End-of-Life Decision Making: Case 2

by Elizabeth Menkin

The public guardian has just been granted healthcare decision making power for Ms. Long, a 78 year-old woman with severe dementia, diabetes with impaired vision, and poor kidney function, recent recurrent pneumonia, and prior strokes. You are seeing her for the first time in a skilled nursing facility. She was transferred there yesterday following a four-month hospitalization.

When you arrive at the skilled nursing facility to see Ms. Long, she looks very thin, and the nurse tells you that there is a large necrotic pressure sore on her sacrum. The aides are repositioning her so that the speech therapist can do her evaluation. There is an IV running fluids in the patient's left arm, and her right arm lies limp on the bed. Some of the time she seems to look at a face and track movements, but sometimes not. She does not give any answers to simple questions, either verbally or with nods or shaking her head, and does not consistently look at the person who is talking to her. She does not give any social smile in response to the speech therapist's attempts to engage her. You notice that the patient grimaces when she's moved, and cries in apparent pain when she is rolled on her back. She opens her mouth when offered a straw but does not suck on the straw. She takes a small amount of ice cream that is offered by spoon, but after two more tries by the speech therapist she pushes it away and slaps using her left hand.

Questions:

• Is Ms. Long terminally ill?
• What are the treatment decisions at this point?
• Artificial nutrition and hydration?
• CPR / DNAR?
• On what basis will these decisions be made?

Elizabeth Menkin is a physician in geriatric and internal medicine at Kaiser-Permanente San Jose/Santa Teresa. She is the founder of Coda Alliance, a Silicon Valley community coalition for end-of-life care.