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HISTORY
GENERAL DATAMA, 43/F, married, Roman Catholic, R-handed from Quezon City
CHIEF COMPLAINTDyspnea
CLINICAL HISTORY
PATIENT PROFILEA diagnosed case of Breast CA, Stage
3B (Apr 2008); undergone 4 cycles of chemotherapy (latest session Mar 2009 PGH-CI)
Nondiabetic and non-asthmatic
HISTORY OF PRESENT ILLNESS
4 months PTA, pt’s chemotherapy session was deferred due to decreased Hgb in CBC results and occurrence of left pleural effusion. Pt was lost to follow-up and noted to be experiencing dyspnea, necessitating nebulization with salbutamol at least 4x/day.
3 weeks PTA – pt had onset of cough with whitish phlegm, (+) easy fatigability, fever (relieved by paracetamol 500 mg/tab prn), 2-pillow orthopnea
HISTORY OF PRESENT ILLNESS2 weeks PTA, worsening of dyspnea, admitted at New
Era Hospital,A>Malignant Pleural effusionP> chest tube thoracostomy (L)Meds: tramadol, co-amoxiclav, other unrecalled meds
3 days PTA, discharged slightly improved; referred to PGH for 2D echo and continuation of radiation therapy; still with mild dyspnea
Day of admission: worsening of symptoms, (+) generalized weakness, consulted at PGH, admitted
REVIEW OF SYSTEMS
(-) fever, (-) vomiting (+) anorexia, (+) weight loss, (+) easy fatigability
(-) headache, dizziness, cough, colds, epistaxis, BOV, otalgia
(+) chest pain (-) palpitations (-) abdominal pain, diarrhea, constipation,
hematemesis/melena/hematochezia (-) polyuria, polydipsia, polyphagia (-) hematuria, frequency, dysuria, urgency (-) cyanosis, jaundice, seizures, (+) pallor
Past Medical History (+) HPN (1997, uncontrolled) (+) Goiter (2000) (-) PTB, DM, BA (-) allergies to foods and meds (-) previous surgeries Family Medical History (+) HPN, BA – both parents (-) Goiter, DM, allergies (-) history of cancer in the family
Personal/ Social History Patient is a college graduate, a graduate of midwifery, but worked
as a saleslady until 1996. She is married with 2 children. His husband is an OFW and is the breadwinner of the family. The patient has no vices. She denies illicit drug use.
Pertinent History Findings
53/F, married Diagnosed case of Breast Cancer
Stage 3B s/p 4 cycles of Chemotherapy Admitted at another institution with
the diagnosis of Malignant Pleural effusion
Referred to PGH for further work-up and radiotherapy
College graduate, midwifery
PHYSICAL EXAMINATIONGeneral Survey: Patient is conscious, coherent, hooked to face mask
Vital Signs: BP 140/100 HR 76 RR 30/min T afebrile
HEENT: Pale conjunctivae, anicteric sclera, (-) nasoaural discharge, (-) tonsillopharyngeal congestion, (-) CLAD (-) NVE (-) ANM, (-) bruits, trachea midline
Chest/Lungs: ECE, decreased breath sounds LLF, (+) occasional rales RLF, (+) necrotic tissue with abscess, L Breast
CVS: AP, DHS, NRRR, (-) murmurs/rubs
Abdomen: Flat, NABS, soft, (-) tenderness/masses
Skin/Extremities: FEP, PNB, CRT<2 sec, (-) edema, cyanosis, clubbing, jaundice
GU: DeferredNeurologic: Awake, conversant, follows command. Intact cranial nerves, No sensory or
motor deficits. No nuchal rigidity.
COURSE AT THE ER
1st HD 7/19/09 Patient hooked to O2 support at 10 lpm via face mask; A> Malignant pleural effusion, L, s/p CTT (July 2009) vs Obstructive Pneumonia, Breast CA t/c pulmo metastasis.
Labs: ABG done which showed respiratory alkalosis (compensated). CBC done showed elevated WBC and neutrophil counts (infection)
Meds: Piperazillin + Tazobactam 4.5 g IV q 8h , paracetamol 500 mg/tab q 4 for fever prn.
POD II: A> Breast Carcinoma Stage IV with Liver Metastasis (t/c Lung Metastasis) with Secondary Bacterial Infection, Malignant Effusion, R; s/p CTT with pleurodesis (July 2009), Hypertension, controlled.
Meds: Shift Pip-Tazo to 1) Oxacillin 2 g IV Q6 2) Clindamycin 300 mg/cap 1 cap Q6 PO. Maintained O2 at 4 lpm via NC. (Referred to TCVS for CTT, Hospice, Med Onco)
2nd HD 7/20/09 DAY MHAPOD: Pertinent PE: Pale conjunctivae, + chest lag, L,decrease breath sounds and fremiti, L, (-) crackles/wheeze. (+) breast mass, L with purulent discharge.
Labs: Chest UTZ with markings, PBS with reticulocyte count.
Meds: Discontinued clindamycin; Start levofloxacin 500 mg/tab OD; Start Moriamin Forte 1 cap BID; Appeton 500mg/tab at HS OD. Continue other meds; (Referred to GS1 for possible thoracentesis.) CDW BID of breast mass wound with Daikin’s Solution.
DAY MHAPOD: S> (+) pleuritic chest pain, lung findings unchanged.
Meds: Continue Oxacillin, hold clindamycin. To start Levofloxacin at 750 mg OD. Continue other meds. Transfusion 4 ‘u’ FFP now then 2 ‘u’ Q12; transfuse 1 ‘u’ pRBC; (Surgery referral done once with chest markings.)
3rd HD 7/21/09 DAY MHAPOD: Patient noted to have decreased serum Mg
P> IVF: MgSO4 drip: 3 g MgSO4 + 250 D5W x 12 hrs; IL pNSS x 12 hrs.
4th HD 7/22/09 NIGHT MHAPOD: Enalapril 20 mg/tab OD started
5th HD 7/23/09 NIGHT MHAPOD O> decreased breath
sounds over L base, (+) decreased breath sounds over the R mid-base, (+) vocal fremiti B bases
Meds: Continue Oxacillin (D0 + 3), Levofloxacin (D2); Plan was to insert CTT c/o TCVS; Patient admitted at W1B19.
PE on Ward Admission
General Survey:
Conscious, coherent, in respiratory distress, on nebulizer with mouth piece
Vital Signs: BP : 130/80 HR 110 RR 36 Temp 36.7 C
HEENT: Normocephalic, pale palpebral conjunctivae, anicteric sclerae , pupils 3mm
EBRTL, (-)CLADs, (+) NVE, (+) whitish oral plaques
Chest/Lungs: (+) necrotic tissue with abscess, L Breast with axillary lymphadenopathy ,
no chest lag, decreased breath sounds L lung field , (+) rales all over R lung field
CVS: (-) heaves, distinct heart sounds, tachycardic, regular rhythm, apex beat
noted at 5th ICS MCL (-) murmurs
Abdomen:GU/IE:
Flat, normo-active bowel sounds, soft, non-tender (-) organomegaly/ masses Deferred
Skin/Extremities:
Pink nailbeds, FEP, CRT < 2 sec, (-) edema, jaundice, cyanosis, clubbing
Neurologic: Awake, conversant, follows command. Intact higher cortical functions.
Intact cranial nerves. No sensory and motor deficits. No nuchal rigidity.
Physical Examination
ASSESSMENT
Breast Carcinoma Stage IV with Liver Metastasis (t/c Lung Metastasis)
with Secondary Bacterial InfectionMalignant Effusion, R s/p CTT with pleurodesis (July 2009)Hypertension, controlled
COURSE IN THE WARDS
6th HD 7/24/09 Patient is persistently tachypneic, BP 120/80, HR 120, RR 36, O2 sat remains 97-98%; refused to be intubated; signed with advanced DNI directive.
7th HD 7/25/09 11PM Patient referred for decreased BP of 70/50, HR 50s, RR 12, O2 sat at 60%. Soon after, code was called, CPR was started with O2 support via facemask and ambubag.
Patient’s husband arrived and decided to reversed previous DNI directive. Patient then intubated and ACLS was started. Patient was revived after 4 min of cardiopulmonary arrest. Patient was hooked to Dopamine and mechanical ventilator.
8th HD 726/09 Still hooked to Dopamine 2 ampules in 250 cc D5W at 48 cc/hr (20 mcg/kg/min) at max dose; BP was stable at 110-90/70-60, HR 140s, RR48;
Patient’s husband reluctant to pursue further laboratory exams; DNR was comtemplated but never consented.
10 AM Patient’s BP went down to 70/40; Dobutamine drip was started as ampules in 250 cc D5W @ 36 cc/hr at max dose. BP maintained at 90-70/60-40. No further inotropes started.
9th HD 7/27/09 9 AM Patient referred for BP 60/40, HR 68, RR 36; Soon after, second code was called; ACLS was started.
At 9 mins post arrest, pt’ s husband decided to stop further resuscitation attempt.
Patient maintained on O2 support via facemask on CAB; no CPR was pursued until cardiac monitor read as asystole. Patient was then declared dead.
Scenario
(6th HD 7/24/09) the doctor explained to the patient that anytime her condition can deteriorate. At this time the patient was conscious, coherent and competent to make decisions for herself.
She was asked if she wanted to be intubated once her condition deteriorates. However, the patient and her husband refused.
(7th HD 7/25/09 11PM) Patient’s condition worsened
BP70/50 HR50s RR12 O2 sat at 60% code was called, CPR was started with O2
support via facemask and ambubag. At this time, the patient’s son was the only one
around No attempt for intubation was done Son was informed of the importance of intubation
however there was an advance directive of DNI, thus the patient was not intubated
Patient’s husband arrived Family was appraised of the patient’s
condition The husband decided to reverse
previous DNI directive Patient was then intubated and ACLS was
started. Patient was revived after 4 min of
cardiopulmonary arrest. Patient was hooked to Dopamine and
mechanical ventilator.
8th HD 7/26/09
Patient’s husband reluctant to pursue further laboratory exams;
DNR was comtemplated but never consented
9th HD 7/27/09 9 AM
Patient referred for BP 60/40, HR 68, RR 36; Soon after, second code was called; ACLS was started.
At 9 mins post arrest, pt’ s husband decided to stop further resuscitation attempt.
Patient maintained on O2 support via facemask on CAB; no CPR was pursued until cardiac monitor read as asystole. Patient was then declared dead.
Pertinent points
When the patient was competent, she refused to be intubated
The husband retracted the DNI order Was it ethical to follow the husband’s
retraction of the DNI order?
Autonomy
affirms that we ought to be the authors of our own fate, the captain of our own ship
emphasizes the personal responsibility we have for our own lives
the right to choose who we wish to be, to make our own decisions and to control what is done to ourselves
includes the capacity to deliberate about a proposed course of action as well as the ability to actualize or carry it out
Advance Directive
This is a document which indicates with some specificity the kinds of decisions the patient would like made should he be unable to participate.
In some cases, the document may spell out specific decisions, while in others it will designate a specific person to make health care decisions for them
Surrogate decision maker In the absence of a written document, people close to
the patient and familiar with his wishes may be very helpful
The law recognizes a hierarchy of family relationships in determining which family member should be the official "spokesperson”
1. Legal guardian with health care decision-making authority
2. Individual given durable power of attorney for health care decisions
3. Spouse 4. Adult children of patient (all in agreement) 5. Parents of patient 6. Adult siblings of patient (all in agreement)
Issues
The patient’s autonomy was not recognized. At the time that the DNI order was signed, the
patient was conscious, coherent, able to follow commands, and with intact higher cortical functions
She was able to… understand her situation, understand the risks associated with the decision at
hand, and communicate a decision based on that understanding.
therefore the patient was competent to make a decision
Beneficence
the positive expression of nonmaleficence
highlights that we have a positive obligation to advance the healthcare interests and welfare of others, to assist others in their choices to live life to the fullest.
Indications for Intubation
In conditions of, or leading to resp. failure, such as;
trauma to the chest or airway neurologic involvement from
myasthenia gravis, poisons, etc. CV involvement leading to
impairment from strokes, tumors, infection, pulmonary emboli
CP arrest
Indications (cont’d)
Relief of airway obstruction Protection of airway (I.e. seizures) Evacuation of secretions by tracheal
aspiration Prevention of aspiration Facilitation of positive press.
ventilation
Issues
Intubation will ensure adequacy of oxygen going into the lungs and circulating in the body
CPR will prolong life
Nonmaleficence
First of all, do no harm. imposes the obligation not to harm
someone intentionally or directlynot necessarily violated if a proper
balance of benefits exists; that is, if the harm is not directly intended but is rather an unfortunate side effect of attempts to improve a person's health or, at the very least, to provide relief from the burden of pain.
Hazards (cont’d)
Accidental intubation of the esophagus or right mainstem bronchus
Bronchospasm, laryngospasm Cardiac arrhythmias resulting from
stimulation of the vagus nerve Aspiration pneumonia Broken or loosened teeth
Later Complications of Intubation
Paralysis of the tongue Ulcerations of the mouth Paralysis of the vocal cords Tissue stenosis and necrosis of the
trachea
Justice
the allocation of healthcare resources according to a just standard
Comparative justice involves balancing the competing claims of people for the same health care resourceswhat one receives is determined by one's particular condition and needs.
Distributive justice determines the distribution of health care resources by a standard that is independent of the claims of particular peopleDistribution is determined according to principles rather than individual or group need.
Learning Points
The patient’s autonomy should have been respected.
At the time that the DNI order was signed (patient was still competent), it should have been explained to the family that the order is final and cannot be reversed even if the patient’s condition deteriorates.
Invictusby William Ernest Henley. 1849–1903
OUT of the night that covers me,
Black as the Pit from pole to pole,
I thank whatever gods may be
For my unconquerable soul.
In the fell clutch of circumstance
I have not winced nor cried aloud.
Under the bludgeonings of chance
My head is bloody, but unbowed.
Beyond this place of wrath and tears
Looms but the Horror of the shade,
And yet the menace of the years
Finds, and shall find, me unafraid.
It matters not how strait the gate,
How charged with punishments the scroll,
I am the master of my fate:
I am the captain of my soul.
Sources:
The New Zealand Catholic Bioethics Center. Bioethical Issues: Bioethical Principles. <http://www.nathaniel.org.nz/?sid=27>
ETHICS IN MEDICINE University of Washington School of Medicine <http://depts.washington.edu/bioethx/topics/dnr.html >
William Ernest Henley. Invictus. <http://www.bartleby.com/103/7.html>