[EMEDPA]

14 hours ago, ohiovolffemtp said:

Familiar with the link - referred to the LLS criteria in another post.  Certainly agree that you should be proud of how you helped the person.  Did you consider any kind of sedation to help prevent the patient pulling lines?

 

Fortunately they did not pull out their 3 lines until they got to the floor and had received a few more units of blood. The hospitalist was on board for my plan and we gave her ICU level care , but on the books it is obs transition to hospice.