END OF LIFE CARE IN INPATIENT PSYCHIATRY: A CASE STUDY ON END-STAGE ALZHEIMER'S DISEASE

Abstract

Introduction Dementia is the sixth leading cause of death in the United States with Alzheimer's disease being the leading cause of dementia. To avoid unnecessary suffering and even harmful resuscitation, patients with dementia, or their designated decision-makers, can choose to sign a do-not-resuscitate (DNR) or do-not-intubate (DNI) order when they are critically ill. These patients and their designated decision-makers may also choose to receive hospice care to treat their symptoms and improve their quality of life in their final days. The percentage of patients with dementia receiving hospice care in 2018 was 11%, and this percentage is fast growing of hospice patients. However, caring for patients with advanced dementia who are nearing end of life poses many challenges for inpatient psychiatrists and staff. This case aims to examine a patient with Major Neurocognitive Disorder due to Alzheimer's disease with behavioral disturbances and the challenges to honoring the patient's DNR/DNI status and coordinating discharge to hospice. Methods Case Description: Patient is a 78-year old male diagnosed with Major Neurocognitive Disorder due to Alzheimer's disease with behavioral disturbances admitted to Vanderbilt Psychiatric Hospital for uncontrollable physical aggression. This was his second psychiatric hospitalization in one year due to aggression. On initial evaluation, he was oriented to self only, which was his baseline. He was admitted on the following medications: donepezil 10mg daily, haloperidol 3 mg twice daily, melatonin 1.5 mg at bedtime, finasteride 5 mg daily, tamsulosin 0.8 mg at bedtime, aspirin 81 mg daily, a multivitamin daily, and comfort medications as needed. Behavioral interventions were initiated to reduce agitation. On hospital days 1-6, he was physically aggressive towards staff during activities of daily living. During this time, he was tapered off haloperidol and risperidone was titrated to target physically aggressive behavior, although this was eventually discontinued due to ineffectiveness. On hospital day 8, he was started on olanzapine for physical aggression, resulting in improvement. During this time, olanzapine was adjusted to 5 mg at bedtime and melatonin to 3 mg at bedtime. While his aggressive behavior improved, his food intake and mobility continued to decline. The geriatric psychiatry team recommended patient's POA consider hospice care. Palliative care was consulted, but declined to see the patient while he was hospitalized psychiatrically. On hospital day 26, the patient started displaying autonomic instability, though did not appear to be in distress. He was started on supplemental oxygen. The Geriatric Medicine consult team recommended morphine 5-10 mg every 2 hours as needed for dyspnea or pain. Two community hospice services were consulted and determined him appropriate for their facilities. The psychiatric nursing staff expressed concern his DNR/DNI could not be honored if he were to decompensate further prior to transfer. The Chief Medical Officer was involved who confirmed the DNR/DNI status could be honored as the policy had recently changed. On hospital day 28, the patient was discharged to a nursing home with hospice care, and he died nine days later. Results Discussion: Inpatient psychiatrists and staff are not as familiar as their counterparts at a medical center in managing end-of-life care and death of patients, despite geriatric psychiatrists commonly treating patients of advanced age or with terminal illness. An increasing number of patients with advanced dementia and associated behavioral disturbances are psychiatrically hospitalized, and they represent the fastest growing group of hospice patients. This patient's agitation needed stabilizing before he could transfer to a nursing home safely. When he began displaying autonomic instability, multiple members of his treatment team were concerned his advanced directives would not be honored if he died while on the psychiatric unit, and expressed additional concerns around the impact his death would have on staff and other patients. Conclusions Experts suggest the final stage of Alzheimer's disease include the inability to ambulate, speak, perform activities of daily living, and appropriately swallow. When these signs are present, it is important to recognize any limitations in the care available, involving hospice or palliative care experts if needed, to honor a patient's end of life wishes accordingly. This research was funded by Not applicable.