Goals-of-Care Conflict at ICU Discharge and the Hospice Eligibility Question
A 79-year-old woman with advanced COPD (FEV1 28%, on 2 L home oxygen, 3 hospitalizations in 6 months) and mild cognitive impairment is in the ICU with a COPD exacerbation and possible aspiration pneumonia. She was intubated 4 days ago. Her son (agent) wants 'everything, including a trach and PEG if needed.' Her documented POLST says 'Do Not Intubate / Comfort-Focused.' The ICU team believes she may wean but is uncertain. She is sedated and cannot participate. The hospitalist asks palliative care to 'get the family to sign a DNR.'
1. How do you approach the mismatch between the POLST and the son's request, and what is wrong with the consult request as framed?
Read the worked answer
The request is framed wrongly. Palliative care's role is not to 'get the family to sign' anything - that is coercion and misrepresents the discipline. The role is to clarify values, support the family, and facilitate goal-concordant decisions.
The mismatch:
- A POLST documents the patient's own prior treatment preferences and should be honored; it is stronger evidence of her wishes than the son's current preference.
- However, POLSTs are written for specific circumstances and should be interpreted in context. The fact that she was intubated suggests either the POLST was not followed, was overridden in an emergency, or its scope was unclear. That must be clarified.
- The son's 'everything' may reflect grief, fear, or misunderstanding rather than true knowledge of her wishes.
Approach:
- Hold a structured family meeting; explore what the son knows about his mother's values and the POLST.
- Explain what a trach and PEG would mean for her (prolonged ventilation, possible long-term care, burdens in advanced COPD).
- Distinguish withholding new burdensome interventions from withdrawing current ones; address the son's fear of 'giving up.'
- If conflict persists, involve ethics; the documented POLST should generally guide care unless clearly invalid.
- Reframe the consult: we are here to align care with her values, not to obtain a signature.
2. If the team and family agree to transition to comfort-focused care, what concrete steps and hospice considerations apply, and how do you handle the son's grief?
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Concrete steps:
- Document the goals-of-care decision and update the POLST/code status consistent with her wishes.
- Withdraw or limit burdensome interventions: extubate to comfort (with pre-medication for dyspnea - opioid ± benzodiazepine), stop labs/monitoring, discontinue non-comfort meds.
- Symptom management: opioids for dyspnea and pain, benzodiazepines for anxiety, anticholinergics for secretions, meticulous mouth care; continue oxygen if it relieves distress (not for a number).
- Hospice referral: she likely meets hospice eligibility (advanced COPD with FEV1 <30%, dyspnea at rest, multiple hospitalizations, declining function). Confirm prognosis and hospice criteria; arrange a hospice consult.
- Disposition: plan for home hospice or inpatient hospice/comfort-care unit depending on family capacity.
The son's grief:
- Acknowledge that agreeing to comfort care can feel like 'letting her die.' Normalize this.
- Reframe comfort care as honoring what she wanted and as active care, not abandonment.
- Offer social work, chaplaincy, and bereavement support; give him time and permission to be present.
- Avoid arguing; document his concerns and the process.
Why this isn't recall: it requires integrating POLST interpretation, ICU ethics, hospice eligibility, and grief support in one moving situation.