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Palliative Care in Assisted Living

      Mrs. M is a 92-year-old woman residing in an assisted living community. Her medical history includes hypertension, gout, hyperlipidemia, atrial fibrillation, hypothyroidism, and melanoma with invasion into the parotid gland; she has had removal of a lesion and a parotidectomy with nerve involvement impacting the 7th cranial nerve. Her medications include oral levothyroxine, 100 μg daily; oral vitamin D, 1,000 units daily; oral probenecid 500/colchicine, 0.5 mg daily; oral lisinopril, 5 mg daily; oral furosemide, 20 mg daily; oral duloxetine, 60 mg for depression; oral carvedilol, 6.25 mg twice a day; oral aspirin, 81 mg daily; oral acetaminophen (Tylenol), 1,000 three times daily; and oral lansoprazole (Prevacid), 30 mg daily. At baseline Mrs. M scored 25 on the Mini-Mental State Exam (MMSE), walked independently, and ate independently although she required thickened and soft food due to nerve changes.
      Mrs. M’s family took her to Florida for the holidays to see relatives. While she was there, despite having been vaccinated and boosted, she contracted COVID-19, and she was treated with monoclonal antibodies. She returned to her assisted living community 10 days after COVID-19 infection, and she was noted to be more confused. She could get up by herself but be unable to ambulate consistently and safely. She sustained multiple falls. Her MMSE score decreased to 12.
      Her physical examination was otherwise unremarkable. Mrs. M’s heart rate was regular at 72, her blood pressure ranged from 142–166/68–72, and she was afebrile. She had normal vesicular breath sounds without rales, rhonchi, or wheezes. There was no peripheral edema.
      A comprehensive metabolic panel revealed that Mrs. M’s sodium level was 133 mmol/L, and her complete blood count revealed a white blood cell count of 15.9 × 103/μL, a red blood cell count of 2.94 × 1012/L, hemoglobin of 9.7 g/dL, and hematocrit of 30.3%. Her blood urea nitrogen level was 22 mg/dL and creatinine was 1.20 mg/dL. Her chest x-ray showed no evidence of pulmonary or cardiac disease or infection, and her urine showed no signs of infection.
      Neurologically there were no specific focal findings. However, Mrs. M’s balance was worse, with a wide-based unsteady gait. She tended to lean on the furniture to help with ambulation.
      The advanced practice nurse discussed the situation with the family, and the likely correlation between Mrs. M’s change in condition and her experience with COVID-19 as well as a possible acute cerebral vascular event. The decision was made that she should remain in her assisted living apartment; they would forego a hospital transfer and promote aggressive comfort measures. The team was contacted to address the best ways to manage palliative care for Mrs. M.

      Attending Physician

      Melvin Hector, MD, FAAFP, CAQ Geriatrics, CMD
      Dr. Hector is a Tucson-based physician with over 30 years of medical director experience.
      The first task is to review Mrs. M’s medications. With no documented coronary artery disease, I have difficulty justifying her continued aspirin. Unless she is taking aspirin, the Prevacid is not justified, and it may be contributing to her possible dizziness, depression, falls, and altered mental status. Given her mental status changes I would halve her duloxetine (especially with the reports of Prevacid and duloxetine together contributing to lethargy, vertigo, depression).
      For Mrs. M’s atrial fibrillation and possible stroke, I would strongly consider a direct oral anticoagulant after further investigation of her central nervous system with imaging. Keep in mind that probenecid rarely can contribute to dizziness. Finally, 3 g of Tylenol per day in a 94-year-old seems safe enough and well tolerated, if indicated. Her anemia begs further definition by readily available laboratory surveys.
      Her monoclonal antibody infusion side-effect window seems well past, but it might have transiently included dizziness. Interstate travel, various health care settings, and isolation from family and familiar surroundings all may have contributed to her symptoms. Long-term COVID can manifest as extreme fatigue, possible chronic fatigue syndrome, depression, anxiety, orthostatic hypotension (which should be checked for), posttraumatic stress disorder, and other symptoms.
      Finally, without additional information, her history of a melanoma involving her parotid cannot be ignored. It is certainly within the realm of palliative care to do imaging to rule out nearby involvement, recurrence, or bleed. For her new susceptibility to falls, physical and occupational therapy evaluations are indicated as well as a dietary evaluation.

      Social Worker

      Paige Hector, LMSW
      Ms. Hector is a social work expert and a coeditor of this column.
      In addition to the MMSE, I would explore a more thorough capacity evaluation to learn how best to involve Mrs. M in decision-making for both health care and daily living preferences. Even with her change in cognition, she may be capable of and want to participate in her care.
      In the book Dementia Together: How to Communicate to Connect (PuddleDancer Press, 2020), Pati Bielak-Smith offers empathy-based questions for basic human needs such as inclusion (Would you like to be part of what’s happening? Would you enjoy people speaking slowly?), mattering (Do you want to know that you matter? Would you like to know that I care about what you need?), mourning (Do you want to show how sad you feel?), and respect (Do you want to be cared about? Would you like to be taken into consideration?). These prompts can help the staff and family to engage with Mrs. M and allow her voice to be heard.
      Given the decision for comfort measures, it might be assumed that she has a Do Not Resuscitate code status, but I would clarify this and ensure there’s a corresponding order and signed documents per facility policy. Gaining clarity about how Mrs. M and her family define aggressive comfort measures is important so that the interdisciplinary team (IDT), which includes the resident and her family, are working in partnership to uphold her wishes.
      In my role as the social worker, I would also ensure that all point-of-care staff receive guidance regarding the care plan to ensure consistency. Given the potential for psychosocial implications around Mrs. M’s rapid change in status, which could be associated with her recent COVID-19 infection, I would assess her well-being to the degree that she is capable of sharing and enlist the help of her family to identify whether there are unmet needs in this area.

      Director of Nursing

      Karen Evans, BSN
      Ms. Evans is nurse manager for Residential Care Roland Park Place.
      The nursing staff will focus on Mrs. M’s comfort care wishes. Given her cognitive changes and increased risk of falls, I will speak with the family about the option of arranging for someone to be with Mrs. M to assist her with safe transfers and ambulation during daytime hours. The staff will continue to optimize her function and physical activity because sitting for long periods of time can cause pain and result in contractures and pressure areas.
      The staff will regularly assess Mrs. M’s level of pain via verbal report and observation, and they will provide nonpharmacologic and pharmacologic interventions as indicated. Because food can be a source of comfort and pleasure, the staff will tend to her food preferences. The nursing staff will contribute to the IDT discussion regarding deprescribing, with recommendations to discontinue vitamin D, furosemide, duloxetine, aspirin, and Prevacid. We will monitor her blood pressure and provide updates to her providers.

      Dietician

      Rebecca Myrowitz, RD
      Ms. Myrowitz is a nutritionist with long-term care experience and currently a research nutritionist at USDA
      Because Mrs. M is transitioning to palliative care, the approach for her nutrition is focused on comfort such as discontinuing the therapeutic diet and liberalizing her diet according to her tolerances and preferences. I would encourage her family to bring in her favorite foods. Discontinuing the vitamin D so she has fewer pills to swallow may also support her comfort.
      With her past medical history of a parotidectomy, she may have a dry mouth, so she should have access to adequate hydration for comfort. Ice chips and providing mouth care may be particularly helpful. I would support her family with education around appetite fluctuations and ways to accommodate her preferences as her condition changes and she approaches the end of life.

      Activities Director

      Diane Mockbee, BS, AC-BC
      Ms. Mockbee is an activity consultant/educator/dementia trainer.
      An important part of activity programming involves food. The activities staff will encourage Mrs. M to eat the foods that she enjoys and offer her soft and sweet foods like protein shakes with peanut butter. Handheld foods also may be helpful as her cognitive status changes.
      The activities staff will support Mrs. M with passive physical exercises done from a seated position accompanied by music, which may help mitigate the risk of injury from a fall. Simple leg and arm exercises can be done using scarves and TheraBands at low elasticity (yellow), also accompanied by favorite music. We would involve the family to learn more about her musical preferences if need be. Her family may be interested in participating in the exercises as well.
      The activities staff would also explore her faith preferences, make arrangements for visits from the chaplain, and provide other faith-based activities that would offer her comfort. During family visits (including via technology) we would encourage the family to share photos for reminiscing and enjoyment. We would encourage all staff to accommodate her rest schedule and honor her circadian rhythm as her body adjusts to her changing needs.
      Additionally, the activities staff will support and reinforce educational interventions to assist the family to cope with Mrs. M’s progression toward the end of life and to maximize connections with caregivers and family.

      Pharmacist

      Nicole Brandt, Pharm D, MBA
      Dr. Brandt is a professor and the executive director of the Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy.
      I would recommend determining whether the aspirin is still clinically warranted due to a possible postvascular event and limited efficacy in individuals with atrial fibulation. Given Mrs. M’s advanced illness and the treatment plan for aggressive comfort measures, I recommend reevaluating her regimen to consider deprescribing the aspirin, vitamin D, and possibly lansoprazole. The lansoprazole may affect the absorption of the levothyroxine, depending on the timing of dosing.
      It also would be useful to determine the clinical indication for the furosemide and lisinopril, given the diagnosis of heart failure, and clarify whether the daily dose of Tylenol at 3 g is the most appropriate pain management strategy. Lastly, I would recommend decreasing the duloxetine because the current dose is too high to treat depression.
      Dr. Resnick is the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore. She is also a member of the Editorial Advisory Board for Caring for the Ages.
      Ms. Hector is a clinical educator and professional speaker specializing in clinical operations for the interdisciplinary team, process improvement and statistical theory, risk management and end-of-life care, and palliative care, among other topics. She is associate editor and a member of the Editorial Advisory Board for Caring for the Ages.

      KEY POINTS

      • The interdisciplinary approach was important to combine each discipline’s unique (and sometimes overlapping) perspective in a balanced set of recommendations.
      • The team was consistent with focusing on comfort measures and upholding the resident’s preferences as well as approaching her care plan with flexibility, especially as her needs and abilities change with diet and sleep habits.
      • Activities should engage Mrs. M with as much physical activity as tolerated and should incorporate music.
      • Mrs. M should be involved in the daily care decisions as much as possible, and the staff should collaborate on all shifts to share information.
      • Multiple team members have recommended deprescribing many of the medications that were potentially harmful and no longer necessary for preventive purposes.
      • The team members support the plan for Mrs. M to remain in her assisted living apartment and will be providing the family with resources to allow Mrs. M to safely live out the remainder of her life in that setting.