Transcript Difficult End-of-Life Issues: Case Histories

Difficult End-of-Life Issues:
Case Histories
The Daughter Rescinded the DNR Order
A 65-year-old widow with a history of DM, hypertension,
and TIA was started on HD for DN. She was cognitively
intact, cooperative, compliant, and able to deal with her
diagnosis of ESRD appropriately. She used the Wheelchair
Van Service because of her desire not to burden friends or
family. She had family support, primarily from her daughter.
Two years after starting dialysis, she signed a DNR Order
and a Health Care Proxy, naming her daughter. About two
weeks later, a CT scan of the brain done to pursue mental
status changes revealed multiple areas of infarction.
Subsequently, she had numerous admissions to the hospital
because of fluid overload and other diagnoses. Dialysis
increased to four times a week. Her mental status
deteriorated further, and she was transferred to a NH.
Subsequently, she was noted to come from the NH
to the Dialysis Facility very agitated and would
upset other patients. She became progressively
problematic, and medications were tried to control
her inappropriate yelling, screaming and agitation,
to no avail. She was transferred to the Hospital
Unit where she could be placed in isolation and
observed more closely, since she was starting to
get out of her chair during treatments and pull out
dialysis needles. Her daughter was repeatedly
informed of her behavior, but her response was to
rescind the DNR order.
The patient’s transfer to the Hospital Dialysis Unit angered the
daughter; she did not accept that the transfer was in the
patient’s best interest. The patient progressively deteriorated.
She became more cachectic and demented. The patient
refused to eat; her weight decreased to 70 lbs from 123. The
daughter avoided face-to-face meetings with the MD and MSW
to discuss long-range planning. However, the daughter made
it clear that she did not wish to stop her mother’s dialysis.
Indeed, she asked about a feeding tube to increase the
patient’s weight. The patient had no difficulty swallowing or
bowel problems that would justify PEG placement. The patient
continued to do poorly and died five years after starting
dialysis and 14 months after becoming incapacitated.