GEM case 5 – Nursing home patients and End of life issues

11 Mar

A 84 year old lady presents to the ED at 2am via Emergency Ambulance with a complaint of shortness of breath and fever. She had a background of dementia and severe osteoarthritis and was a local nursing home resident. As per the ambulance handover she was febrile at 38.6 with increased work of breathing and worsening confusion, and as a result an emergency ambulance was called.  Her information from the nursing home included basic demographic information, a nieces overseas emergency contact number and a list of medications including lisinopril, simvastatin, iron supplementation, and ibuprofen.  There was no advanced directives.

Evaluation of the patient revealed an elderly, frail appearing woman who appeared sleepy, dyspnoeic  and in mild discomfort.  On questioning she knew her name only and that her back, and right knee were hurting.  She didn’t know the date, her location, or any medical history.  She asked that you contact her daughter whose name she couldn’t remember.  The vital signs were: T 39.1, BP 94/56, HR 116, RR 24 with accessory muscle use and oxygen saturations of 87% on room air.  Physical examination was notable for left lower lobe crepitation on examination and pain with passive movement of the right knee.

A quick call to the nursing home revealed the patient was confused at baseline, but able to answer basic questions.  According to the staff, she normally would remember her daughters name as the daughter visited twice a week and lived locally.  They were unable to give details regarding do not resuscitate orders.  They provided the daughters phone number.