Tuesday, May 1, 2012

Blogs to Boards: Question 8


This is the fourth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).  

We welcome comments about any aspects of the questions or the answers/discussions.  The feedback that we hope to get in the comment sections of the post will help us all learn important aspects for the boards. We also welcome an interdisciplinary viewpoint when answering these questions, so even if you are not taking the medical boards, your input is still very much welcome.


Mr. Smith is a 72 year old patient was admitted to hospital from his nursing home for respiratory distress due to CHF exacerbation. Despite aggressive diuresis attempts, his respiratory distress continued and his urine output remained minimal (~30ml/day). 

PMH: heart failure, moderate dementia, renal insufficiency 

Home medications: furosemide 40mg po bid, metoprolol 25mg bid, donepezil 10mg daily, olanzapine 5mg qhs.

After a conversation with his son (health care proxy) the patient was "made CMO" (comfort measures only) by the hospitalist service and resident team two days ago. He was then started on a morphine drip “titrate by 1mg as needed for pain or shortness of breath”, his donepezil, olanzapine and diuretics continued, other medications stopped. 

His intern calls in a panic: “We promised to make him comfortable, that he would die in 2 days, but he is still alive and the family does not know why he is in such pain – even with light touch – crying out & jerking.”

What is your recommendation? 

a) Stop morphine drip and start fentanyl and lorazepam prn
b) Increase morphine and olanzapine
c) Increase morphine and add lorazepam prn
d) Stop morphine drip and start fentanyl, increase olanzapine


Discussion:

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