Continuing Education

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments. Over the course of the following year, the patient’s son and daughter were contacted at various points to re-establish care, but he continued to miss scheduled appointments and treatments. During a hospital admission, a palliative care team determined that the patient did not have capacity to make complex medical decisions. He was discharged to a skilled nursing facility, and then to a board and care when he failed to improve. He missed two more oncology appointments before being admitted with cancer-related pain. Based on the patient’s poor functional status, he was not considered a candidate for additional therapy. After a discussion of goals of care with the patient and daughter, he was enrolled in hospice. The commentary outlines key elements for assessing patient capacity, the importance of understanding the patient’s psychosocial history, and strategies to strengthen psychosocial training for medical and nursing trainees.

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role of brain radiotherapy for palliation to meet the goal of maintaining independence. The patient successfully completed a course of central nervous system (CNS) radiation, which resulted in improved strength, energy, speech, and quality of life. This case represents a perceived delay in palliative radiation, an “error” in care. The impact of the delay was lessened by the hospice team who role modeled integration of disease directed therapy with palliative care, a departure from the historic model of separation of hospice from disease treatment. 

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.

A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Although no timeline for the transfer had been established, the patient’s code status was changed to “Do Not Resuscitate” (DNR) with a plan for him to remain in the ICU for a few days to stabilize. Unfortunately, the patient was transferred out of the ICU after the palliative care team left for the weekend and his respiratory status deteriorated. The patient died in the hospital later that week; he was never able to go home as he had wished. The associated commentary describes how care inconsistent with patient goals and wishes is a form of preventable harm, discusses the need for clear communication between care team, and the importance of providers and healthcare team members serving as advocates for their vulnerable patients.

A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.

A patient with progressive mixed respiratory failure was admitted to the step-down unit despite the physician team’s request to send the patient to the ICU. The case reveals issues of power dynamics, hierarchies, and implicit bias as young female physicians interact with experienced male members in the interdisciplinary team.

An elderly woman with a history of dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the emergency department and found to meet criteria for sepsis. Due to her CHF, she was admitted to a unit with telemetry monitoring, which at this institution was performed remotely. When the nurse came to check the patient's vital signs several hours later, she found the patient to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, but the patient died. Although the telemetry technician had recognized progressive bradycardia and called the hospital floor several minutes before the code, he was placed on hold because the nurse was busy with another patient. While he was holding, he observed worsening bradycardia, eventually transitioning to asystole, and tried to redial the unit, but no one answered.

A woman who had been taking naltrexone to treat alcohol use disorder was discharged to a skilled nursing facility (SNF) on opioids for pain following spinal fusion surgery. Although her naltrexone was held at the hospital in anticipation of starting opioids for pain control, the clinician performing medication reconciliation at the SNF overrode the drug–drug interaction alert and restarted the naltrexone. The SNF providers did not realize that the naltrexone blocked the pain-relieving effect of the opioids.

Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.

Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.