Mr. Eddie Brown is a 62-year-old Caucasian man brought to the Emergency Department (ED) by Emergency Medical Services (EMS) today at 2 pm. He was found by his landlord, lying on the floor of his trailer, with altered mental status (AMS). Review of previous medical records indicates he has a history of cirrhosis from hepatitis C, most likely contracted from intravenous (IV) drug use when he was in his mid-twenties. The electronic health record (EHR) lists his sister, Julie Brown, as his next of kin.
In the ambulance on the way to the ED, he vomited a moderate amount of coffee ground emesis suggesting upper gastrointestinal (UGI) bleed.
An IV line was started by EMS and normal saline is running at 150 mL/hr.
Blood type and crossmatch for 4 units of blood is sent. In the interim, 2 units of unmatched packed red blood cells (PRBCs) are infused. A Foley catheter is placed for measurement of urine output and he is intubated for airway protection.
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1Advanced trauma life support (ATLS®): the ninth edition. ATLS Subcommittee et al. J Trauma AcuteCare Surg. (2013).
In addition to the doctor or advanced practice provider (APP), which professionals should be involved with Mr. Brown’s care at this time? Click on each correct answer to see the role of each provider at this time.
The causes of upper GI bleeding are varied. With Mr. Brown’s history of cirrhosis, esophageal and/or gastric variceal bleeding is suspected. Varices are a complication present in half of patients with cirrhosis and correlates with severity of liver disease.
Guidelines for Prevention and Management of Variceal Hemorrhage in CirrhosisBased on the Guidelines, what are your next steps to manage Mr. Brown’s hematemesis in the setting of potential variceal bleeding?
Prior to transfer, Mr. Brown received the following treatment in the ED:
Mr. Brown remains on mechanical ventilation and is resting comfortably.
The ED social worker contacted Mr. Brown’s sister to let her know he was admitted to the hospital. The critical care provider now calls Ms. Brown to obtain information relevant for Mr. Brown’s care.
Listen to the conversation between Ms. Brown and the critical care provider:
Mr. Brown’s sister, Julie, arrived at the hospital earlier in the day and was given a brief update about her brother’s status. Mr. Brown does not show any more signs of bleeding and he is successfully extubated after a spontaneous breathing trial in the morning. His mental status is improving. He is still slow to respond to questions, but his responses are relevant and rational. He has 2+ pitting edema to knees with a distended abdomen, positive fluid wave and bulging flanks, which are worse since admission.
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Before Mr. Brown’s current condition and goals of care can be discussed, it is important to assess his cognitive ability to understand his medical condition and the decisions needing to be made at this time.
Click here to learn more about assessing decision making capacity
After assessing Mr. Brown’s decision making capacity, it is determined that he is able to make decisions about his care. A family meeting will be scheduled to discuss goals of care. When asked if he would like anyone else at the meeting, Mr. Brown says that he would like his sister included because his memory is not reliable.
Decision making capacity should be re-assessed often as it can wax and wane.
Julie Brown arrives to visit her brother this morning. When she arrives, the nurse informs her that her brother is more awake today. She also learns the team caring for him would like to have a meeting with them both to discuss his care.
One strategy to determine if a goals of care discussion is warranted with a cirrhosis patient is if the patient meets at least one of the following criteria. Which criteria does Mr. Brown meet?
The conversation begins with asking what the patient and family understand about what brought the patient to the hospital. It is important to listen to their understanding of the situation, answer any questions they have, and ask again to confirm they have all their questions answered before moving to the next part of the conversation. What are some questions that might be asked at this time?
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The next step is to focus on the goals of the patient and his family.
It is important to frame the discussion so the patient does not feel there is a right or wrong way to proceed with care. Examples of unbiased statements/questions are:
* Questions are intended to elicit patient’s feelings about life, death and healthcare at end of life.
Boyd, K., Kimbell, B., Murray, S., Iredale, J. A “Good Death” with Irreversible Liver Disease: Talking with Patients and Families about Deteriorating Health and Dying. Clinical Liver Disease Vol 6, (1), July 2015.
Mr. Brown stabilized enough to be transferred to the medical floor on hospital day 4. After transfer, Mr. Brown developed worsening hepatic encephalopathy, and his liver function this morning is now worse with elevated creatinine and INR. He is no longer deemed to have decisional capacity based on inability to reason and retain information.
He is moaning and writhing and holding his abdomen.
On physical exam, he has persistent ascites, with 3+bilateral pitting edema to groin.
Ultrasound demonstrates cirrhosis and ascites.
Potassium 5.1 mEq/L - ↑ from 4.0
Sodium 127 mEq/L - ↓ from 131
Glucose 120 mg/dL
GFR 29 mL/min
Creatinine 3.0 mg/dL - ↑ from 1.7
Bilirubin 2.2 mg/dL ↑ from 2.1
Albumin 2.1 g/dL ↓ from 2.5
ALT 70 IU/L ↑ from 66
AST 71 IU/L ↑ from 50
Alk Phos 150 IU/L ↓ from 180
INR 2.0 ↑ from 1.7
Platelets 65,000 mm3
Hgb 9.0 g/dL
Hct 28%
Here is Mr. Brown’s previous problem list. Please mark which of his problems are resolved and can be removed from his list.
Based on Mr. Brown’s current condition and the labs from Screen 15, what new problems need to be added to his list?
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Given Mr. Brown’s worsening encephalopathy and impaired decision making capacity, his sister Julie is contacted to re-evaluate goals of care. She is concerned over the change in his condition, particularly his mental status, but states that she still wants all life prolonging measures for him and a liver transplant if possible.
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Mr. Brown’s symptoms improve enough that he is discharged from the hospital to home with close outpatient follow-up with primary care and gastroenterology/hepatology. He will live with his sister in her house immediately post discharge, but plans to relocate his trailer to his sister’s driveway as soon as possible and live there.
Fair
[x] Home [_] Skilled Nursing Facility [_] Other: _
Primary Care Clinic in 1 week
Gastroenterology in 2 weeks
Hepatic/Renal Panel in 1 week prior to PCP visit
None
Decrease lactulose to 30 mL three times daily or titrate to 4 BMs/day
New allergies identified this visit:
vancomycin - reaction(s): Red Man Syndrome
| Drug | Dose |
|---|---|
| Furosemide 40 mg | 1 tablet daily |
| Spironolactone 50 mg | 1 tablet daily |
| Lactulose 30 mL | 3 times daily |
| Ondansetron 8 mg | Every 12 hours as needed for nausea |
| Rifaximin 550 mg | 1 tablet twice daily |
| Oxymetazoline 0.05% nasal spray | 1 spray each nostril as needed for nosebleed prevention |
Full Code
Attending Day of Discharge Note:
I saw the patient and spent
[_] greater than 30 minutes
[x] 30 minutes or less
personally providing discharge day management services. I agree with the findings and plan as documented in the note written above.
End-Stage Liver Disease
GI bleed
Ascites
AKI
Mr. Brown, with the help of his sister, has been actively pursuing completing the requirements for liver transplantation. He presents to the clinic, but unfortunately his liver disease has continued to deteriorate and he reports that he feels worse, more so in the last 2 weeks and is currently in pain (3/10). His current Na-MELD score is 19 with a Child-Pugh score (CTP) of “C” which suggests a median survival of 6-12 months.
Click here for information on survival measurement tools.
A discussion reviewing patient/family goals of care is warranted since there has been a change in condition. This should occur regardless of transplant status. In this case, the patient now has a predicted survival of about 6-12 months in the context of worsening liver function and overall health status. These are poor prognostic indicators and should prompt further discussion.
Core skills for effective communication around end-of-life issues center on:
Patient beliefs, or anxiety and fear, may cause patients to choose a plan of care different from the one practitioners might choose. Practitioners should provide accurate, clear information about the patient’s condition and treatment options, and then to support the patient and family to make the decision that they believe is best for them.
If ethical issues arise related to the patient’s chosen plan of care, an ethics consultation may be sought. Some possible ethical conflicts include a patient request for treatment viewed as futile by the health care team or intrafamily conflict about goals of care.
Click here to review the ethical decision making tool
Mr. Brown clarified that he continues to want treatment and further testing for liver transplantation. Due to concerns for inducing hepatic encephalopathy, opioids for pain management are avoided at this time.
There are no formal guidelines for pain management in patients with cirrhosis/ESLD. These patients often are undertreated for pain due to lack of provider knowledge. Reduced dose acetaminophen (2-3 g/day) is safe to use in patients, but non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided. Opioids have an increased risk of inducing hepatic encephalopathy, particularly in patients with low albumin levels. Should opioids be necessary for pain management, immediate-release formulations are recommended in conjunction with laxative co-prescription.
Dwyer JP, Jayasekera C, Nicoll A. Analgesia for the cirrhotic patient: a literature review and recommendations. J Gastroenterol Hepatol. 2014;29(7):1356-60.
Mr. Brown’s ascites has become refractory to diuretics and he is requiring weekly paracentesis for comfort. His current functional status has declined. He:
He has reflected more on the discussion of goals of care that occurred a month ago and asks to revisit this discussion with the health care team. He verbalizes that his hopes for his future have changed. He decides that he no longer wants to pursue transplant, and would rather spend his time with his family at home in maximal comfort for whatever time he has left without further interventions.
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The social worker at the Specialty Care Clinic contacts hospice to transition Mr. Brown’s care. He is admitted to home hospice, staying at his sister’s house so he can spend his remaining time with her and his nephew. He states his desire for his nephew to take care of his dog “after he is gone.”
Mr. Brown dies 6 weeks later with his sister and nephew by his side.
You have now completed the case study. Please click on the link below to provide feedback on your experience.
Palliative Care EvaluationCommunication in the ICU: Holding a family meeting.
Wood, Jordan J. Chaitin, Elizabeth. Arnold, Robert M. In: UpToDate, Post, Ted (Ed), UpToDate, Waltham, MA, 2016.
(Will only be accessible for those with UpToDate Subscription)
The Human Connection of Palliative Care: Ten Steps for What To Say and Do
https://www.youtube.com/watch?v=7kQ3PUyhmPQ&index=5&list=PL2cT-oThj8N3b_Bnz9w2sIAxyV6VoRahPEnd-of-life Decisions
National Hospice and Palliative Care Organization
Webinars, conference calendar, delivery models, payer-provider toolkit
Center to Advance Palliative Care (CAPC)
Patient and family resources, health care provider resources, calendar of events
Cambia Palliative Care Center of Excellence, University of Washington
Please listen to the conversation and suggest how improve it.
Please listen to the conversation below and suggest how improve it.
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The clinical pharmacist’s role is to manage a large number of required medications.
Based on his current state of worsening hepatic encephalopathy, lactulose should be prescribed and titrated to 3-4 bowel movements a day. Given his change in mental status, he may need a nasoenteric tube for medication administration. If lactulose alone is not effective in improving hepatic encephalopathy adding rifaximin at a dose of 550 mg BID could be considered. Due to worsening encephalopathy and renal function, diuretics should be discontinued. Doses of current medications should be evaluated for adjustment to account for worsening renal function. Medication education for the patient would not be appropriate at this time due to his altered mental status. Family should be educated about hepatic encephalopathy, but this is not an appropriate time to educate about medication given the stress related to this acute episode.
The social worker’s role is to assist patients and families coping with medical illness and to coordinate care plans. S/he works collaboratively with the family and team to address social and emotional needs to meet the patient’s stated goals of care.
The hospitalist’s role is to maintain the quality of life, promote health, and prevent re-hospitalization of the patient. It is important they continue to have conversations about the goals of care and clearly document these goals.
The registered nurse’s (RN’s) role is to work in collaboration with other health providers to anticipate and meet the needs of the patient and family facing serious and/or life-limiting illness. S/he also provides psychosocial, spiritual and culturally-sensitive support.
The role of the spiritual care provider is to offer culturally sensitive emotional and spiritual support to patients, families, and staff.
The priority for the spiritual care provider at this time is to:
The role of the dietitian is to assess a patient’s nutritional status, take anthropometric measurements to assess muscle stores, and provide nutrition recommendations to the team.
The priority for the dietitian is to assure the patient has:
Additionally, the dietician will:
The role of the nephrologist is to assist the care team in diagnosing and managing kidney disease.
Due to Mr. Brown’s condition, the priority for the nephrologist is to:
The role of the gastroenterologist is to assist the care team in symptom management of end-stage liver disease and lead discussions regarding lifesaving therapies (i.e., liver transplantation).
The priority for the gastroenterologist is to:
In many serious chronic illnesses, curative therapies such as transplantation exist, but patients have to be “sick enough to die,” but not “too sick” to be accepted onto a transplant list. In addition, many people have misinformation about what is required to be accepted onto a transplant list. Practitioners must ensure patients receive high quality therapeutic interventions while paying attention to evolving patient and family goals and values. Identifying deteriorating health status early and talking with the patient and family about the status is key to supporting them to make the most informed decision, even if that is not the decision a provider would recommend.
Pai, R., Karvellas, C.J. Is palliative care appropriate in a liver transplant candidate? Clinical Liver Disease, 6(1), 2015.
The role of palliative care is to help patients and their families explore and articulate their goals of care, and to ensure the patient's goals of care are factored into the healthcare team’s plan.
The priority for palliative care is to:
In institutions where there is a palliative care team, they often handle these discussions. However, there are many institutions that do not have a palliative care service. In that case, these tasks are completed by the providers caring for the patient. Some providers embrace the concept that palliative care is everyone’s responsibility, and will engage with patient and family around this topic, while others may not. It is important that the health care team have an open discussion about which members will participate in the discussion, who will lead the discussion, and when this discussion will take place.
General: Ill appearing man seen on stretcher in mild distress.
Neck: Supple, neck veins flat
CV: S1/S2 auscultated, regular rate and rhythm. Tachycardic. No murmur, rub or gallop. Extremities without cyanosis, clubbing. 1+ pitting edema present to ankle bilaterally.
Resp: Lungs clear to auscultation bilaterally.
GI: Bowel sounds (BS) positive, abdomen slightly distended with ascites but soft and tender to palpation in the right upper quadrant (RUQ), but no rebound tenderness. Liver and spleen not palpable.
Neuro: Opens eyes when name called, otherwise, minimally responsive, oriented to person. Moves all extremities. Negative for asterixis.
The social worker must balance respect for Mr. Flores and his desire to be included in the plan of care with Mrs. Castillo’s privacy. Mr. Flores, while a friend of Mrs. Castillo, is not legal next of kin. He must be treated considerately, but the social worker must also maintain Mrs. Castillo’s privacy and focus on locating legal next of kin.
Blood Alcohol Level: 0
INR: 1.0 (normal)
PTT: 35 seconds
CBC:
Hgb 9.9 g/dL
Hct 38%
Platelets 152,000/mm3
WBC 12,000 cells/mcL
Neutrophils 70% - Hi
Lymphocytes 23%
Monocytes 6%
Eosinophils 1%
Basophils 0.2%
BMP:
BUN 27 mg/dL
CO2 22 mmol/L
Creatinine 0.95 mg/dL
BUN/Creatinine Ratio: 28 - Hi
Glucose 310 mg/dL - Hi
Sodium 112 mEq/L - Lo
Chloride 85 mEq/L
Potassium 4.3 mmol/L
GFR calculated: 57.7 mL/min/1.73 m2 - Lo
Troponin: 0.01 ng/mL negative
CK: 50 U/L
U/A- wnl, except for + protein
Urine Toxicology Screen-negative
Multiple left-sided rib fractures. Most of these appear to be chronic and healed; however, there are acute-subacute appearing fractures of the anterolateral aspect of the left 4th and 5th ribs. Ununited chronic fracture of the lateral aspect of the left 6th rib.
Spine CT: No fractures.
Head CT: 3mm right acute on chronic holohemispheric subdural hematoma without shift. No noted skull fractures.
Photo courtesy of UW Medicine.
The rationale for obtaining this consult is the presence of multiple rib fractures; need for assessment of possible elder abuse and locating legal next of kin (LNOK).
Social worker reports that she has attempted to contact patient’s daughter, but has not been able to reach her. Social worker will continue to reach out to daughter and locate other family members. Once family has been reached, social worker will conduct safety assessment for Mrs. Castillo, including assessing for possible elder abuse or neglect due to rib fractures.
The rationale for obtaining this consult is for surgical evaluation of the patient’s subdural hematoma.
Neurosurgery finds that the SDH is non-operable and recommends the transfusion of a 6-pack of platelets.
Aspirin therapy, such as Mrs. Castillo was receiving, disrupts platelet function by inhibiting COX-1 for the life of the platelet (~7-10 days). Presently, platelet transfusion for patients receiving antiplatelet agents, such as aspirin, is controversial and requires further study. A summary of work in this area is provided in the link below.
