What difference would the involvement of the interdisciplinary hospice and palliative care team have made
Solomon Katz, a 75-year-old retired postal worker, experienced progressive weakness in his left leg for over a year, but he sought care in the emergency department only after he fell and could not get up by himself. After an array of tests, he was diagnosed with lung cancer metastatic to the brain. He accepted medication but refused a lung biopsy. Hospital staff described him as “in denial,” but a psychiatric consultant assessed him as reacting appropriately and capable of making his own decisions. He revealed that his wife died of cancer two years earlier; he did not want to go through the treatments she had. After continued pressure from the oncology team, he agreed to a biopsy, which confirmed the previous diagnosis. They offered options for life-prolonging but invasive treatment; he declined. He was discharged home with home care and follow-up appointments at two clinics. The medical staff did not refer him to the hospital’s social work staff, and no one sat down with Solomon Katz and his family to talk with them about the prognosis, palliative care options, or their concerns and preferences. He did not keep his follow-up appointments, but no one checked to see why. Three months later, Mr. Katz was again brought to the emergency department following grand mal seizures. He was lethargic and could not talk; a CT scan showed progression of the brain tumor, including partial brain stem herniation. He was started on intravenous medications and fluids, and then oxygen and nasogastric tube feedings. The neurology team wanted to resect the brain tumor. His son, a grocery store clerk, refused surgery and asked for a do-not-resuscitate order on the basis of his father’s previously expressed wishes. During the next three weeks, Mr. Katz was minimally responsive but repeatedly removed the nasogastric tube despite restraints. After pressure from the hospital staff, the son agreed to insertion of a percutaneous gastrostomy tube. On the following day, Solomon Katz died of a cardiac arrest with no family present.
• If you had been Mr. Katz’s nurse from the oncology team, what could you have done to insure that he received quality care?
• If Mr. Katz were your loved one, how would you feel at this point?
Solomon Katz continued:
The son was upset by the entire experience, particularly when he later learned that his father’s dying could have been a less brutal experience and that his care could have been managed differently with an emphasis on understanding his goals as his life ended and providing physical and emotional comfort. The case attracted the attention of the hospital ethics committee, which concluded such clearly inappropriate care indicated serious system problems. It began to mobilize an institution-wide effort at self-examination, staff education, process changes, and quality measurement and improvement.
• What difference would the involvement of the interdisciplinary hospice and palliative care team have made in Mr. Katz’s EOL care?Nu