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God has been so good to me. Several months ago I discovered I had Acute Myeloid Leukemia cancer and after a month in the hospital- I came home. I gained strength enough to walk again this week. I was not recommended for post remission or consolidation in hospital. God has blessed me- so thankful for the prayers, cards, meals, visits and just being able to spend this time at home with Jan. My neighbors have been wonderful and I have seen what the news is truly like in those around me. It has been such a wonderful time. I made this video to share some of my blessings and remind you God hears our prayers, I have not given up- God is a good God.

"Home" Dennis - YouTube

Here I am on 10-29-21

Here are some of the Dr. reports while I was in hospital;

Note From Your Admission on 04/08/21

Progress Notes by GENEVIEVE O'SULLIVAN, MD at 05/05/21 1034

Palliative Care Progress Note   Subjective   Hospital Course / Interval History: Nursing, hospitalist, notes reviewed. Discussed with chaplain who visited yesterday. Per nursing, taking medications with applesauce in the evening was difficult. Concern for possible aspiration. O2 requirement has remained stable. Afebrile.   Dennis tells me his appetite is improved. He is wanting more smoothie or juice this morning. No abdominal pain, nausea. His abdomen continues to be distended. No fevers. He feels like it's difficult to swallow, and that he is noticing a bit of a cough.   Looking forward to going home. Discussed hospice again which he voices he still would like to do. He remains hopeful that he will feel better but tells me he knows he will die.   Called Janis and updated her about possible aspiration and consideration of abx. She has questions regarding hospice.   I called Lynn at hospice and discussed discharging tomorrow with open on Satuday     Objective

IMPRESSION: 66-year-old man with:

 

1. AML, status post induction with idarubicin and cytarabine, initial oncologist Dr. Buckley, transitioning to Dr. Smith. His neutropenia has resolved. Platelets have normalized. Hemoglobin is stable from yesterday at 8, although down from 2 days prior 10. He has had a very rough time with this 26-day hospitalization, including extensive time in ICU on the ventilator, as outlined separately, with subsequent intermittent periods of acute hypoxic respiratory failure requiring high flow oxygen. I speak with him briefly about how all this has been for him, he is quite clear that he would not want reintubation in the event of progressive respiratory failure,, but I really have not taken the discussion any further, as there is palliative care meeting with the patient is best previously scheduled for today, see above, with patient expressing wish to transition to comfort measures only after that discussion per Dr. O'Sullivan, who has written those orders for comfort measures and DNR status. Dr. Sullivan will communicate directly Dr. Smith regarding this.

 

2. Acute hypoxic respiratory failure. Etiology is not entirely clear with persistent hypoxemia. I have personally reviewed his chest x-ray from yesterday, with mild pulmonary vascular congestion with stable mild basilar opacities. He did respond to a dose of furosemide at the time of his high flow requirement, now on 5 L. He had a CT angiogram which was negative for pulmonary embolism on April 10, has not had interval imaging in that regard. His renal function did worsen following that study, and currently his creatinine is 1.62. His LV systolic function was normal on echocardiogram in 4/28. In any event, he does want to focus on comfort only as of the palliative care discussion today, although if in the hospital was more comfortable on high flow he would be okay with that for a short period. He is afebrile, has resolved neutropenia, antibiotics discontinued today, as well as prophylaxis in the setting of wish for DNR only and enrolling in hospice.

 

3. Ogilvie syndrome. This developed in the setting of a fentanyl infusion in the ICU. He was treated with neostigmine on 4/23 and colonoscopy for decompression on 4/24. Eric continues to have bowel movements, scheduled senna is continued.

 

4. Cardiac tamponade with cardiogenic shock. About 6 and 50 cc of amber-colored fluid was removed by pericardiocentesis and ultimately he went for a pericardial window and drain placement, drain removed on 4/20, and repeat limited echo on 4/28 with resolution of effusion. He is tachycardic but needs of his overall goals of care have not repeated an echo.

 

5. Troponin bump up to 2.1 to peak in setting of his critical illness, not further assessed currently. No chest pain today. He was hospitalized in March 2021 with angina symptoms and surprisingly normal coronaries on angiographic evaluation, and was subsequent to that that his AML was diagnosed.

 

6. Acute kidney injury. Peak creatinine was 3.07. Nephrology followed, signed off on 4/18. Creatinine started rising again on 5/3, lisinopril was discontinued, but he is also diuresed for worsening respiratory flora at the time but creatinine is not coming down, we will not continue to monitor, continue off lisinopril.

 

7. Severe protein calorie malnutrition. He has been on TPN. He is increasing oral intake of milk shakes today. TPN is discontinued following completion of today's bag as noted above.

 

8. Subdural hematoma. The timing of onset this is unclear, it was an incidental finding on his CNS imaging, with no progression on follow-up CT on 4/29, Dr. Whitson consulted, no neurosurgical intervention recommended at that time.

 

9. Possible nephrogenic diabetes insipidus. Fluid management has been difficult, balancing tendency toward volume overload and respiratory failure with renal function, see off service note from Chad McBride from yesterday. In transitioning care with comfort the only goal, not desiring prolongation of life, not following further labs.

 

10. Melena noted earlier in his stay. Was not on PPI prior to pressure, has been on Protonix during the admission. Platelets have risen, stable H&H from yesterday to today, focusing on comfort, stop surveillance labs.

 

11. Delirium with critical illness. Although is quite fatigued, appears resolved, able to coherently tell me details about his life, children, etc.

Progress Notes by GENEVIEVE O'SULLIVAN, MD at 04/28/21 0958

Palliative Care Progress Note   Subjective   Hospital Course / Interval History: Nursing, hospitalist, and therapy notes reviewed. He was able to work with PT today and is currently sitting up in a chair. Swallow reassessed yesterday and was he demonstrated improved oropharyngeal swallow function and his diet was advanced to nectar thick liquids and dysphagia puree.   Palliative Care Discussion   Dennis voices he feels much better today. He was very happy to have been able to work with PT, to get up to a chair. He feels like he has more energy. He has some yogurt in front of him as well as a juice, and he feels better now that he can eat and drink.   He tells me he still feels a bit confused. He was talking about radiology calling him, and he doesn't understand why he can't get a call back from them. He is also wondering why Janis hasn't visited. I reviewed the visitor policy with him. He declined my offer to help him call this morning.     Objective   Scheduled and PRN medications reviewed MAR Reviewed   Vital signs: Temp: [97.5 °F (36.4 °C)-99.2 °F (37.3 °C)] 98.3 °F (36.8 °C) Pulse: [89-138] 126 BP: (107-169)/(65-109) 137/102 Resp: [21-50] 30 SpO2: [92 %-98 %] 96 %   Physical Exam: Gen: Sitting up in a chair, appears to be more awake and have more energy than yesterday. HEENT: NCAT, pupils are equal and anicteric. Dry lips. Poor dentition. Active bleeding from gums. CV: RRR Pulm: Respirations are unlabored. Supplemental O2 via NC MSK/Ext: Thin extremities. Sitting up in a chair. Skin: Pale. Warm. Neuro: Alert, oriented, clear speech. Psych: attention is improved.   Last Bowel Movement: 4/28 I/Os reviewed   Labs: Labs Reviewed     Palliative Care Assessment and Recommendations Mr. Hendricks is a 66 yo gentleman with AML, with a prolonged and complicated hospital course since admission on 4/8. He is expected to still need around 2 weeks for hematologic recovery after his induction, though he still has many hurdles to cross before he discharges from the hospital. He has acute delirium which is improving. He also now able to eat and drink, and is staring to have some slight improvements in his functional status. He seems to be improving after complications from Ogilve's syndrome. His prognosis is very guarded. His wife Janis expressed surprise at the prognosis and needs time to process this as well as the myriad of other issues he is facing at this time. She is very supportive of him, and expressed wanting to honor his wishes, particularly hoping that he may be able to participate more in goals of care conversations in the days to come.    Goals of Care: Continue current level of care. We made a plan to check in over the next several days to see how he is progressing clinically. Code Status: Changed to DNR at initial consult with wife as surrogate; This is in line with his previous expressed wishes POLST: Will complete if/when he discharges from the hospital Advance Directive / DPOAHC: Wife Janis is surrogate   -Palliative care to continue to provide support to patient and family -Will continue to address goals during hospital journey -Plan to reach out to Janis again on Friday, unless clinical status changes

Consults by GENEVIEVE O'SULLIVAN, MD at 04/26/21 1012

Consult Orders

1. Inpatient consult to Palliative Care [65148291] ordered by Simita Singh, MD at 04/25/21 0917

Palliative Care Consult   Reason for Consult: The Palliative Care service is consulted by Dr. Singh for goals of care.   Outpatient Medical Team: CHRISTOPHER CAMPBELL, PA-C   ID/CC/HPI: Mr. Hendricks is a 66 yo gentleman with AML. He has had a prolonged hospital course since admission on 4/8/21. He was admitted for management of presumed AML, with BM biopsy confirming it on 4/9. He started induction that was completed on 4/19. He had progressive respiratory decline between 4/10 - 4/12 and was intubated from 4/12 - 4/16. On 4/13 he was found to have cardiac tamponade he and he underwent a pericardiocentesis with drain placement. He required pressor support until 4/16, and then was transferred out of the ICU, only to return the next day for recurrence of severe colonic dilation due to Ogilvie syndrome. He had had issue with aspiration and ability to maintain nutrition and has been receiving TPN. He is pending reassessment of swallowing today, though assessment had previously been postponed due to his respiratory rate. On 4/19 he underwent a decompressive colonoscopy and and has required subsequent neostigmine which was successful.   On 4/25 he expressed to the ICU physician that he wants to be made comfortable and a meeting with palliative care was discussed.   I spoke with Dr. Smith today. She is taking over his oncologic care from Dr. Buckley and has reviewed his case and she had previously talked to his wife, Janis.   Palliative Care Discussion: Participants: Mr. Hendricks, Mrs. Janis Hendricks We met all together in Mr. Hendrick's room and it quickly became apparently that he was delirious and becoming distraught and paranoid while we were in the room. Janis and I made the decision to have the conversation out of his room.   When I had initially seen him in the morning, he was less delirius. He told me, "If I'm going to die, I want to go home and be with family." This was an unprompted comment. He was tearful. I had asked him if I could invite Janis in so we could all meet together and he agreed. When we met with Janis he was much more confused, saying several times, "They are all lying to you." He warned me not to listen to "them" and that they are lying to me and to him. He voiced he was very confused and didn't know what was happening.   Background/social history: -Retired right before COVID. They had been planning a cruise that was cancelled -Janis describes that Dennis was starting to become paranoid, though COVID was a conspiracy, and was having memory issues   Understanding/perspective of illness: -Her understanding was that he had a very good chance at surviving and recovery / remission. She voiced that the prognosis is "good" -She allowed me to voice my understanding of his prognosis from Dr. Smith - 20-30% do not survive hospitalization, that if he survives and is discharged will need three more cycles of chemotherapy for a chance at remission; 30% obtain remission. This is all barring making it out of the hospital, maintains a functional status that allows for chemotherapy -We discussed how there are a lot of hurdles right now - currently NPO with swallow eval pending, delirium, neutropenia, etc and that he will be in the hospital at least about 2 more weeks as we are awaiting hematologic recovery   Hopes -Janis wants Dennis to be able to participate in these conversations -We discussed delirium, that he may take days to weeks to recover and that his mental status may wax and wane and that based on how he is today, he cannot make decisions for himself   Acceptable quality of life:   Fears/concerns/worries: -She has been concerned about communication, not being able to visit Dennis, and not knowing everyone involved in his care -I provided a list of consultants and recent physicians participating in his care -Worried that he is not going to recover   Communication preferences: -Directly with her and Dennis, and to include Dennis as we can in conversations -She has zoomed with him several times   Past experience with serious illness/hospice: -She was her mother's DPOAH and had to make decisions regarding EOL care for her   Code Status: -She was not with Dennis when he changed his code status to DNR. -She reversed this when he was in respiratory distress -She believes he would want to be DNR/DNI if he had little to no chance of survival. -We discussed how CPR (chest compressions) is used when you heart stops, and this means you have died. If this were to be the case she believes he would not want resuscitation.     Review of Systems: A 12 point review systems was performed and negative except per HPI and Symptom above   History Medical/Surgical History: Reviewed in Epic Chart Social History: Reviewed in Epic Chart, for additional details see background / social history above in HPI Family History: Reviewed in Epic Chart   Home Medications and MAR reviewed Allergies reviewed   Physical Exam BP 112/75 | Pulse 103 | Temp 98.1 °F (36.7 °C) | Resp 24 | Ht 1.829 m (6' 0.01") | Wt 81.5 kg | SpO2 95% | BMI 24.36 kg/m² Gen: Sitting up in bed, tearful. HEENT: NCAT, pupils are equal and anicteric. Dry lips. Poor dentition. CV: RRR Pulm: Respirations are unlabored. Supplemental O2 via NC Abd: Soft. GU: Clear yellow urine MSK/Ext: Thin extremeties Skin: Pale. Warm. Neuro: Alert, oriented, forgetful. Psych: Attentive to conversation. Good insight.   Labs - Reviewed in Epic chart WBC < 0.1, ANC 0. CMP from yesterday reviewed. Cr 1.23, Sodium 153 , Albumin 2 Imaging - I have reviewed the following imaging reports and the images when pertinent: Xray Abdomen from yesterday reviewed.   Palliative Care Assessment and Recommendations Mr. Hendricks is a 66 yo gentleman with AML, with a prolonged and complicated hospital course since admission on 4/8. He is expected to still need around 2 weeks for hematologic recovery after his induction, though he still has many hurdles to cross before he discharges from the hospital. He has acute delirium, progressively poor functional status, and has been NPO with swallow evaluation pending. He seems to be improving after complications from Ogilve's syndrome. His prognosis is very guarded. His wife Janis expressed surprise at the prognosis I expressed today and needs time to process this as well as the myriad of other issues he is facing at this time. She is very supportive of him, and expressed wanting to honor his wishes, particularly hoping that he may be able to participate more in goals of care conversations in the days to come.   Goals of Care: Continue current level of care. We made a plan to check in over the next several days to see how he is progressing clinically. Code Status: Changed to DNR today with wife as surrogate; This is in line with his previous expressed wishes POLST: Will complete if/when he discharges from the hospital Advance Directive / DPOAHC: Wife Janis is surrogate   -Palliative care to continue to provide support to patient and family -Will continue to address goals during hospital journey -Changed code status today   Discussed with Dr. Singh and Dr. Smith today Thank you for this consult. Palliative Care Team will continue to follow the patient and provide support during this hospitalization

4-18-21- Dr. Buckley;

Assessment/Recommendations: 66 y.o. male with AML Monoblastic subtype, with critically illness at presentation and initiation of induction chemotherapy. He will complete his civi ARA-C in approximately 24 hours. This will complete his induction chemotherapy, and treatment recommendations are to continue aggressive care, treat and prevent infections, transfuse prn. He will remain pancytopenic for 2-3 additional weeks, and is at risk of bleeding, and infection during that time.

 

Tumor lysis labs are stable to improved.

 

Transfusion guidelines hgb 7.5 or less, platelets 10 or less. Irradiated, leukoreduced, pathogen free products. Today he will receive platelets in addition to 2 units red blood cells.

 

I would continue aggressive transfusion support, IV antibiotics, avoid suppositories if possible, try to get bowel moving from above.

 

4-15-21- Dr. Buckley;

Assessment/Recommendations: 66 y.o. male with a recent history of a type II NSTEMI who had what appeared to be a transient bicytopenia with self resolving neutropenia and very mild thrombocytopenia that was followed by 2 to 3 weeks of progressive constitutional symptoms and an elevated white count above 30,000 blasts on the peripheral smear review concerning for AML. Bone marrow biopsy and flow cytometric analysis of peripheral blood returned positive for AML with

monotypic differentiation. FISH for PML/RARA was negative.

 

Cytogenetics normal. FLT3-. Genomics pending currently appears to be standard risk.

 

#AML

-Today is day 6 of 7+3, day 3 of idarubicin held due to hemodynamic instability, cytarabine held for 2 days during severe hemodynamic instability and need for pericardiocentesis now restarted and on fourth day of administration.

-He is still on 2 pressors he was able to come off of Levophed at some point today but after diuresis for volume management which he responded well to in regards to urine output he had worsening hypotension and is now back on both pressors with Levophed and vasopressin.

-Access is by PICC line

-TTE showed a normal EF

-His LDH is downtrending, his phosphorus is up trending secondary to lysis and acute renal failure

-His renal failure secondary to leukemia and ATN, responded well to a diuretic challenge today. Currently not needing dialysis.

-Plan to continue broad-spectrum antimicrobial coverage until he is no longer neutropenic. Currently on acyclovir, meropenem, and posaconazole

-His lack of improvement in mental status during sedation vacation today is somewhat concerning, does withdraw to noxious stimuli

-Continue standard transfusion threshold with hemoglobin of 7.5 or less, platelets 10 or less spontaneously, 20 unless febrile, as needed if bleeding.

-He will need irradiated packed red blood cells due to his neutropenia

 

Prognosis continues to be guarded but his intent of treatment is definitive in nature with a prognosis measured in years if he is able to recover from acute events.

 

4-13-21- Dr. Buckley;

Assessment/Recommendations: 66 y.o. male with a recent history of a type II NSTEMI who had what appeared to be a transient bicytopenia with self resolving neutropenia and very mild thrombocytopenia that was followed by 2 to 3 weeks of progressive constitutional symptoms and an elevated white count above 30,000 blasts on the peripheral smear review concerning for AML. Bone marrow biopsy and flow cytometric analysis of peripheral blood returned positive for AML with monotypic differentiation. FISH for PML/RARA was negative.

 

#AML

-Today is day 4 of 7+3, day 3 of idarubicin held due to hemodynamic instability cytarabine also held initially. His hemodynamics have improved with the interventions today including pressor support, intubation, pericardiocentesis. We will plan to continue continuous infusion cytarabine. If he is able to improve and come off of pressors we can consider adding in his last day of idarubicin.

-White blood cell count 4.5 he is now neutropenic with an ANC of 0.9 hemoglobin stable at 8.6 platelets low at 20

-Access is by PICC line

-TTE showed a normal EF

-His LDH is downtrending, his phosphorus is up trending secondary to lysis and acute renal failure

-Urine output continues to worsen. Think there are certainly some contribution from infiltration from AML potentially also some ATN from his hemodynamic instability.

-Plan to continue broad-spectrum antimicrobial coverage until he is no longer neutropenic. Currently on acyclovir, meropenem, and planning to add posaconazole for prophylaxis due to his anticipated long-term neutropenia.

 

Prognosis continues to be guarded. His hemodynamics have improved throughout the day after his pericardiocentesis. His LDH continues to downtrend his overall burden of AML should be improving. Hopefully he is passed the initial severe inflammatory response from the degranulation process secondary to his aggressive leukemia and also the cytotoxic effects from his chemotherapy on his leukemia. Updated his wife today regarding the details and an additional 30-minute advanced care planning conversation.