The Case Continues

Cardiology was consulted and felt that Mr. Stanton had suffered a silent, recent and evolving MI, perhaps a week prior to admission. Cardiologists wanted to catheterize the patient but deferred this as patient refused to consider the possibility of a ICU stay and because he was hypotensive and had urosepsis. Patient continued to deteriorate and at the recommendation of Cardiology, palliative care was consulted.

In the past few months, his daughter, Karen has seen her father aging in front of her eyes. Many times, he started to talk about his wife and about his death, but she usually cut him off with “Dad, stop this destructive thinking. All this ‘death talk’ is making me depressed.”

In the hospital, the doctor tells Karen that her dad has had a heart attack and is very sick. When they discuss the future, Mr Stanton states clearly “No ICU Karen! No machines! Let me go with peace and dignity. Remember what happened to mom..she spent weeks in the ICU and suffered so much. I could not bear it! Let me go in peace,” says Mr. Stanton adamantly. Karen agrees.

Over the past two days, Mr. Stanton is getting sicker. He has frequent chest pain and is on numerous medications. He is usually too tired or sleepy to talk. Karen wants to talk to her dad, but he is unable to talk for very long. Karen is slowly realizing that this may be the end for her dad.

Mr. Stanton’s path, his dying trajectory, is a typical one for cardiovascular disease (Teno 2001). As is often the case, the family seems shocked by his rapid decline (Christakis 1999).

We do not know how the cardiologist discussed his prognosis or what was done to prepare for this almost inevitable decline. Some additional coaching on what could be expected might have softened the shock of this bad news (Baile 2002; VandeKieft 2001). Certainly, clinicians must be careful not to frame referral to hospice in terms of “nothing more that can be done” or in terms of a lack of hope (Morita 2004).

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