PC Qi Rounds

Would Palliative Care Consultation have changed this trajectory?

April 1/20

• 72 M transferred from Haro Park with staff concerns over hyperglycemia and fever.
• Diagnosed on March 18/20 with COVID 19.

PMHX

• Lewey Body Dementia
• DM2
• Dyslipidemia
• Vascular Dementia (?)

Investigations

• WBC 17.7
• HGB 175
• POCUS B Lines
• CXR bilateral hazy infiltrates consistent with PNA (COVID)
• Na 175
• HCO3 20
• Lactate 4.2
• Cr 194 (GFR 29)

GOC

• "At this point given this patient's underlying comorbidities and current respiratory status, I do not feel this patient would be an appropriate referral for critical care admission."

Family Response (phone)

• "I have discussed his care and possible prognosis with his daughter at length. She reiterated that her family concerns that he is a fighter and would want every chance to recover."

I will discuss with Internal Medicine and Palliative Care for likely admission and comfort measures

CTU Admission Note April 2 0200

• Noted that prior to transfer that patient was DNR3 though daughter insisted on transfer and full code.
• CTU agreed that patient should not be for Critical Care.
• Palliative Care was consulted, to see in am.
• Dx: HHS, hypernatremia, COVID 19
• Target-get patient back to baseline where he was reported to be talkative and ambulatory with walker.
• DNR M3

Critical Care Consult #1 0225

• Reviewed with resident on phone, agreed that DNR 3 (noted to have been signed in past) is most appropriate and not for Critical Care admission
• At that time, the assessment was that the patient was improving with fluids in terms of his ALOC.

Critical Care Consult #2

• Initiated by CTU/ICU as the patient remained unrousable and daughter insistent on full code measures.
• Inability to reach consensus with daughter, and CC MD 2 consult requested

CC Consult 2

• "It is my opinion that no critical care intervention including intubation and ventilation (as we are discussing COVID 19) would alter the course of this disease, and as such would represent futile, uncomfortable care for this gentleman. I agree with his current DNAR3 status as the most appropriate level of intervention."

April 2 1420

• Family Conference document
• "Given the family's persistent wishes for the patient to remain full code despite understanding it to likely provide benefit and bring harm, I will reverse his code status as a full code."
• Patient still remained drowsy and hypovolemic, now on D5W @ 200 cc/hr.

CCOT x 4 visits April 2, 3

Transfer to ICU 0334 April 3 with Airway Team consulted

Other stuff

• L sided PTX (pigtail)
• Briefly DNR 4
• April 12-query improvement, hopeful for extubation?
• Ongoing AKI secondary to ATN
• SVT
• Worsening pressure ulcer on coccyx
• CT-low attenuation, no large vessel occlusion. 5 MM pulm nodule in LUL.
• R inguinal hernia, not reducible

April 21 EEG

• findings consistent with bilateral diffuse non specific cortical disturbance

April 23 Palliative Med Consult

• Patient chart reviewed, seen in the ICU and reviewed with nursing and ICU staff in person
• Called daughter on phone
• No in person or video chat to patient from family at that time since admission 3 weeks prior

Ongoing near daily GOC discussions

• Noted to have increasing tone of distrust, lack of empathy, second opinion seeking, and disbelief in bedside assessments by daughter

May 1
GO FAR gofarcalc.com

May 2
Pursue teach given no LOC improvement

Could we have helped to prevent this?