Ethical Issues in the Management of Geriatric Cardiac Patients
Ethical Issues in the Management of Geriatric Cardiac Patients
Ethical Issue: A 69-year-old woman dying of severe ischemic cardiomyopathy and peripheral arterial disease is developing gangrene of her toes without pain or overt signs of infection. Should you perform an arteriogram, attempt repeat angioplasty of either or both lower limbs?
LA was 68 when you, cardiologist B, first saw her in April, 2001. According to the patient, she was told by cardiologist A that he couldn't do anything more for her. Her only son lives in New Jersey and has no time for her. Your notes indicate that she has the following problems:
When you saw LA in April she told you about her last encounter with cardiologist A, at which time she was found to have nonsustained ventricular tachycardia on an electrophysiologic study and received an automatic implantable cardioverter/defibrillator (AICD) device in February 2001, to guard against syncopy.
You, cardiologist B, discuss with the patient whether to emphasize the quality or quantity of her life. She chooses to be free of pain and suffocation, to be able to sleep well, and interact with others as much as possible. You enroll her in Hospice care and simplify her medication to digoxin 0.125 mg q.d., furosemide 120 mg q.a.m., spironolactone 25 mg q.d., glyburide and morphine, alprazolam, and lorazapam as needed, and specifically, you discontinue the antiplatelet agent, anticholesterol agent, and other agents. You communicate the reasons for their discontinuation to the primary care physician; however, these agents were then reinstituted without your knowledge by the primary care physician.
The patient did very well in Hospice care and had to be hospitalized briefly a year later because of syncopy that was found to be due to dehydration. This was rapidly corrected by withholding diuretics for one day.
Because of progressive gangrene of the toes, especially on the right side, LA was referred to cardiologist A by the primary care physician in June 2002 for an angiogram and possible angioplasty of the right, and possibly both, lower extremities. She received 150 mL of contrast injection and was found to have:
Before the angiogram, the electrolytes were normal, blood urea nitrogen was 59 mg/dL and creatinine was 2.2 mg/dL. After the angiogram the patient became anuric and died 2 days later in an intensive care unit.
Ethical Issue: A 69-year-old woman dying of severe ischemic cardiomyopathy and peripheral arterial disease is developing gangrene of her toes without pain or overt signs of infection. Should you perform an arteriogram, attempt repeat angioplasty of either or both lower limbs?
LA was 68 when you, cardiologist B, first saw her in April, 2001. According to the patient, she was told by cardiologist A that he couldn't do anything more for her. Her only son lives in New Jersey and has no time for her. Your notes indicate that she has the following problems:
Ischemic cardiomyopathy and New York Heart Association class IV heart failure. Currently the patient's ejection fraction is 15%, she has moderate mitral regurgitation, severe pulmonary hypertension (pulmonary systolic pressure equals systemic pressure), high venous pressure, and chronic atrial fibrillation.
Chronically decreased systemic pressures with systolic pressures of 70-80 mm Hg making her sensitive to angiotensin-converting enzyme inhibitors and a angiotensin blockers.
Bypass surgery in 1976 with three grafts and again in 1985 with four grafts for treatment of myocardial infarction and triple vessel coronary artery disease.
Severe cerebrovascular disease requiring right internal carotid end arterectomy in 1985 and left internal carotid end arterectomy in 1987 with 70% residual stenosis of the left internal carotid artery.
Severe peripheral vascular disease, status post-bilateral femoral-popliteal artery bypass surgery in 1976. The iliac arteries were noted to be totally occluded at the time with ample collaterals from proximal aortic segments.
Marked hyperlipidemia with total cholesterol of over 300 mg/dL, low-density lipoprotein of over 230 mg/dL, high-density lipoprotein below 30 mg/dL, and triglycerides above 300 mg/dL. The hyperlipidemia is corrected by Zocor 40 mg q.h.s.
History of diabetes mellitus type 2 since the early 70s, on oral therapy.
Hypothyroidism on thyroid replacement therapy.
Several admissions to the hospital because of gastrointestinal bleeding due to arteriovenous malformations in the small and large intestine. She received several upper and lower endoscopies.
Moderate renal failure with creatinine of 1.6-2.3 mg throughout 2001.
When you saw LA in April she told you about her last encounter with cardiologist A, at which time she was found to have nonsustained ventricular tachycardia on an electrophysiologic study and received an automatic implantable cardioverter/defibrillator (AICD) device in February 2001, to guard against syncopy.
You, cardiologist B, discuss with the patient whether to emphasize the quality or quantity of her life. She chooses to be free of pain and suffocation, to be able to sleep well, and interact with others as much as possible. You enroll her in Hospice care and simplify her medication to digoxin 0.125 mg q.d., furosemide 120 mg q.a.m., spironolactone 25 mg q.d., glyburide and morphine, alprazolam, and lorazapam as needed, and specifically, you discontinue the antiplatelet agent, anticholesterol agent, and other agents. You communicate the reasons for their discontinuation to the primary care physician; however, these agents were then reinstituted without your knowledge by the primary care physician.
The patient did very well in Hospice care and had to be hospitalized briefly a year later because of syncopy that was found to be due to dehydration. This was rapidly corrected by withholding diuretics for one day.
Because of progressive gangrene of the toes, especially on the right side, LA was referred to cardiologist A by the primary care physician in June 2002 for an angiogram and possible angioplasty of the right, and possibly both, lower extremities. She received 150 mL of contrast injection and was found to have:
Distal aortic occlusion as well as occlusion of both iliac arteries with reconstruction of common femoral arteries;
Bilateral occlusion of superficial femoral arteries with occlusion of what appears to be old femoral popliteal bypass grafts. Run off is via the profunda collaterals with two good distal run off vessels below the knee on the right and one good vessel run off on the left.
Before the angiogram, the electrolytes were normal, blood urea nitrogen was 59 mg/dL and creatinine was 2.2 mg/dL. After the angiogram the patient became anuric and died 2 days later in an intensive care unit.
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