Care Planning and In-the-Moment Clinical Decisions

While reviewing a patient’s chart at the start of my overnight ICU shift, the first line from my attending’s note earlier that day caught my eye. Under the bold header DISCONTINUATION OF COMFORT CARE, he (BB) had written, “This is an unusual situation.” Hooked, I read on.

The patient was an older man who had been admitted to the ICU for acute pulmonary edema and hypoxemic respiratory failure. After confirming with his loved ones that he would not accept invasive mechanical ventilation, my daytime colleagues had treated him with a combination of diuresis, afterload reduction, and bilevel positive airway pressure (BPAP). Unfortunately, after 2 hours of intensive supportive care, he had minimal urine output and remained in respiratory distress. He did, however, wake up enough to ask the team to “stop.” And so, at his request, they removed BPAP and transitioned to comfort care.

When my attending returned to the patient’s bedside an hour later, he found the patient in the middle of a longwinded story about his life, surrounded by family who listened attentively. He was not, it seemed, actively dying. How could this be? The 1.5 L of fresh urine in the Foley bag provided the answer. The treatments, it turned out, had worked.

“This might be jarring,” BB said, “but I’m not really sure this is the end.”

“I was ready for heaven,” the patient reflected.

“I don’t know what you did, but they sent you back.”

With this unexpected and dramatic improvement, the team rescinded the “comfort care” orders. This was, as my attending had written, unusual. I had never heard of or considered revoking comfort care before.

As I signed into the first-call role and prepared myself to be the responding clinician overnight, I had a million questions. What would I do if the patient became hypoxemic again? How long would it be appropriate to trial BPAP? What if he became hypotensive? Would we start vasopressors?

What I was looking for was a plan, spelled out in advance, for how I should address hypothetical problems that might come up overnight. Many things could go wrong, and I wanted to make sure my care would align with the patient’s goals and values.

There has long been a desire for tools to help clinicians discern what patients would want in different clinical situations, especially those who lack the ability to express their wishes, which is common in the ICU. Initial efforts focused on the documentation of specific instructions in written advance directives. Unfortunately, predicting what might happen to someone in the future is difficult. Values and perspectives can also change. BPAP may be reasonable to try in one moment but excessively burdensome in another. Thus, explicit advance directives have proven to have significant limitations (1).

Back in 2010, Sudore and Fried (2) wrote a seminal paper in Annals arguing that it was time to “redefin[e] the ‘planning’ in advance care planning.” In their formulation, rather than trying to prespecify treatment preferences, advance care planning is best considered as a series of steps aimed at preparing patients and surrogates “to work with their clinicians to make the best possible in-the-moment medical decisions.”

In the subsequent decade, the field has continued to evolve with a proposed reconceptualization of advance care planning as the "care planning umbrella” (3), an evocative term meant to illustrate that care planning is important at every stage of life and illness. Under this paradigm, care planning becomes the responsibility of all clinicians, from primary care providers to intensivists, and can occur in the outpatient or inpatient setting.

So was I wrong to ask for guidance on how I should handle situations that may arise overnight? After all, isn’t that the purpose of taking sign-out?

What I have come to realize is that not all medical decisions can be determined in advance. Part of our job is to continuously revisit a patient’s health status and trajectory, pairing our clinical assessment with their wishes, values, and preferences to arrive at a treatment plan. My daytime colleagues can help prepare me, as the night resident, to do this by relaying their understanding of the clinical condition and the patient’s goals. But things can change rapidly, especially in the ICU, and treatments may need to change accordingly.

For this patient, the twists and turns would only continue. While he slept well and my first night caring for him was uneventful, he ended up having recurrent episodes of pulmonary edema during that admission. In isolation, these episodes were reversible, but the underlying pathophysiology was not. Ultimately, after iteratively revisiting his medical situation, goals, and values, he pivoted back to wanting comfort-focused cared and was discharged home on hospice.

References

1. Morrison RS, Meier DE, Arnold RM. What's wrong with advance care planning? JAMA. 2021;326:1575-1576. [PMID: 34623373] doi:10.1001/jama.2021.16430
2. Sudore RL, Fried TR. Redefining the "planning" in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153:256-61. [PMID: 20713793] doi:10.7326/0003-4819-153-4-201008170-00008
3. Hickman SE, Lum HD, Walling AM, et al. The care planning umbrella: The evolution of advance care planning. J Am Geriatr Soc. 2023. [PMID: 36840690] doi:10.1111/jgs.18287