Facilitating Discharge Home for End-of-Life Care in a Patient with Severe COPD
The next step for the AGACNP is to facilitate discharge home for this patient who wants to transition to comfort care at home.
Understanding the Patient's Current Status and Wishes
- The patient is a 60-year-old man with severe COPD who has been dependent on CPAP 20 at 100% for 5 days 1, 2
- He has a documented DNR/DNI status and has clearly expressed his wish to transition to comfort care at home 1, 3
- His recent severe desaturation to 60% with increased anxiety and shortness of breath indicates worsening respiratory status 4
- This represents end-stage COPD characterized by very severe airflow limitation, declining performance status, and chronic respiratory failure 5
Rationale for Facilitating Home Discharge
- DNR/DNI status reflects the patient's autonomous choice to limit certain interventions but does not limit other treatments that align with his goals of care 1, 3
- The American Thoracic Society recognizes that for patients with terminal illnesses, home care goals include physical and psychological comfort and making dying at home possible 1
- Hospice services are specifically provided for patients with a predicted life expectancy of 6 months or less who have elected palliative rather than curative care 1
- The patient's explicit request for comfort care at home should be respected as part of patient-centered care 3, 6
Implementation Steps
1. Immediate Care Planning
- Consult with palliative care specialists to develop an appropriate symptom management plan before discharge 3
- Ensure adequate pain and symptom management medications are prescribed, including morphine for dyspnea relief 3
- Document the specific limitations of care and interventions still permitted based on the patient's DNR/DNI status 3
2. Discharge Planning
- Arrange for home hospice services to provide ongoing support for end-of-life care 1
- Ensure home oxygen and necessary respiratory equipment are arranged prior to discharge 1
- Coordinate with social services to assess home needs such as equipment to assist in daily living 1
- Provide financial assessment and guidance on benefits the patient may be eligible for 1
3. Family and Patient Education
- Educate the patient and family about what to expect during the dying process 3, 6
- Ensure family members understand their role in providing care and when to contact hospice services 1, 7
- Discuss medication administration, including use of as-needed medications for breakthrough symptoms 3
- Address any perceived discordance between patient and family treatment preferences, as this can impede advance care planning 7
Important Considerations and Potential Pitfalls
- Avoid delaying the discharge if the patient is stable enough for transport, as this would not respect his autonomous choice 3, 6
- Do not remove CPAP support until appropriate home oxygen and comfort measures are in place to prevent unnecessary suffering 2, 8
- Recognize that ordering 10 mg morphine and removing CPAP without a comprehensive discharge plan could cause unnecessary distress 3
- Understand that referring to inpatient hospice would contradict the patient's explicit wish to be at home 1
- Do not consider intubation as this would violate the patient's DNI status 1
Follow-up Recommendations
- Ensure a clear handoff to the home hospice team regarding the patient's condition and care plan 1
- Establish a timeline for the home hospice team to make their first visit, ideally within 24 hours of discharge 1
- Document all discussions with the patient and family regarding goals of care and comfort measures 3, 6
- Provide emergency contact information for the hospice team to the patient and family 1, 9
By facilitating discharge home with appropriate hospice support, the AGACNP respects the patient's autonomy and dignity while ensuring comfort during end-of-life care.