Case Discussions Challenges in End of Life

Care15/11/14

MRS M

MRS M 85 year old Care Home Resident

Type 2 diabetes, leg ulcer Meds:

PPI Statin, Metformin, + recent Amitriptyline, MST, Oramorph

Social Orientated, alert, communicates with

staffNOK – Nephew

Background

Foot ulcer 6/12 care of DNs but mobile

8th June: …lost weight, poor appetite, worsening foot pain

Commenced MST, + Oramorph prn Late June: Still pain ?Neuropathic-

Amitriptyline commenced Due review 1st July by Community

Geriatrician for A CP

30th June – phone call – on call GP, Mon 2pm

“Mrs M deteriorated over morning, not herself”

Visit In Bed, Difficult to rouse All Obs normal Looked Dry. General exam NAD Pupils reacting- Not co-operative for neuro

exam, No obvious infection…… No urine to test LOOKED LIKE SHE WAS DYING

WHAT DO YOU DO NOW?ADMIT OR LEAVE IN NURSING

HOME??

Staff want admission unless GP does DNACPR form and ACP immediately

Nephew in a meeting. Staff say spoken to him. He would be keen for admission. Not able to disturb until meeting ends at 7pm

Note – was due to have ACP discussion in a few days.

Discussion

Unable to ask Mrs M her wishesNo prior discussion recorded

(due imminently)No family available to ask what

Mrs M would have wishedPatient best interests ..Benefits v burdens of courses of

action.

WHAT HAPPENED NEXT?

Arranged admission as sudden change even though appeared end of life…… Ambulance booked

Nursing home staff happy, GP troubled. Later… Nursing Home phoned- managed to

contact nephew who preferred to leave Mrs M in Home

Unable to take anything orally, sub cutaneous meds arranged

2/7 died peacefully surrounded by family