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A 78-year-old male lives alone with no known relatives or friends. A social worker performing a routine welfare check finds him down on the floor and he is hospitalized for several days with Wernicke-Korsakoff syndrome. He is medically optimized, and discharge planning is now being discussed. His cognitive assessment scores are abnormal. There is no advance care plan document or health care power of attorney. The patient states that he wants to return home, but you have significant concerns about that decision and do not feel it would be safe. When you discuss your concerns with the patient and ask about his plans for obtaining and preparing food and other instrumental activities of daily living, he simply asserts that he'll be "fine." He is not able to provide any further explanation of his thoughts, and he becomes upset and refuses to answer further questions.Reasonable strategies for managing this situation include which one of the following?Transfer the patient to a skilled nursing facility and perform a capacity and competency determination at a later time Consult the ethics committee at your institution to determine his decision-making capacity Assign durable power of attorney for health care to one of the medical social workers who is familiar with his case Work with the court system to establish guardianship for the patient D
As with any medical procedure, discharge planning should be done with the consent of the patient involved. Because this patient does not appear to have the capacity to consent to any plan, a surrogate decision maker should be sought. Capacity is not the same as competence. It is important to distinguish the terms precisely in clinical practice. Competence is a legal term that is determined by the court system, whereas capacity is a medical term that is determined by the treating physician. According to their strict definitions, lack of competence refers to impairment of global decision-making regarding matters such as finances, property, and wills, whereas lack of capacity refers to the inability to make decisions about proposed medical treatments and other aspects of care. Capacity can vary with circumstance and the relative complexity of the decision that is being made.Once the physician has determined that no communication barriers exist, such as hearing loss, language barriers, or dysarthria, and that no medically reversible causes are present, medical decision-making capacity should be assessed. The patient should be able to demonstrate understanding of the situation, appreciation of the consequences of the decision, and reasoning in the thought process. They also must be able to communicate their wishes. If it is still unclear whether the patient has the capacity to make decisions, a structured interview should be done using a validated tool. Common assessment tools include the Aid to Capacity Evaluation 1 / 4
(ACE), the Hopkins Competency Assessment Test (HCAT), the Understanding Treatment Disclosure, and the MacArthur Competence Assessment Tool for Treatment. Assessing cognition with a mental status examination is not always necessary to determine medical decision-making capacity.If there is no valid medical power of attorney, the closest relative usually becomes the surrogate. Currently, 44 states have enacted surrogate consent laws. There are two types of laws pertaining to this: hierarchy surrogate consent laws and consensus surrogate consent laws. In four of the states with surrogate consent laws, the law is only applicable to consent for medical research and certain facility admissions. Currently, there are seven states with no surrogate consent laws (Massachusetts, Minnesota, Missouri, Nebraska, New Hampshire, Rhode Island, and Vermont). The hierarchy laws set up a hierarchy of who should be the designated relative to act as surrogate if a patient has not left written instructions.In Colorado and Hawaii, consensus surrogate statutes require that all reasonably available "interested persons" come to a consensus about who should act as the decision-maker.Most hospitals have an ethics committee available with reasonable notice, allowing the hospital to convene a multidisciplinary group of caregivers who are familiar with the legal and ethical requirements of situations such as the one presented here. Their determinations are not binding, and they do not determine capacity or competency.The durable power of attorney for health care is a form of advance directive that a patient creates while competent, and goes into effect when the person is unable to make medical decisions. Most power-of-attorney forms specifically prohibit members of the medical team from serving as a patient's decision-making proxy.The legal determination that a patient is unable to make decisions on his or her own behalf most often requires the opinion of at least two different professionals (SOR C). This can be two physicians or a physician and a psychologist.The court system is the appropriate venue for designating a guardian (or conservator) for patients who have lost the capacity to make or communicate decisions about their own care (SOR C). This is a legal proceeding that will require due process on behalf of the patient. Counsel will be assigned to represent the patient and an attempt will be made to contact interested friends and family. Temporary guardianship may be assigned if action is required before a more permanent representative can be found. This guardian will (at the discretion of the judge) be allowed to manage the patient's finances, determine his/her living situation, and consent to or refuse medical care.A 64-year-old female presents to the emergency department with 3-4 days of worsening abdominal pain, nonbloody diarrhea, a subjective fever, and chills. She has not had any vomiting or urinary symptoms. Her abdominal pain is somewhat localized to the entire left side of her abdomen, but she reports that her whole abdomen feels tender. She has not eaten anything for at least 36 hours. She tried to drink some water earlier today but says it made her abdominal pain worse. Her previous medical history includes hypertension, uncontrolled diabetes mellitus treated with insulin, and COPD.On examination the patient appears uncomfortable and ill. Her vital signs include a temperature of 38.2°C (100.8°F), a blood pressure of 140/91 mm Hg, a heart rate of 102 beats/min, a respiratory rate of 16/min, and an oxygen saturation of 94% on room air.A cardiopulmonary examination is unremarkable except for mild tachycardia. An abdominal examination reveals normal active bowel sounds and tenderness to palpation in the left lower quadrant with voluntary guarding but no rebound.Laboratory FindingsSodium............129 mEq/L (N 136-145)Potassium............3.4 mEq/L (N 3.5-5.1)Carbon dioxide............19 mmol/L (N 22- 2 / 4
28)Chloride............109 mEq/L (N 98-107)Creatinine............1.8 mg/dL (N 0.6- 1.1)Glucose............315 mg/dLCalcium............8.6 mg/dL (N 8.6-10.0)WBCs............14,200/mm3 (N 4300-10,800)Hemoglobin............15.0 g/dL (N 12.0-16.0)Platelets............365,000/mm3 (N 130,000-400,000)Lipase............75 U/L (N 23-300)AST............35 U/L (N 10-59)ALT............30 U/L (N 10-28)Total bilirubin............0.9 mg/dL (N 0.2-1.2)Urinalysis............normalFindings on CT with contrast include localized thickening of the sigmoid colon, pericolonic fat stranding, and a 2.5-cm pericolonic abscess of the sigmoid colon. CT is otherwise unremarkable.In addition to fluid resuscitation, which one of the following would be appropriate treatment?Oral amoxicillin/clavulanate (Augmentin) and metronidazole Intravenous piperacillin/tazobactam (Zosyn) Intravenous vancomycin and ceftriaxone Partial sigmoid resection B
This patient has acute complicated diverticulitis. Given that she has a small diverticular abscess, the initial management should be intravenous antibiotics that cover gram-negative and anaerobic bacteria, such as piperacillin/tazobactam. There are no randomized, controlled trials that delineate the best antibiotic course. Patients presenting with a diverticular abscess <3 cm or sometimes even 4 cm in diameter often respond to antibiotics alone and do not need surgery or percutaneous drainage. This patient should be hospitalized, given her uncontrolled diabetes mellitus, fever, and inability to eat or drink. Outpatient management with antibiotics and bowel stimulation with magnesium citrate may be appropriate for patients with mild uncomplicated disease. Oral antibiotics can be used in cases with small abscesses, as they have been shown to be as effective as intravenous antibiotics, and some patients may not require any antibiotics.Surgery is not indicated in the acute management of diverticulitis unless pneumoperitoneum or peritonitis is present.A 58-year-old male with type 2 diabetes has undergone elective knee surgery. After the surgery all of his usual medications were restarted, with intensive glucose monitoring. The next morning he is found to be confused and lethargic with a blood glucose level of 32 mg/dL.When used alone, which one of the following diabetes medications is most likely to cause hypoglycemia?Glipizide (Glucotrol) Metformin (Glucophage) Pioglitazone (Actos) Sitagliptin (Januvia) A
Some diabetes medications can lead to hypoglycemia in hospitalized patients, including glipizide, which stimulates insulin production (SOR B). Metformin and pioglitazone both help control diabetes by sensitizing the body to the effects of insulin. Sitagliptin is a DPP-4 inhibitor and works by blocking the enzyme that releases GLP-1. Its greatest effect is reducing 3 / 4
postprandial hyperglycemia. These medications are not a direct cause of hypoglycemia when given at usual dosages in most situations (SOR B).Which one of the following is an advantage of a durable power of attorney for health care compared to a living will?It is not legally binding It is the only advance directive that satisfies the Patient Self-Determination Act It is applicable in more clinical scenarios than a living will It allows first responders to avoid cardiopulmonary resuscitation It allows the person designated to make health care decisions to manage the patient's finances and legal matters as well C
The durable power of attorney for health care (DPOA-HC) is a type of advance directive in which a competent person designates someone to make health care decisions if the person becomes unable to do so. A living will is a different type of advance directive in which a person writes down instructions to avoid or receive specific medical care in the event that the person is diagnosed with a terminal medical condition. Living wills go into effect only in the event that a patient is diagnosed with a terminal condition, which is often difficult to determine. A living will is therefore not useful if a patient is suffering from an acute illness such as a reversible infection, or from a chronic debilitating disease such as a stroke or other neurologic condition. The National Institute on Aging has a helpful website for educating patients and clinicians about these documents at https://www.nia.nih.gov/health/advance-care-planning-health-care- directives.A DPOA-HC is legally binding if filled out according to the law of the state in which it was written. The DPOA-HC limits a designated person to decisions related only to health care.Establishing legal and/or financial power of attorney requires a separate document. The Patient Self-Determination Act of 1990 is national legislation that requires hospitals to offer every patient the opportunity to complete an advance directive. The law does not describe any specific advance directive.First responders are required to provide needed cardiopulmonary resuscitation unless there is a valid do-not-resuscitate order such as a POLST document (Physician Orders for Life Sustaining Treatment) present at the time of their evaluation. A POLST is not a legal document, but is a physician order set that reflects the patient's wishes for care and is many times useful in end-of-life care.A 78-year-old male has been hospitalized for an acute exacerbation of heart failure and is now being discharged to his home. Which one of the following has the most impact on reducing readmissions and all-cause mortality?Simplification of his medication regimen A phone call from a nurse within 48 hours of discharge A home visit from a nurse A visit with his primary care physician 1 month after discharge C
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