When working in the hospital, there comes a time for many of your patients where the transition to palliative care is possible or even necessary. While on the wards, I have been part of the care of several patients that were in the process of being transferred to hospice care. It isn’t easy making these sorts of decisions, but it is important to know when and how to approach them.
In one case, my team was taking care of a ~90 year old male transferred from a nursing home for concomitant CHF exacerbation and sepsis secondary to a UTI. This was his third admission in a month, and he was delirious and unable to communicate. Given his two co-morbid conditions, our team was stuck between a rock and a hard place – should we diuresis him for his CHF exacerbation, or give him fluids for his sepsis? We decided to do neither, and just treat him with antibiotics and supportive care. Meanwhile, his creatinine was steadily rising, a marker for acute renal failure. At that point, palliative care was consulted, whom arranged a family meeting to discuss the prognosis and options for their loved one.
After lengthy discussion, the son and daughter decided that they did not want dialysis for the patient, and wished to transition him to hospice care. Afterwards, the patient was taken off his medications and allowed to be made as comfortable as possible. We administered morphine for the pain, and allowed him to eat and drink whatever he wanted. Despite the prognosis, transition to palliative care was a significant relief for both the family and the treatment team. The family had witnessed the patient’s multiple hospitalizations and the pain that he was suffering, so they knew that this decision was for the best. Meanwhile, we as providers did not want to have the patient’s last weeks of life spent hooked up to dialysis machines in a hospital. Overall, it was the best outcome for everyone involved, and the patient was allowed to pass peacefully in the presence of his family.
