What Would You Recommend?

Case history.

93 year old demented patient hospitalized one month prior for Acute inferior MI and acute decompensated systolic heart failure.

Had a troponin max out at about 20.

She is left with an ischemic cardiomyopathy with an ejection fracture of 25%. Moderate aortic stenosis, moderate mitral regurgitation.

Previous chest xray one month prior suggested either a very tortuous aorta or a lung mass in the left upper lobe.

The patient was discharged to a "rehab" facility (using the words loosely), where she has been falling uncontrollably for several days.

Reference here


where I talk about how it is impossible to have it both ways. Keeping delirious/demented people from falling while simultaneously keeping them from getting injured with restraints.

Old demented people fall.

That's what they do.

Unless you strap them to their wheel chair with duct/duck tape, they will always be at risk for falling for the rest of their lives.

Well, guess what happened now.

This last fall resulted in a hip fracture and head laceration.

So here I have a 93 bony demented female less than 6 weeks out of an MI, EF 25%, lung mass, shows up in the ER with an O2 sat of less than 85% on room air. Systolic blood pressures in the 90's. Her head CT suggests old to subacute bilateral middle cerebral artery infarcts.

Her chest xray looks like fibrosis and that darn lung mass.

At least the EKG doesn't show anything acute.

Her leg dopplers are negative for DVT.


From a risk stand point, she represents the highest possible risk you can assign any surgical patient. Her perioperative mortality is almost guaranteed.

I had a chance to talk with the ER doc, who graciously brought up the possibility of conservative management with the POA. Gone before I could talk with him, he apparently told the ER doc that his 96 year old uncle is still thriving (I'm paraphrasing)

Hopefully, he is not extrapolating this thriving scenario to his Aunt, who lays babbling on the bed without a muscle on her bones, likely entering her last days/weeks of life.

I placed a consult for our palliative nurse to see. If ever there was an indication for hospice, she would qualify.

Unfortunately, I also placed a consult for orthopaedics because at my facility the only way a consult can't be rejected is if the ER on call consultant is called through the ER.

The last thing I want is for the POA to demand surgery and then have no surgeon willing to see her on the floor as a floor consult. Then, that's a problem I"m not willing to take on.

If I had the legal backing of state or federal laws that granted me immunity from civil prosecution for making hospice/futile care decisions against the wishes of the POA, then I would push for conservative management, pain control, and palliative evaluation.

As it stands now, the patient gets both a palliative (the right move) and a surgical evaluation which will likely cost thousands and thousands of dollars in resources, and IF she lives the first 24-48 hours after surgery, her mortality will most certainly approach 100% in the next 30 days.

That's how I get to spend your tax dollars.

Any questions?