Opinion Teachable Moment
diagnosis of pneumonitis, which can support the decision to discontinue empirical antimicrobial therapy. A shorter course of therapy in our patient might have prevented the development of C difficile colitis and his untimely death. Published Online: February 9, 2015. doi:10.1001/jamainternmed.2014.8030.
This case highlights the potential harms of prescribing antimicrobial therapy “just-in-case” in patients with acute aspiration. Distinguishing aspiration pneumonitis from pneumonia provides a key opportunity to improve antimicrobial prescribing practices.
Conflict of Interest Disclosures: None reported.
2. Bynum LJ, Pierce AK. Pulmonary aspiration of gastric contents. Am Rev Respir Dis. 1976;114(6): 1129-1136.
1. Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010. Am J Infect Control. 2014;42(10):1028-1032.
3. Rebuck JA, Rasmussen JR, Olsen KM. Clinical aspiration-related practice patterns in the intensive care unit: a physician survey. Crit Care Med. 2001; 29(12):2239-2244.
TEACHABLE MOMENT
Joshua Feblowitz, MS Harvard Medical School, Boston, Massachusetts. Jeremy Richards, MD, MA Harvard Medical School, Boston, Massachusetts; and Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
490
5. Murray HW. Antimicrobial therapy in pulmonary aspiration. Am J Med. 1979;66(2):188-190.
LESS IS MORE
What Are the Patient’s Wishes? Story From the Front Lines An 83-year-old man with coronary artery disease and chronic renal insufficiency underwent a pyloruspreserving pancreaticoduodenectomy (Whipple procedure) for a pancreatic tumor. Although the patient was not considered an ideal surgical candidate given his comorbidities, he strongly favored undergoing the procedure, and his surgeon agreed to proceed after comprehensive preoperative evaluation. Prior to surgery, the patient told both his surgeon and his wife—also his health care proxy—that he wished to be “full code,” but if he could not be “brought back to [his] normal self,” he did not want to be “kept alive artificially” or have a feeding tube. Surgery was performed without immediate complications; however, on postoperative day 3, the patient became delirious and had a myocardial infarction. He subsequently developed acute respiratory failure and was intubated. Treatment with vasopressors was begun, and he was transferred to the intensive care unit. He then developed a ventilator-associated pneumonia and treatment with broad-spectrum antibiotics was started. His kidney function worsened, and dialysis was initiated. After several days, total parenteral nutrition was started. Despite these interventions, he continued to require multiorgan system support. When his final pathology report revealed locally advanced pancreatic adenocarcinoma, his health care proxy made the decision to discontinue life-sustaining treatments, and he died on postoperative day 14.
A Teachable Moment Corresponding Author: Joshua Feblowitz, MS, Harvard Medical School, 104 Queensberry St, Apt 4, Boston, MA 02114 (Joshua_feblowitz @hms.harvard.edu).
4. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665-671.
Throughout this patient’s hospitalization, our team was faced with numerous, complex decisions about each successive intervention. Identifying limits on aggressive care near the end of life is challenging, especially when patients cannot contribute their perspective to the process. In this case, our patient’s voice was notably absent from decisions to pursue high-intensity treatments
that were potentially inappropriate based on his circumstances and prognosis. Evidence suggests that this situation is common; in a study of patients older than 60 years, more than 70% lacked decision-making capacity at a time when care decisions were required.1 Multiple—albeit imperfect—tools exist to preserve a patient’s voice in such decisions, including selecting a health care proxy, creating an advance directive, or discussing goals of care. Such tools are frequently underused even when they are clearly indicated. Tan and Jatoi2 demonstrated that only 15% of patients with unresectable pancreatic cancer had an advance directive documented. 2 Furthermore, even when such tools are used, they may be insufficient to guide care. Recently, Hartog and colleagues3 showed that other than being less likely to receive cardiopulmonary resuscitation, patients with advance directives received life-sustaining treatments similar to patients without such directives.3 Our patient faced a likely terminal diagnosis and underwent a planned intervention, perhaps one of the most appropriate times to initiate a thoughtful discussion about goals of care. Yet, even in similar situations, these conversations may occur too late or not at all. In a prospective study of patients with advanced lung and colorectal cancer, only 73% had any form of end-of-life care discussion, and these occurred on average 33 days before death.4 In our patient’s case, it became clear that the preoperative goals-of-care discussion had been insufficient. Although his code status and health care proxy assignment were clear, we were missing other— perhaps more valuable—information: an understanding of his desires for quality of life, his grasp of his prognosis and available options, his fears and concerns, and his priorities for his remaining time. Ultimately, we did not understand his goals and preferences well enough to confidently pursue or withhold aggressive interventions once unforeseen postoperative complications arose.
JAMA Internal Medicine April 2015 Volume 175, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Fudan University User on 05/16/2015
jamainternalmedicine.com
Opinion
Whenfacinglife-threateningillness,patients—aswellastheirfamilies—are often confronted with complex, unanticipated, and emotionallychallengingmedicaldecisions.Meaningfulconversationsabout goals of care are a crucial part of creating a feeling of partnership and shared understanding with their clinicians. In our patient’s case, there were missed opportunities to establish greater clarity regarding his priorities and goals, to prepare him and his health care proxy for difficult and potentially unforeseen medical decisions, to revisit his values and preferences over time, and to thus develop a more valuable kind of advance directive through ongoing conversation. In their recent review, Bernacki and Block5 delineate best practices for more effective end-of-life care discussions by clinicians, including (1) assessing patient understanding of prognosis, (2) elicitPublished Online: February 16, 2015. doi:10.1001/jamainternmed.2014.7991. Conflict of Interest Disclosures: None reported. 1. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13): 1211-1218. 2. Tan TS, Jatoi A. An update on advance directives in the medical record: findings from 1186 consecutive patients with unresectable exocrine pancreas cancer. J Gastrointest Cancer. 2008;39(14):100-103.
jamainternalmedicine.com
ing preferences about decision making and information sharing, (3) delivering accurate prognostic information, (4) discussing patient fears, goals, and acceptable level of function, (5) exploring tradeoffs in quality and length of life, and (6) appreciating family involvement in care and decision making. By exploring these areas through meaningful end-of-life discussions, clinicians can better prepare themselves to answer the question “What are the patient’s wishes?” and thus preserve each patient’s voice in the decision-making process. Despite the inherent challenges of these conversations, clinicians should endeavor to embrace rather than avoid them. Indeed, it is part of our duty to patients to improve the depth and frequency of these interactions to better appreciate and honor each patient’s end-of-life wishes.
3. Hartog CS, Peschel I, Schwarzkopf D, et al. Are written advance directives helpful to guide end-of-life therapy in the intensive care unit? a retrospective matched-cohort study. J Crit Care. 2014;29(1):128-133.
Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994-2003.
4. Mack JW, Cronin A, Taback N, et al. End-of-life care discussions among patients with advanced cancer: a cohort study. Ann Intern Med. 2012;156(3): 204-210. 5. Bernacki RE, Block SD; American College of Physicians High Value Care Task Force.
(Reprinted) JAMA Internal Medicine April 2015 Volume 175, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Fudan University User on 05/16/2015
491
diagnosis of pneumonitis, which can support the decision to discontinue empirical antimicrobial therapy. A shorter course of therapy in our patient might have prevented the development of C difficile colitis and his untimely death. Published Online: February 9, 2015. doi:10.1001/jamainternmed.2014.8030.
This case highlights the potential harms of prescribing antimicrobial therapy “just-in-case” in patients with acute aspiration. Distinguishing aspiration pneumonitis from pneumonia provides a key opportunity to improve antimicrobial prescribing practices.
Conflict of Interest Disclosures: None reported.
2. Bynum LJ, Pierce AK. Pulmonary aspiration of gastric contents. Am Rev Respir Dis. 1976;114(6): 1129-1136.
1. Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010. Am J Infect Control. 2014;42(10):1028-1032.
3. Rebuck JA, Rasmussen JR, Olsen KM. Clinical aspiration-related practice patterns in the intensive care unit: a physician survey. Crit Care Med. 2001; 29(12):2239-2244.
TEACHABLE MOMENT
Joshua Feblowitz, MS Harvard Medical School, Boston, Massachusetts. Jeremy Richards, MD, MA Harvard Medical School, Boston, Massachusetts; and Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
490
5. Murray HW. Antimicrobial therapy in pulmonary aspiration. Am J Med. 1979;66(2):188-190.
LESS IS MORE
What Are the Patient’s Wishes? Story From the Front Lines An 83-year-old man with coronary artery disease and chronic renal insufficiency underwent a pyloruspreserving pancreaticoduodenectomy (Whipple procedure) for a pancreatic tumor. Although the patient was not considered an ideal surgical candidate given his comorbidities, he strongly favored undergoing the procedure, and his surgeon agreed to proceed after comprehensive preoperative evaluation. Prior to surgery, the patient told both his surgeon and his wife—also his health care proxy—that he wished to be “full code,” but if he could not be “brought back to [his] normal self,” he did not want to be “kept alive artificially” or have a feeding tube. Surgery was performed without immediate complications; however, on postoperative day 3, the patient became delirious and had a myocardial infarction. He subsequently developed acute respiratory failure and was intubated. Treatment with vasopressors was begun, and he was transferred to the intensive care unit. He then developed a ventilator-associated pneumonia and treatment with broad-spectrum antibiotics was started. His kidney function worsened, and dialysis was initiated. After several days, total parenteral nutrition was started. Despite these interventions, he continued to require multiorgan system support. When his final pathology report revealed locally advanced pancreatic adenocarcinoma, his health care proxy made the decision to discontinue life-sustaining treatments, and he died on postoperative day 14.
A Teachable Moment Corresponding Author: Joshua Feblowitz, MS, Harvard Medical School, 104 Queensberry St, Apt 4, Boston, MA 02114 (Joshua_feblowitz @hms.harvard.edu).
4. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665-671.
Throughout this patient’s hospitalization, our team was faced with numerous, complex decisions about each successive intervention. Identifying limits on aggressive care near the end of life is challenging, especially when patients cannot contribute their perspective to the process. In this case, our patient’s voice was notably absent from decisions to pursue high-intensity treatments
that were potentially inappropriate based on his circumstances and prognosis. Evidence suggests that this situation is common; in a study of patients older than 60 years, more than 70% lacked decision-making capacity at a time when care decisions were required.1 Multiple—albeit imperfect—tools exist to preserve a patient’s voice in such decisions, including selecting a health care proxy, creating an advance directive, or discussing goals of care. Such tools are frequently underused even when they are clearly indicated. Tan and Jatoi2 demonstrated that only 15% of patients with unresectable pancreatic cancer had an advance directive documented. 2 Furthermore, even when such tools are used, they may be insufficient to guide care. Recently, Hartog and colleagues3 showed that other than being less likely to receive cardiopulmonary resuscitation, patients with advance directives received life-sustaining treatments similar to patients without such directives.3 Our patient faced a likely terminal diagnosis and underwent a planned intervention, perhaps one of the most appropriate times to initiate a thoughtful discussion about goals of care. Yet, even in similar situations, these conversations may occur too late or not at all. In a prospective study of patients with advanced lung and colorectal cancer, only 73% had any form of end-of-life care discussion, and these occurred on average 33 days before death.4 In our patient’s case, it became clear that the preoperative goals-of-care discussion had been insufficient. Although his code status and health care proxy assignment were clear, we were missing other— perhaps more valuable—information: an understanding of his desires for quality of life, his grasp of his prognosis and available options, his fears and concerns, and his priorities for his remaining time. Ultimately, we did not understand his goals and preferences well enough to confidently pursue or withhold aggressive interventions once unforeseen postoperative complications arose.
JAMA Internal Medicine April 2015 Volume 175, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Fudan University User on 05/16/2015
jamainternalmedicine.com
Opinion
Whenfacinglife-threateningillness,patients—aswellastheirfamilies—are often confronted with complex, unanticipated, and emotionallychallengingmedicaldecisions.Meaningfulconversationsabout goals of care are a crucial part of creating a feeling of partnership and shared understanding with their clinicians. In our patient’s case, there were missed opportunities to establish greater clarity regarding his priorities and goals, to prepare him and his health care proxy for difficult and potentially unforeseen medical decisions, to revisit his values and preferences over time, and to thus develop a more valuable kind of advance directive through ongoing conversation. In their recent review, Bernacki and Block5 delineate best practices for more effective end-of-life care discussions by clinicians, including (1) assessing patient understanding of prognosis, (2) elicitPublished Online: February 16, 2015. doi:10.1001/jamainternmed.2014.7991. Conflict of Interest Disclosures: None reported. 1. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13): 1211-1218. 2. Tan TS, Jatoi A. An update on advance directives in the medical record: findings from 1186 consecutive patients with unresectable exocrine pancreas cancer. J Gastrointest Cancer. 2008;39(14):100-103.
jamainternalmedicine.com
ing preferences about decision making and information sharing, (3) delivering accurate prognostic information, (4) discussing patient fears, goals, and acceptable level of function, (5) exploring tradeoffs in quality and length of life, and (6) appreciating family involvement in care and decision making. By exploring these areas through meaningful end-of-life discussions, clinicians can better prepare themselves to answer the question “What are the patient’s wishes?” and thus preserve each patient’s voice in the decision-making process. Despite the inherent challenges of these conversations, clinicians should endeavor to embrace rather than avoid them. Indeed, it is part of our duty to patients to improve the depth and frequency of these interactions to better appreciate and honor each patient’s end-of-life wishes.
3. Hartog CS, Peschel I, Schwarzkopf D, et al. Are written advance directives helpful to guide end-of-life therapy in the intensive care unit? a retrospective matched-cohort study. J Crit Care. 2014;29(1):128-133.
Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994-2003.
4. Mack JW, Cronin A, Taback N, et al. End-of-life care discussions among patients with advanced cancer: a cohort study. Ann Intern Med. 2012;156(3): 204-210. 5. Bernacki RE, Block SD; American College of Physicians High Value Care Task Force.
(Reprinted) JAMA Internal Medicine April 2015 Volume 175, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Fudan University User on 05/16/2015
491
