How to manage a patient with septic shock and POAD with a non-healing ulcer who refuses ICU admission and wants home care?

Managing a Patient with Septic Shock and POAD Who Refuses ICU Admission

When a patient with septic shock and peripheral occlusive arterial disease (POAD) with a non-healing foot ulcer refuses ICU admission and opts for home care, a goals-of-care discussion with the family is essential, focusing on the high mortality risk without intensive care support.

Initial Family Discussion

1. Establish clear communication about prognosis:

   • Explain that septic shock is a medical emergency with high mortality risk without proper ICU management 1
   • Clearly state that home management of septic shock carries a significantly higher risk of death compared to ICU care
   • Use simple, direct language to ensure understanding of the severity

2. Discuss goals of care:

   • Implement early goals-of-care discussion as recommended by the Surviving Sepsis Campaign 1
   • Address goals of care within 72 hours (ideally immediately in this urgent situation) 1
   • Determine if the patient has advance directives or previously expressed wishes 2

3. Explain treatment limitations at home:

   • Limited ability to provide IV fluids at the rate and volume needed (minimum 30 mL/kg within first 3 hours) 2
   • Inability to provide vasopressor support if needed
   • Challenges with frequent monitoring of vital signs and laboratory values
   • Limited capacity for rapid intervention if condition worsens

If Family Persists with Home Care Decision

If after thorough discussion the family still wishes for home care:

1. Document informed refusal:

   • Clearly document the risks explained to the family
   • Have family members sign informed refusal of hospital/ICU care
   • Document capacity assessment of the patient if they are participating in decision-making

2. Establish home care plan with palliative focus:

   • Set up home nursing visits at maximum frequency possible
   • Arrange for portable equipment (oxygen, vital sign monitoring)
   • Establish clear parameters for when to call emergency services
   • Consider palliative care consultation for symptom management

3. Medication management:

   • Antibiotics: Provide broad-spectrum antibiotics based on likely pathogens 2
     • For diabetic foot infection with sepsis: cover gram-positive, gram-negative, and anaerobic organisms 1, 3
     • Consider oral options if IV not feasible at home, though less optimal
   • Fluid management: Oral hydration if possible, or arrange home IV fluids if available
   • Pain control: Adequate analgesia for comfort
   • Wound care: Appropriate dressing and debridement plan for the non-healing ulcer 1

4. Family education and support:

   • Train family on basic monitoring (temperature, blood pressure if equipment available)
   • Teach recognition of worsening symptoms requiring emergency services
   • Provide emotional support and counseling
   • Connect with community palliative care resources

Ethical Considerations

1. Respect autonomy while ensuring informed decision:

   • Ensure the family fully understands the high mortality risk of home management
   • Discuss that septic shock has specific evidence-based treatments that significantly improve survival 1, 2
   • Consider ethics consultation if there are concerns about decision-making capacity

2. Explore compromise options:

   • Short ICU stay for initial stabilization with early transition to floor care
   • Treatment of septic shock in hospital with agreement for no escalation (e.g., no mechanical ventilation)
   • Hospital admission with DNR/DNI orders in place

Follow-up Plan

1. Establish frequent reassessment schedule:

   • Daily home nursing visits at minimum
   • Telephone follow-up by physician
   • Clear triggers for emergency evaluation

2. Wound management for POAD ulcer:

   • Arrange for wound care specialist visits 1
   • Implement appropriate debridement and dressing changes
   • Monitor closely for signs of worsening infection 4

Common Pitfalls to Avoid

1. Failing to emphasize the gravity of the situation:

   • Septic shock has high mortality even with optimal care; home management significantly increases this risk
   • Be direct about poor prognosis without proper treatment

2. Inadequate antibiotic coverage:

   • Ensure broad-spectrum coverage appropriate for likely pathogens 2
   • Consider source control needs that may be impossible at home 3

3. Insufficient monitoring:

   • Establish clear parameters for when to call emergency services
   • Ensure family understands warning signs of deterioration

4. Neglecting psychological support:

   • Provide resources for family members who will be witnessing potentially distressing symptoms
   • Connect with grief counseling services if appropriate

By following this approach, you can respect the family's wishes while ensuring they are fully informed about the risks and limitations of home care for a patient with septic shock and POAD with a non-healing ulcer.