Start With Well Done

Greater Vision wrote/sing "Start With Well Done"- a favorite of mine. I took time to add photos of the first 6 months of 2021. This includes the surprise time spent in hospital for heart and A M Leukemia as well as my recovery up to July. I give God credit for answering prayer. Janice has done a super job to take care of me under Hospice. I would like to thank those who pray for me, those who shared meals, sent cards, mowed our lawn, visited us, as well as the hospital and hospice staff who have been wonderful. 

Dr. Julie Smith from last months visit to Dr.  

Assessment/Recommendations: 66 y.o. male with AML Monoblastic subtype, with critically illness at presentation and initiation of induction chemotherapy. He was discharged eventually the first week of May has been home with hospice since it in many regards has had substantial improvement in his quality of life and symptom management. He has now eating better, and has at this point a temporary hematologic improvement and stabilization of his white count and platelet count, his anemia is also improved from 3 weeks ago likely due to his improvement in nutrition.

 

However his exam findings are fairly classic today for leukemia cutis. This is not surprising given monoblastic acute leukemia subtype, as monoblastic leukemia has a predilection for soft tissues including soft tissues of the skin, kidneys, other organs, gums, and in patients who develop leukemia cutis this is considered ominous, with impending hematologic relapse. I discussed that this is not a curable condition and treatment with aggressive chemotherapy would be extremely difficult if not harder than he had before. His goals are to not have treatment that would make him weaker or take away from his current quality of life even knowing that his leukemia is terminal.

 

Regarding prognosis it may be that during the next several weeks to 1 or 2 months he would have other signs and symptoms of progressive leukemia such as symptomatic anemia, development of purpura and petechiae, bone pain, etc. Also gum swelling and bleeding from his gums would be something to watch for.

 

He would like to stay on hospice and given his subtype of leukemia, its aggressiveness, and the findings on exam today in addition to noncurative treatment I also recommend that he continue on hospice treatment.

 

Start With Well Done - YouTube

Here are some of the Dr. reports from 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

Palliative Care Assessment/ Recommendations

Mr. Hendricks is a 66 yo gentleman with AML, with a prolonged and complicated hospital course since admission on 4/8. We have had several goals of care discussions throughout his course, the most recent yesterday. He has communicated with this family, and they are supportive, that he wants to go home, and be on hospice. He holds on to hope that he may get better, though does not desire ongoing medical intervention in the hospital setting. He has made it clear that he knows he will die, and he is comfortable with this.

 

He is currently stable and able to be cared for at home by his family. Hospice open date is Saturday.

5-4-21

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 MORGANNE MCCANN, OT at 05/03/21 0857

Pt initially agreeable to therapy this morning, however, OT attempted to facilitate supine to sit EOB, pt states " I don't want to do this I am ready to go to heaven". OT offered to assist with feeding to increase caloric intake, but pt continued to state " I am not afraid to die" and "I just want to be in heaven". Pt refused his breakfast and politely declined therapy. Rn notified of pt's comment and behavior.

 Progress Notes by GENEVIEVE O'SULLIVAN, MD at 04/27/21 1314

Palliative Care Progress Note Hospital Course / Interval History: Nursing, hospitalist, and therapy notes reviewed. Transfusions today.   Palliative Care Discussion   I reached out to Janis today. She feels like we should keep moving ahead with everything. She feels like we are slowly moving in the direction we should be. She doesn't feel that we need to make any other decisions right now unless his status changes, or if he is not improving (referring to his blood counts) over the next two weeks when they are suppose to. She is planning on calling Dennis later today.   I provided her a medical update and an update about my conversation with Dennis.   When I visited with Dennis this morning he told me several times "I am so confused." He is able to tell me that he has leukemia. When I talked about chemotherapy he told me, "I didn't even know I got any. I am so confused." He does state he wants to go home but that he wants to go because he doesn't understand why we can't do what we are doing in the hospital at home. I explained how sick he is and that if he wants further treatment for his cancer that he would need to continue to be int he hospital for now. I did offer the alternative - not having more treatment and going home, focusing on his comfort. I am not confident that he could completely grasp this as he still has acute delirium, though he did say that he is not what he meant (about going home).   He has found religion a strength for him and voiced he was saved at age 9 at camp. He is not afraid to die. Objective Scheduled and PRN medications reviewed MAR Reviewed   Vital signs: Temp: [97.5 °F (36.4 °C)-98.4 °F (36.9 °C)] 98.3 °F (36.8 °C) Pulse: [94-138] 99 BP: (107-156)/(75-106) 155/92 Resp: [19-50] 25 SpO2: [90 %-98 %] 98 %   Physical Exam: Gen: Sitting up in bed, tearful.  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 Abd: Soft.  GU: Clear yellow urine  MSK/Ext: Thin extremities. Sitting up in a chair. Skin: Pale. Warm. Neuro: Alert, oriented, forgetful.  Psych: poor attention, poor insight   Last Bowel Movement: 4/27 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, 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 prognosisand 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 -Plan to reach out to Janis again on Friday, unless clinical status changes