When the Prognosis Leads to Indifference
Abstract
Case Discussion in Palliative Medicine When the Prognosis Leads to Indifference JOSEPH J. FINS, M.D., F.A.C.P.1 CHARLES von GUNTEN, M.D., Ph.D., F.A.C.P., Feature Editor2 CASE A 55- YEAR -OLD WOM AN was transferred to a free-standing inpatient hospice unit to die. She was admitted to another hospital 1 month prior to transfer with a severe headache. A serious intraventricular hemorrhage was diagnosed. After a hospital course complicated by mechanical ventilation, parotiditis, herpes simplex virus pneumonia, methicillin-resistant staphylococcus aureus (MRSA) sepsis and persistent delirium, her durable power-of-attorney for health affairs agreed to transfer for comfort care with the expectation she would die in a few days. Medicaid insured her. Her past medical history was significant for liver failure due to heavy alcohol use. She was reportedly sober for 5 years and was on a liver transplant waiting list. She was divorced with a 13 year-old child who lives in another state. She lived with her boyfriend in a remote rural area. She was unemployed. Her sister was her proxy. Her initial physical examination was remarkable for a waxing and waning delirium. Dehydration secondary to iatrogenic diuresis was treated with intravenous fluids. Over succeeding days, her sensorium cleared and it