Difficult End-of-Life Issues: Case Histories

The Daughter Rescinded the DNR Order A 65-year-old widow with a history of DM, hypertension, and TIA was started on HD for DN. She was cognitively intact, cooperative, compliant, and able to deal with her diagnosis of ESRD appropriately. She used the Wheelchair Van Service because of her desire not to burden friends or family. She had family support, primarily from her daughter. Two years after starting dialysis, she signed a DNR Order and a Health Care Proxy, naming her daughter. About two weeks later, a CT scan of the brain done to pursue mental status changes revealed multiple areas of infarction. Subsequently, she had numerous admissions to the hospital because of fluid overload and other diagnoses. Dialysis increased to four times a week. Her mental status deteriorated further, and she was transferred to a NH.

Subsequently, she was noted to come from the NH to the Dialysis Facility very agitated and would upset other patients. She became progressively problematic, and medications were tried to control her inappropriate yelling, screaming and agitation, to no avail. She was transferred to the Hospital Unit where she could be placed in isolation and observed more closely, since she was starting to get out of her chair during treatments and pull out dialysis needles. Her daughter was repeatedly informed of her behavior, but her response was to rescind the DNR order.

The patient’s transfer to the Hospital Dialysis Unit angered the daughter; she did not accept that the transfer was in the patient’s best interest. The patient progressively deteriorated. She became more cachectic and demented. The patient refused to eat; her weight decreased to 70 lbs from 123. The daughter avoided face-to-face meetings with the MD and MSW to discuss long-range planning. However, the daughter made it clear that she did not wish to stop her mother’s dialysis. Indeed, she asked about a feeding tube to increase the patient’s weight. The patient had no difficulty swallowing or bowel problems that would justify PEG placement. The patient continued to do poorly and died five years after starting dialysis and 14 months after becoming incapacitated.