Clinical Geriatrics

Case Presentation

Mr. K is a 58-year-old Caucasian male with a long-standing history of diabetes mellitus, hypertension, and chronic kidney disease who has been on continuous ambulatory peritoneal dialysis for 3 years. Initially, treatment achieved good adequacy of dialysis, and the patient reported a feeling of well-being. During the last 6 months, however, his dissatisfaction with dialysis increased, which he attributed to the increased time needed to perform exchanges and his weight gain. Mr. K underwent right lower-extremity, below-knee amputation secondary to gangrenous foot as a complication of severe peripheral vascular disease. The postoperative course was complicated by symptomatic gallstone disease and acute cholangitis requiring laparoscopic cholecystectomy. After the abdominal surgery, the patient underwent temporary hemodialysis.

It was felt that Mr. K could benefit from a comprehensive rehabilitation program to maximize functional independence prior to his return home. He was admitted to the inpatient Rehabilitation Unit. Despite the patient’s determination, he was not able to participate in the rehabilitation program due to generalized weakness and recurrent hypoglycemic and hypotensive episodes.

On the twenty-first hospital day, Mr. K developed an acute respiratory distress, and he was then transferred to the Intensive Care Unit (ICU). He was diagnosed with sepsis due to peritonitis and right pleural empyema. During his ICU stay, the patient reported feeling “fed up,” but he continued to request aggressive care and support as long as there was a chance for survival. He was optimistic about the prospect of being a kidney transplant recipient, and he was willing to continue with hemodialysis.

Throughout the course of his illness, Mr. K had episodes of delirium with waxing and waning lethargy, and periods of agitation requiring administration of small doses of haloperidol. When the patient experienced delirium, the family—with the patient’s wife acting as durable power of attorney—requested that all aggressive care be discontinued. Contrary to the treating physician’s impression, his family stated that this was the patient’s wish. Mr. K’s advance directives were not available.

The patient’s medical condition gradually stabilized. Unfortunately, his functional status significantly deteriorated. He now required moderate assistance with bed mobility, and he had to be re-admitted to the acute Rehabilitation Unit. The goals of rehabilitation were to return to independence regarding basic activities of daily living and to successfully ambulate household distances with an assistive device. Mr. K’s progress in therapy was slow, so the treatment team raised the possibility of therapy continuation at a nursing home. The patient’s family was included in this discussion.

On the sixth week in the clinical course, Mr. K refused hemodialysis, saying that he wanted to end his life. Psychology and psychiatry consults were requested for depression and its possible impact on the patient’s decision to decline dialysis.

Key Points from the Psychology Consultation

Mr. K, a retired salesman, resides with his wife of 37 years in a mobile home. The couple has four adult children. Prior to his decline over the last 3 years, he had been an avid water skier. He had also been the primary caregiver for his wife, who has multiple sclerosis and has significant deficits in her functional status. Mrs. K is wheelchair-bound.

The patient has struggled with depression over the past few years. Prior to worsening of his medical status, there was no history of any kind of mental illness. He denied any use of alcohol or illicit drugs. He said that he is “religious” and so chose not to use alcohol. He complained of being in pain, but he was most concerned with the “limitations” of his life. The patient said, “I love my wife and kids,” and he expressed grief that Mrs.