This case has been on my mind for some time and I thought that I would share it with the world and get some opinions.

A very elderly lady, Mrs. Y presented to the ER for worsening congestive heart failure (CHF). She was diagnosed with CHF about 2 years ago. She had decompensated in the past 4-5 months and had been in and out of the hospital and rehab facility for CHF exacerbations. In the ER, she said that she does not want any treatment and wants to die since she cannot live with her family and is tired of being sick. Therefore in consultation with the family (who were present in the ER) she was changed to comfort measures and admitted to the medical floor.

When I saw the patient, I thought she was depressed and most likely did not have the capacity to take her own decisions. The family supported the patients decision for comfort measures although they admitted that they would like the patient to be treated for CHF.

It was a difficult situation for me, as I clearly knew that the patient’s CHF was easily reversible and the patient was depressed and most likely unable to take decisions. Also I was unable to reverse the patients code status.

I decided to take the midline approach i.e. treat the patient for CHF with high dose diuretics and give her morphine for difficulty in breathing (which is also a treatment for pulmonary edema and CHF) along with an antidepressant. I hoped that if she responds to the diuretics (and morphine) her breathing would get better and by 2-4 weeks her depression would be under control by the anti-depressants. On the other hand if she does not improve or deteriorates, she would be on morphine which would keep her comfortable and thus honor her desire to be on comfort measures.

What would you do?

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Tags: CHF, CMO, Comfort measures, heart failure

This entry was posted on Sunday, July 6th, 2008 at 12:49 pm and is filed under Viewpoint. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.