Defining limits in care of terminally ill patients

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Abstract
Clinical scenario A 78 year old recently widowed man with non-small cell lung cancer and chronic obstructive pulmonary disease is admitted with pneumonia and impending respiratory failure for the third time within 10 months. His medical history includes congestive heart failure with an ejection fraction of 20%, a cerebrovascular infarct with mild cognitive impairment, and coronary artery disease. He has previously been difficult to wean from the ventilator and required a tracheostomy. During his last admission, he was finally weaned after 8 weeks. Afterwards, the patient told his wife and the team several times he never wanted to be on a ventilator again, but he did not complete an advance directive. The doctor starts bilevel positive airway pressure, but intubation seems impossible to avoid. Because the patient is confused, his care is discussed with his son, who has not previously been involved. The son wants “everything” done for his father. The respiratory therapist and the house officer who have cared for the patient at former admissions recommend against intubation and suggest a do not resuscitate order based on the patient's previously stated wishes.

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