# Clinical Cases: End-of-Life Care and Goals of Care

## Case 1: Goals of Care Conversation and Code Status

### Clinical Image
![Physician having goals of care discussion with patient and family](case_01_image.jpg)
*Source: [Wikimedia Commons - Doctor-Patient Communication](https://commons.wikimedia.org/wiki/Category:Doctor-patient_relationship) - CC BY-SA 4.0*

### Case Presentation
A 78-year-old man with stage IV non-small cell lung cancer with brain and bone metastases is admitted for worsening dyspnea and pain. His oncologist confirms he has exhausted all systemic treatment options. His ECOG performance status has declined from 2 to 4 over the past month. He is alert and has decision-making capacity. The sub-intern is asked to lead a goals of care discussion with attending supervision. She begins by asking about his understanding of his illness ("What have the doctors told you about where things stand?"). He responds, "I know it's bad, but I'm hoping for a miracle." She gently asks what he hopes for and what he fears most. He expresses that he does not want to suffer and wants to be home with his family. She explores his values: "If we reach a point where your heart stops or you can't breathe on your own, would you want us to try to restart your heart with chest compressions or put you on a breathing machine?" She explains honestly that CPR in his situation has less than 5% chance of success, and if it did work, he would likely be in the ICU on machines. She asks what he would consider an acceptable outcome. He says, "I don't want to die in an ICU. I want to be comfortable and with my family." She makes a recommendation aligned with his values: "Based on what you've shared, I would recommend that we focus on keeping you comfortable and maximizing your time with family, rather than interventions like CPR that are unlikely to give you the outcome you want." He agrees to a DNR/DNI status and asks about hospice. A palliative care consult is placed, and he is discharged home with hospice services.

### Key Learning Points
- Goals of care discussions should elicit patient values and fears before discussing specific interventions; ask "What are you hoping for?" and "What do you fear most?"
- CPR outcomes vary dramatically by clinical context; for metastatic cancer, survival to discharge is only 5-10%, with even lower rates of meaningful neurologic recovery
- Making a recommendation is appropriate and helpful when aligned with patient values; saying "I recommend we focus on comfort" is more supportive than asking "What do you want us to do?"
- POLST/MOLST forms translate patient preferences into actionable medical orders that travel across settings

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## Case 2: Symptom Management at End of Life

### Clinical Image
![Morphine syringe for symptom management in palliative care](case_02_image.jpg)
*Source: [Wikimedia Commons - Morphine](https://commons.wikimedia.org/wiki/Category:Morphine) - CC BY-SA 3.0*

### Case Presentation
A 68-year-old woman with end-stage heart failure (EF 15%, NYHA Class IV) is admitted with cardiogenic shock. Despite maximum medical therapy including dobutamine and milrinone, she continues to deteriorate with rising lactate and worsening renal function. She is not a candidate for advanced therapies (LVAD, transplant) due to comorbidities. After a family meeting, she and her family decide to transition to comfort-focused care. The sub-intern works with the palliative care team to develop a symptom management plan. Her primary symptoms are dyspnea (despite BiPAP) and anxiety. For dyspnea, morphine 2 mg IV is given, which provides noticeable relief within 15 minutes; a scheduled order for morphine 2-4 mg IV q2h PRN is placed. A fan is positioned to blow cool air across her face, which also reduces her sensation of breathlessness. For anxiety, lorazepam 0.5 mg IV q4h PRN is ordered. As secretions build (death rattle), glycopyrrolate 0.2 mg IV is given to dry secretions, reducing the distressing sound for family (though reassured that it is not causing her distress). Cardiac monitoring is discontinued, as are routine vital signs. Her family is at bedside and is counseled about expected changes: mottling, Cheyne-Stokes breathing, and decreased responsiveness. She dies peacefully 8 hours after transitioning to comfort measures, surrounded by her family.

### Key Learning Points
- Opioids are first-line for dyspnea at end of life; they reduce the sensation of breathlessness even in the absence of pain
- The principle of double effect: actions taken to relieve suffering are ethical even if they have a foreseeable but unintended effect of hastening death, as long as the intent is comfort and doses are proportionate
- Death rattle is distressing to families but not to patients (who are typically unconscious); antisecretory medications (glycopyrrolate, scopolamine) reduce the sound
- Monitoring that does not contribute to comfort (telemetry, routine vitals, labs) should be discontinued when the focus shifts to comfort

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## Case 3: Hospice Referral and Family Support

### Clinical Image
![Hospice care team providing support at home](case_03_image.jpg)
*Source: [Wikimedia Commons - Hospice Care](https://commons.wikimedia.org/wiki/Category:Hospice) - CC BY-SA 4.0*

### Case Presentation
A 72-year-old man with advanced Parkinson's disease and dementia is admitted for aspiration pneumonia, his third hospitalization in 6 months. He has progressive dysphagia requiring pureed diet and has lost 20 pounds over the past year. His wife has been his primary caregiver but is exhausted. He is non-verbal and cannot participate in decision-making. His wife is his designated healthcare proxy. During a family meeting, the physician explores what the patient would have wanted. His wife recalls him saying, "When I can't recognize you anymore, don't let them keep me alive with tubes and machines." She describes his current quality of life as poor: he no longer recognizes family, requires total care, and seems uncomfortable much of the time. The physician explains that his current trajectory suggests a prognosis of weeks to a few months. She explains hospice services: nursing visits, aide assistance, medications for comfort, equipment like hospital bed and oxygen, 24/7 phone support, and bereavement services. She clarifies that hospice focuses on comfort rather than cure, and that hospitalization is generally avoided unless absolutely necessary for symptom management. She recommends hospice as a way to provide comfort and support at home, honoring what he would have wanted. The wife is initially hesitant, feeling like she's "giving up," but comes to understand hospice as a way of providing the best quality of remaining life. The patient is discharged home with hospice services. A follow-up call from the sub-intern 2 weeks later reveals he is comfortable at home, and his wife is receiving caregiver support. He dies peacefully at home 3 weeks later.

### Key Learning Points
- Hospice eligibility requires prognosis of less than 6 months and patient/family agreement to focus on comfort rather than curative treatment
- Hospice provides comprehensive services: nursing, aide, social work, chaplain, bereavement support, medications, and equipment
- Families may perceive hospice as "giving up"; reframe as "choosing comfort" and "honoring what [patient] would have wanted"
- Bereavement follow-up (condolence calls, bereavement services) is part of quality end-of-life care for families