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Brief History and Hospital Course
This 82 year old married white male had had fairly rapid decline in mental status thought to be due to multi-infarct dementia, rule/out Alzheimer’s. He had a twenty year history of IDDM, long history of hypertension with CAD, was S/P CABG 10 years prior, renal insufficiency, and end stage mycoses fungoides (info>>) previously treated with total body irradiation. He had been at Sunshine Terrace Nursing Center, but had recently become highly agitated and aggressive; hitting, scratching, kicking; he threw a wheelchair and fractured the hip of another (female) resident there. Ativan 3 mg. IM twice did little to calm him, and the nursing home was unable to contain him; he was transferred to Davis Hospital.
On admission Mr. Alldredge proved extremely difficult as he was still quite strong for his age, and frequently hurt the nurses. He was continued on insulin, Pepcid, L-thyroxine, Bumex, Micro-K, Hytrin, Oxybutynin, and ASA, and started on Risperdol 1mg. tid, Buspar 10 mg. tid and trazodone 100 mg.qhs. Because he frequently refused oral medication, and was extremely combative, a danger to himself and others; he received Haldol 10 mg. and Ativan 1 mg. IM as now and prn orders but he remained intermittently quite agitated until late on the fourth hospital day.
MRI on the third day of admission revealed what appeared to radiology to be a new left occipital infarct. He was also pyuric and dehydrated at this point. An IV was started for hydration, as the patient would not swallow fluids or medication.
On the fourth hospital day a family conference was held; the wife was called. The CVA was described and the family told that an occipital stroke might cause blindness. The situation with the patient’s refusal to swallow and diabetes necessitating IV fluid for survival was discussed. In view of the patient’s rather clear and compelling Living Will of July, 1993, (which precluded IV) his family was offered withdrawal of interventions and palliative care, or transfer to ICU. His family elected to withdraw care, and the IV and most all previous medications were discontinued; instead the patient received regular doses of morphine 10 mg. IM q3hrs (due to patient "grimacing" and "moaning") (Go to Merck Manual>>) and Ativan 0.5 mg. q3hrs until he died the next day.