Moderator EMEDPA Posted July 2, 2021 Moderator Share Posted July 2, 2021 Along the lines of the recent DNR who wanted everything done post... 95 yr old male with no listed pmh or meds. has not seen a doctor in 40+ years presents with progressive weakness over the last week. went from walking unassisted to a cane to a walker to bedbound. Appears quite pale. A+O x 4. He and family request limited interventions, but DNR/DNI T 37, P 64(sinus), bp 77/40, sao2 98% on ra, R 18 brief exam: pale skin, gingiva and conj white neck supple lungs clear heart rrr abd nt, rectal heme neg brown stool pv no c/c/e neuro no deficits, mae well obviously a broad ddx for hypotension and weakness. Had a PA student with me for this and we were thinking : GI bleed, sepsis, heart failure, dehydration/aki/rhabdo, malignancy, acs, electrolyte imbalance, arrhythmia, etc So, initial management with 2 IVs, fluids, laid flat, labs and imaging ordered. head ct and cxr nl. ekg nl relevant labs: trop nl, wbc 18000, hgb 6.6, cath ua > 100 wbc, lactic acid 3, VBG nl. Cr 3, lytes ok, ck nl, bnp minimally elevated but no clinical evidence of heart failure. after 2.5 L IV fluids bp to 92, pt ok with blood transfusion so given with improvement, 2 gm rocephin given IV, pressures persistently 85-95 systolic. Pressors for a pt listed as limited interventions? decided against. admitted med/surg tele . Pt declined foley. pt declined colonoscopy. 1 Quote Link to comment Share on other sites More sharing options...
MediMike Posted July 2, 2021 Share Posted July 2, 2021 3 hours ago, EMEDPA said: Along the lines of the recent DNR who wanted everything done post... 95 yr old male with no listed pmh or meds. has not seen a doctor in 40+ years presents with progressive weakness over the last week. went from walking unassisted to a cane to a walker to bedbound. Appears quite pale. A+O x 4. He and family request limited interventions, but DNR/DNI T 37, P 64(sinus), bp 77/40, sao2 98% on ra, R 18 brief exam: pale skin, gingiva and conj white neck supple lungs clear heart rrr abd nt, rectal heme neg brown stool pv no c/c/e neuro no deficits, mae well obviously a broad ddx for hypotension and weakness. Had a PA student with me for this and we were thinking : GI bleed, sepsis, heart failure, dehydration/aki/rhabdo, malignancy, acs, electrolyte imbalance, arrhythmia, etc So, initial management with 2 IVs, fluids, laid flat, labs and imaging ordered. head ct and cxr nl. ekg nl relevant labs: trop nl, wbc 18000, hgb 6.6, cath ua > 100 wbc, lactic acid 3, VBG nl. Cr 3, lytes ok, ck nl, bnp minimally elevated but no clinical evidence of heart failure. after 2.5 L IV fluids bp to 92, pt ok with blood transfusion so given with improvement, 2 gm rocephin given IV, pressures persistently 85-95 systolic. Pressors for a pt listed as limited interventions? decided against. admitted med/surg tele . Pt declined foley. pt declined colonoscopy. If the patient is interested in extending their time I've got no issues starting pressors on a DNR/DNI patient, I'll avoid central access though and just run peripherally. UA was only remarkable for the WBC? Top of my list would be GIB and UTI. It's refreshing to hear about a patient who is up front and reasonable about goals. I've had a plethora of metastatic badness recently who insist on every single intervention and procedure. Also a lady who is melting in bed as family won't transition to comfort. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 3, 2021 Author Moderator Share Posted July 3, 2021 1 hour ago, MediMike said: If the patient is interested in extending their time I've got no issues starting pressors on a DNR/DNI patient, I'll avoid central access though and just run peripherally. UA was only remarkable for the WBC? Top of my list would be GIB and UTI. It's refreshing to hear about a patient who is up front and reasonable about goals. I've had a plethora of metastatic badness recently who insist on every single intervention and procedure. Also a lady who is melting in bed as family won't transition to comfort. I am assuming GI bleed despite the neg rectal exam. I guess some kind of marrow failure is also on the list, but less likely. I did treat for urosepsis as well. The ua was + wbc, no epis, packed bacteria. I decided against the pressors as in my mind this was a road to nowhere. you turn them off and the pressure crashes again. Quote Link to comment Share on other sites More sharing options...
MediMike Posted July 3, 2021 Share Posted July 3, 2021 2 hours ago, EMEDPA said: I am assuming GI bleed despite the neg rectal exam. I guess some kind of marrow failure is also on the list, but less likely. I did treat for urosepsis as well. The ua was + wbc, no epis, packed bacteria. I decided against the pressors as in my mind this was a road to nowhere. you turn them off and the pressure crashes again. All depends on the patient's goals. If they need to maintain a pressure the keep them alive to see family, finish affairs (paperwork or...other...), see their dog one last time whatever I'm good with it. If there is a reversible cause i.e. urosepsis and his functional status is otherwise fine, which it sounds like it was, I'd definitely have no issues treating him aggressively to give him a chance and prevent worsening organ failure due to hypoperfusion. I've seen 90+ year olds have better outcomes than hospitalized 60-70yos, they clearly have the appropriate protoplasm. Just my thoughts, know practice patterns vary and it's a lot different when you're speaking with them patient in front of you rather than armchair quarterbacking from a couple hundred miles away. 1 1 Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted July 3, 2021 Moderator Share Posted July 3, 2021 Agree with medimike. To me, “keep it minimal” means low expense and non-invasive. Patient already has an IV, so to me pressors are the same as antibiotics and fluids. Wouldn’t do a central or a-line. Give him a little extra time, maybe the bleed stops as it sounds like a slower bleed, or antibiotics kick in. I’m not an authority on the matter, but that where I draw my line 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 3, 2021 Author Moderator Share Posted July 3, 2021 fair enough. he had family at the bedside and was at peace with his life. Getting him to accept blood was a stretch. I told him it would make him feel a lot better and it did. He said no heroic measures and in my mind I guess that meant no pressors. I can see both of your point if there is reason to extend life for 24 hrs, but for this guy he would have been fine going home and dying in bed. 2 Quote Link to comment Share on other sites More sharing options...
MediMike Posted July 3, 2021 Share Posted July 3, 2021 3 hours ago, EMEDPA said: fair enough. he had family at the bedside and was at peace with his life. Getting him to accept blood was a stretch. I told him it would make him feel a lot better and it did. He said no heroic measures and in my mind I guess that meant no pressors. I can see both of your point if there is reason to extend life for 24 hrs, but for this guy he would have been fine going home and dying in bed. And that's what it all comes down to, helping the patient meet their (reasonable) goals. Giving someone the opportunity to die at home surrounded by family is something I don't get the chance to do too often these days and it hurts my soul a bit. Did manage to get a guy a couple tall boys for him and his brother to drink after he did a terminal d/c of his BiPAP. He chose 211. He chose poorly in my mind but it is what it is. 1 Quote Link to comment Share on other sites More sharing options...
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