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The Correct Answer is C!

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Question:

A 72 year-old man is admitted to the hospital with worsening dyspnea. The patient has a 120-pack-year smoking history, was noted to have extensive emphysema on CT imaging of the thorax, and has been oxygen-dependent for the past two years. He is unable to walk from his bedroom to the kitchen without becoming acutely short of breath. He also has a prior history of three-vessel coronary artery disease for which he has been managed medically because it was determined by his cardiologist that his pre-operative risk was unacceptable to undergo invasive procedures. The patient indicates that he does not want any “heroic measures,” has completed an advanced medical directive, and stated on several occasions to his primary care physician that he requests only comfort care measures should he develop another severe respiratory exacerbation. He appears weak and chest retractions are noted. He is tachypenic and ashen. Several estranged family members arrive at the hospital, requesting to speak to the treating provider and demanding that “all reasonable measures” be pursued.

Which of the following is the most effective management?

  1. Request consultation for a heart-lung transplant
  2. Contact the hospital attorney to sit in on the conversation with family members
  3. Explain to the family that the patient has clearly stated his wishes are for comfort care only
  4. Intubate the patient and immediately begin mechanical ventilation

Rationale:

The correct answer is to explain to the family that the patient has clearly stated his wishes for comfort care only. In this case, the patient has previously expressed his wishes to pursue comfort care only as opposed to more invasive measures, which, although might prolong life, would not likely affect the patient’s quality of life as judged by him. Intubating the patient, or requesting consultation for a heart-lung transplant are invasive procedures declined by the patient previously, and are not indicated based upon the scenario presented. Having the hospital attorney sit in on the conversation would also not be necessary since creating what could be perceived as a defensive environment would create needless confusion and animosity at a time when compassion for the patient and his wishes should be of the highest priority.

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1.  Source: "Comparative Analysis of Pre/Post Assessments of Live/Didactic Course Attendees when compared to Mico-Learning/Online Course Users., "Knowledge to Practice, 2017.

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