TABLE 3.
Theme: Practitioner‐driven – Moving along the pathway
| Quote | Exemplar passages from notes | Note title; setting; service (day) |
|---|---|---|
| 3a | family meetings held to discuss best path forward for [patient]. He has been anorexic for weeks with significant weight loss, decreasing cognition, refusing medications and persistent hypotension…All of these indicate that veteran's body is wearing down and that his life expectancy is less than 6 months. | Consult; Inpatient; Palliative Care |
| 3b | his [dialysis center] will not accept him on hospice and will likely be unable to dialyze him with SBP in the 80s. Altogether, it seems that the patient's heart failure is preventing dialysis and the most reasonable path forward is home hospice without dialysis. I discussed this with palliative care and we will discuss it as a team this afternoon or tomorrow | Progress; Inpatient; Medicine |
| 3c | Wife brought in orange DNR or medical determination form to complete. Patient would not commit to any decision on his care or the suspension of care. He states it depends on how sick he is. | Progress; Outpatient; Primary Care |
| 3d | [Nephrologist] reviewed [patient's] clinical course over the last several months and stated that dialysis is hurting [patient] and that he would not recommend replacing his dialysis catheter. [Wife] was noticeably silent during this and avoiding eye contact with anyone. [Hospitalist] recommended that veteran be transferred to [hospice ward] and we focus on his comfort. I acknowledged [wife's] silence and affirmed the struggle she has had with this process | Consult; Inpatient; Palliative Care |
| 3e | Palliative Care suggested a family meeting with patient's decision makers/care providers, hospitalist team and palliative care in order for all to be “on the same page” with regard to patient's discharge care plan. | Progress; Inpatient; Social Work (0) |
| They all voiced their opinion that, although they want him to be comfortable, they are not yet ready for comfort‐focused care at the end of life. They wish to pursue physical therapy and continue hemodialysis. | Progress; Inpatient; Palliative Care (+1) | |
| We have previously discussed the hospice philosophy of care, and he is not yet ready to choose this type of care…Please place an Ethics consult today and speak with Chief of Staff to address the ethical dilemma of continuing HD in this patient with ESRD where it is felt that placing another tunneled catheter is not in the patient's best interest. | Consult; Inpatient; Palliative Care (+43) | |
| [Son] reports feeling torn about the circumstances and wants to “fight” for his father to get better….After more discussions, he eventually agreed to enroll his father in hospice | Consult; Inpatient; Palliative Care (+48) | |
| 3f | Patient remains somewhat confused with limited insight. Reviewed current treatment plan and goals of care. To continue aggressive interventions and reassess. | Progress; Inpatient; Cardiology (0) |
| Plan to have a meeting with family on Monday regarding options for hospice but daughter said that her dad needs dialysis. | Progress; Inpatient; Medicine (+21) | |
| I have discussed hospice option again with daughter today. | Consult; Inpatient; Palliative Care (+74) | |
| [Patient] insists that he wants to live and intends to “fight” his multiple medical comorbidities. | Consult; Inpatient; Mental Health (+75) | |
| I explained what CPR would look like including pain, chest trauma (rib fracture, lung/spleen trauma, electric shock), invasive procedures including with multiple IV access lines, a tube in nose to lung attached to another machine besides his dialysis machine. I explained that this would not be a dignified way to die or comfortable way to die. | Progress; Inpatient; Palliative Care (+96) | |
| Goals of care discussion yesterday, still full code…Continue goals of care discussion every other day. | Progress; Inpatient; Medicine (+98) | |
| Given decline in clinical condition and overall poor prognosis, patient was made DNR in the afternoon after discussion with the patient and his daughter. | Progress; Inpatient; Medical Intensive Care (+104) |
Abbreviations: LST, life‐sustaining treatment; CPR, cardiopulmonary resuscitation; DNR, do not resuscitate; HD, hemodialysis; IV, intravenous.