Author Affiliation: Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, New York.
An 85-year-old woman with multiple medical problems, including dementia, coronary artery disease, renal insufficiency, and peripheral vascular disease, was admitted to our hospital with urosepsis. Her hospital course was complicated by the development of dry gangrene of her left foot, Candida sepsis, Clostridium difficile enterocolitis, and multiple deep sacral and trochanteric pressure ulcers. When housestaff asked her son if he wanted us “to do everything,” he always answered yes. She was able to be weaned from the ventilator and was transferred to a medical unit for continued treatment of hospital-acquired C difficile enterocolitis and wound care of her multiple stage 4 ulcers. She underwent 4 surgical debridements under general anesthesia in the operating room over a several-month period but remained persistently febrile despite continuous treatment with broad spectrum antibiotics.
The patient was withdrawn, tense, and turned toward the wall in a fetal position, but she screamed and cried out for her mother, moaned in pain, and tried to hit and strike out at the nurses when they performed her twice-daily dressing changes. She refused all efforts to feed her or offers of sips of fluid and received all nourishment and hydration through her feeding tube. She did not respond to the voice or touch of her son or grandsons when they visited.
On day 63 of her hospitalization, a palliative care consultation was requested by the nurse manager on the floor because of nursing staff distress about their perception of having to hurt the patient during dressing changes. The attending physician had refused to order preprocedure opioids before dressing changes because he was concerned that it would increase her cognitive impairment and confusion. With assent of the attending, the palliative care team met with her son (her health care proxy) and her 2 grandchildren.
During a 90-minute discussion, the team asked the family what they hoped we could accomplish for their mother and grandmother. The son asked, “Can't you do something about her pain?” The team reviewed the hospital course and clarified her diagnoses, prognosis, and what to expect in the future with her family. Sources of her escalating discomfort and pain were identified, and the benefits and potential risks of opioid analgesics discussed. The son asked for a trial of opioids, and his request was relayed to the attending physician, who agreed with the plan as long as the palliative care team took responsibility for prescribing and managing the opioid analgesic regimen, as he was not comfortable doing so. A treatment plan was initiated that included low doses of concentrated liquid morphine for the pain (5 mg every 6 hours via gastrostomy tube around the clock) with preprocedure dosing of an additional 5 mg 30 minutes before each dressing change. Antibiotics were discontinued because she had demonstrated no improvement after 6 weeks of broad spectrum treatment. Fevers were managed with acetaminophen. Within 12 hours her mental status was improved enough that she recognized and smiled at her son and tolerated her dressing changes without evident distress or agitation.1 Two days later the patient moved back to her original nursing home for continuing palliative and wound care from a hospice team, who managed her complex and twice-daily wound care and her pain management. Calls to the family after discharge revealed that the patient was comfortable and more interactive than she had been in months. After she died months later, the family wrote to our CEO and called to express gratitude to the palliative care team for the comfort and peace that she experienced during the last few months of her life.
Correspondence: Dr Meier, Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, PO Box 1070, New York, NY 10029 (email@example.com).
Published Online: July 2, 2012. doi:10.1001/archinternmed.2012.2088
Financial Disclosure: None reported.
Funding for Less Is More: Staff support for topics research funded by grants from the California Health Care Foundation and the Parsemus Foundation.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Internal Medicine editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 1
Customize your page view by dragging & repositioning the boxes below.
Care at the Close of Life: Evidence and Experience
Agitation and Delirium at the End of Life: "We Couldn't Manage Him"
Care at the Close of Life: Evidence and Experience
Delirium, Cognitive Dysfunction, and Fatigue
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.