From the Guidelines
The most appropriate next step for this 72-year-old man is to begin supportive treatment, but withhold active cardiopulmonary resuscitation, as this aligns with his reported wish for no heroic measures. Given his complete left-sided paralysis, incoherence, and hypertension, a stat CT scan of the brain should be obtained to confirm the suspected diagnosis of acute stroke 1. His bradycardia should be monitored closely as it may represent Cushing's reflex (bradycardia with hypertension), which can indicate increased intracranial pressure.
While managing his condition, it is essential to prioritize his comfort and symptom management, as outlined in the principles of palliative care for people living with heart failure, which includes addressing ethical dilemmas, advance care planning, and spiritual care 1. The patient's landlady has reported his wish for no heroic measures, which should be respected, and a palliative care consultation would be appropriate to ensure his comfort and symptom management.
Some key considerations in his care include:
- Stabilizing his blood pressure with appropriate antihypertensive medications
- Maintaining his airway and ensuring adequate oxygenation
- Preventing complications like aspiration pneumonia and pressure ulcers
- Monitoring his bradycardia closely
- Obtaining a neurology consultation urgently to discuss goals of care based on his previously expressed wishes
- Involving palliative care to ensure comfort and symptom management, as the patient's condition appears to be consistent with the dying phase, characterized by progressive weakness, immobilization, and cognitive impairment 1.
By taking this approach, we can balance the need for immediate medical intervention with respect for the patient's autonomy and previously stated wishes regarding end-of-life care, prioritizing his quality of life and minimizing unnecessary suffering.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Assessment and Treatment of the Patient
The patient presents with complete left-sided paralysis, incoherence, hypertension, bradycardia, and a reported wish for no heroic measures. The first step is to assess the patient's airway, breathing, and circulation (ABCs) and to evaluate the patient's disability and exposure (DE) as part of the ABCDE approach 2.
Hypertension Management
Given the patient's hypertension, management with intravenous antihypertensive agents such as labetalol or nicardipine may be necessary. Studies have shown that both labetalol and nicardipine are effective in managing hypertension in critically ill patients, with nicardipine providing more predictable and consistent blood pressure control 3, 4, 5.
Consideration of Patient's Wishes
The patient's reported wish for no heroic measures should be taken into consideration when determining the appropriate course of treatment. However, this does not necessarily mean withholding all treatment.
Appropriate Next Steps
The most appropriate next step would be to:
- Begin supportive treatment to manage the patient's hypertension and other symptoms
- Withhold active cardiopulmonary resuscitation (CPR) if the patient's wishes are respected and if CPR is not likely to be beneficial
- Not withhold all treatment until a family member or hospital administrator gives permission, as this could delay necessary treatment
- Not withhold all treatment until legal guardianship is granted by a judge, as this is not a feasible or timely solution in an emergency situation
Key considerations include:
- Managing the patient's hypertension with appropriate antihypertensive agents
- Respecting the patient's wishes regarding heroic measures
- Providing supportive treatment to manage the patient's symptoms and prevent further deterioration
- Communicating effectively with the patient's family and healthcare team to ensure that the patient receives appropriate care.