Northeast Florida Medicine, Spring 2016

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DCMS online. org Northeast Florida Medicine Vol. 67, No. 1 2016 39
Palliative Care
interventions should not thwart ‘Divine Will’. An advance
directive that had been written in her 60s was clearly ex-
ecuted and known to all of her health care providers, her
family, friends and her church community.
This case represents how a well-planned life and thought-
ful AD evolves into a well-lived life and a well-lived death.
Furthermore, respect for the ethical principles of autonomy,
beneficence and non-maleficence were manifest. There
was no duress for unwanted treatments. Perhaps even
more illustrative, the manifest serenity, tranquility and
equanimity in the last four days of her life were witnessed
and enjoyed by many siblings, children, grandchildren and
health care providers in her journey to join her husband
who died many decades earlier.
Case Two: Mr. P presented to the ED and was subse-
quently admitted for evaluation of altered mental status,
superimposed on severe end stage dementia with a FAST
score of 7C.10 (Table 1) He previously had innumerable
outpatient palliative care visits, ED visits and hospital
admissions, preceded by an approximate six to seven
year inexorable cognitive decline. His primary physician
referred him for a palliative care evaluation after multiple
neurological evaluations confirmed the diagnosis of Alz-
heimer’s dementia.
The patient’s surrogate spoke with confidence regarding
the patient’s substituted wishes and provided documenta-
tion as the surrogate and power of attorney for health care.
It was also evident that this child was suffering tremen-
dously at the prospect of losing her father. She was alone
in the world; her father was the only close relationship.
Since the patient could not speak for himself and didn’t
generally seem to suffer, the caring physicians often found
themselves more worried about the daughter’s well-being
than the patient’s.
Regrettably, no documentation of a health care directive
manifested during the years of outpatient consultations,
emergency visits and hospitalizations. Additionally, these
frequent admissions ultimately created a significant angst
in virtually everyone involved in her care.
After considerable debate and legal counsel, the clinic
legal department was able to obtain the patient’s “living
will-advance directive” which in essence precluded the
diagnostics and therapeutics rendered over the preceding
years. Ultimately, Adult Protective Services required the
daughter/health care surrogate to allow Mr. P’s enrollment
in hospice services consistent with his living will.
The moral of this story is to “trust; yet, verify,” especially
in the cases of incompetent patients. Our caring and trusting
nature was exploited to the chagrin and disappointment of
all and with the very real possibility of unintentional harm.
Domain 4- Social Aspects of Care:
This domain engages social services with integration
and referral services.
Domain5-Spiritual, Religious, andExistentialAspects ofCare:
This domain addresses the worldviews and cosmologies
that patients consider important and is sensitive to their
religious beliefs and traditions.
Domain 6- Cultural Aspects of Care:
This domain allows the patient to articulate cultural ritu-
als, language and culture-specific needs into their care plan.
Domain 7- Care of the Patient at the End of Life:
This domain begs timely assessment and informing of
impending death in a compassionate manner.
Domain 8- Ethical and Legal Aspects of Care:
This domain mandates that the patient’s goal of care is
obtained in an ethically respectful manner consistent with
the patient’s expressed interest (or surrogate) while staying
congruent with state and federal statutes. Advanced Care
Planning is a key component of this domain.
The palliative care interdisciplinary team (IDT) includes
a broad spectrum of health care professionals including
physicians, nurses, social workers, chaplains, counselors,
case managers, rehabilitation specialists, speech and lan-
guage pathologists and pharmacy professionals. This team
assesses and treats the palliative needs of the patient and
family, facilitates patient-centered communication and
decision making and coordinates continuity of care across
settings throughout the disease continuum.
Case Studies: A Closer Look
Here are the cases evaluated from both a primary care
and a palliative care perspective:
Case One: Mrs. S presented to the emergency department
(ED) near her 84th birthday in a dire medical crisis with
acute multiple myeloma based on bone marrow biopsy.
This explained her complaints of bone pain and hurt-
ing all over. The pancytopenia contributed to epistaxis,
fatigue, and dyspnea, and her pruritus was attributed to
elevated bilirubin. She also suffered with mild congestive
heart failure. She wanted information about diagnosis,
additional options and advice; however, once informed,
she declined additional evaluation or treatment other than
symptom-driven care. Her doctor passionately stated, “Mrs.
S, you will die if you don’t. Why won’t you?”
Her reply: “God’s will, has no why!”
Indeed, her Roman Catholic faith was so resolute that
she informed the medical staff that medicines and medical