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Question

Difficulty: EasyEnd-of-Life and Palliative Care

A 78-year-old man with end-stage chronic obstructive pulmonary disease (COPD) is evaluated in the outpatient clinic. He requires continuous supplemental oxygen and has had four hospitalizations in the past year for severe acute exacerbations. He is now completely bedbound and states, "I am tired of going to the hospital and being poked with needles. I just want to stay at home and be comfortable for whatever time I have left." His physician estimates his life expectancy to be less than 6 months. The patient is alert, fully oriented, and clearly articulates an understanding of his prognosis and the medical consequences of his decision. Which of the following is the most appropriate next step in management?

  1. Refer the patient to a home hospice programAnswer
  2. B
    Refer the patient to a long-term acute care facility for intensive respiratory rehabilitation
  3. C
    Request a psychiatric consultation to determine the patient's legal competence to refuse care
  4. D
    Contact the patient's next of kin to obtain surrogate consent for transitioning to comfort care
  5. E
    Order an annual low-dose chest CT scan for routine lung cancer screening

Answer

Refer the patient to a home hospice program.
The correct action is to refer the patient to a home hospice program. Hospice care is indicated for patients with a terminal illness and a life expectancy of 6 months or less who choose to forgo curative or life-prolonging therapies in order to focus on symptom burden and quality of life. This patient meets all criteria: he has end-stage COPD with a short prognosis, retains full decision-making capacity to dictate his own care, and clearly states his goal is to remain at home and focus on comfort.

Step-by-Step Solution

1
Assess the patient's clinical status and estimated prognosis.
The patient has end-stage COPD, is bedbound, and has a life expectancy of less than 6 months.
Establishing prognosis is necessary to determine eligibility for hospice care.
2
Evaluate the patient's decision-making capacity and stated goals of care.
The patient is capacitated and explicitly desires to prioritize comfort at home over life-prolonging hospitalizations.
Medical care must align with the capacitated patient's autonomous values and goals.
3
Match the patient's clinical status and goals with the appropriate healthcare service.
Home hospice care perfectly aligns with the requirement for comfort-focused care at home for a terminal illness with a <6-month prognosis.
Hospice provides comprehensive symptom management and psychosocial support for patients at the end of life.

Key Concept

Hospice eligibility criteria and patient autonomy
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Topics

End-of-Life and Palliative Care

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