Problem Based Learning Case Study in End-of-Life Care. Mrs. Gill .
Mrs. G is a 84 year old woman with a history of insulin-dependent diabetes mellitus and coronary artery disease who presents to the ER with a 2 day history of severe pain in her right calf and foot. Prior to this she would get a cramping in her right calf when she walked 1-2 blocks, relieved with rest. She is writhing in pain when she comes in.
O = other sxs: No swelling, no redness, but rt. foot pale and cold
P = palliative/provocative factors: worse when she puts any pressure but even keeps her up at night
Q = quality: throbbing ache
R = region: from rt knee down all the way around leg
S = severity: 10 on a 0 to 10 scale
T = timing: constant for last 2 days
U = untoward effects on QOL: cannot do anything anymore, very overwhelming at this point
* Acute ischemic limb pain
The vascular surgeons feel surgery is the only option. In fact her renal function is rapidly deteriorating, and unless she gets an emergent amputation, she will likely die in 1-2 weeks. In fact, they bluntly told Mrs. Gill this and she adamantly refused, greatly upsetting the surgeons who immediately want a psych consult.
On talking with Mrs. Gill, she does realize she will die without an amputation, but cannot give reasons why she does not want it, saying that God works miracles all the time and there must be other ways because she does not trust the surgeons. Her mental status does fluctuate during the day.
Her only close relative is a daughter who was present at this discussion. The daughter states that her mom has become increasingly confused over the last few months and that she feels her mom is not capable of this decision. She never filled out advanced directives.
You all agree Mrs. Gill is not able to make this decision.
Based on what the daughter knows about her mom, the fact that her mom never wanted to undergo any other surgeries after her by-pass and that her mom just wants to be able to stay at home comfortably, the daughter agrees to not have her mom go through the surgery.
For the first 2 days in the hospital, Mrs. Gill needed to take 2mg of IVP morphine every 1-2 hrs, about 20 doses in a day, to stay comfortable, getting her pain down to a 2 on the pain scale, where she wanted it.
At first she was drowsy, but gradually woke up, wanting to go home. Home hospice was agreed upon, though she wanted the IVs stopped. She had no nausea or other side effects.
She got home the next day, pain very well controlled, with home hospice. She had moments of lucidity where she was able to resolve issues with daughter and say good-byes.
She needed a hospital bed and commode, along with nursing aide visits daily to help the daughter care for her at home.
She gradually slipped off into a coma and died peacefully within 1 week of discharge. The daughter, though sad, was very grateful in how her mother passed away. The hospice bereavement team is following the daughter.