The unbefriended: Introducing hospice

A 75 year old man was admitted to custodial care in a skilled nursing facility with a history of malnutrition and failure of self-care, weight loss and anemia. Fifteen months prior he had Stage 2C transmural colonic adenocarcinoma with regional lymph node involvement, and now had multiple hepatic metastases. He had a 4 year history of urinary retention, reportedly attributed to prostatic hypertrophy, but now also had a markedly elevated PSA. He had a history of medical noncompliance with multiple failed outpatient appointments, failure to take medications on an outpatient basis, involvement of adult protective services, and a diagnosis of mild dementia following a CVA 18 months ago. Despite his history, psychiatric evaluation had deemed him to have intact decision-making capacity - at least sufficient to sign himself in for the SNF admission - and determined that he did not need court-appointed conservatorship. "Wants full code" said the prior physician's report, "Code status discussed with patient: full life-sustaining interventions for now. He says ‘life is precious.' "

In answer to the ‘tell me what you understand about your illness' question , the patient was able to acknowledge that his life expectancy was in months rather than years. So the nursing facility attending physician introduced the card-sorting exercise, saying, "These are things that other people whose time might be short have said are important to them. I was wondering if any of them are really important to you, or if there are other things not on these cards that are very important to you." The patient had difficulty reading the cards for himself, but listened to each one being read aloud and indicated whether he thought it was important, so-so, or not important. For one who had distinguished himself as a loner, it came as a bit of a surprise that it was very important to him to have medical care givers who know him as a person and whom he could trust. He wanted to have an advocate who would know his wishes and who would help him sort out some financial issues.

Review of the preferences he had expressed in the Go Wish exercise revealed opportunities where hospice could help meet several of his expressed needs: He could develop a relationship with a hospice nurse that he could trust, the hospice social worker could help him with getting his financial affairs in order and also help with his funeral planning, and hospice staff would pay attention to his physical comfort. Hospice was introduced as a program that could help him meet these goals, he agreed to the referral, and his goals were incorporated into the hospice plan of care.