This post is Part 1 of a multi-part series.

Concurrent Palliative Care – Peace of mind in the setting of an uncertain prognosis

Jean S. Kutner, MD, MSPH

I was in Asheville, N.C. for a professional meeting when I received a call from a medicine resident at our hospital saying that she was transferring my mom to the ICU for closer management of her intractable dyspnea (shortness of breath). My mom, who has an atypical presentation of Parkinson’s, had been admitted to the hospital with tachypnea (rapid breathing) and respiratory alkalosis (low blood pH caused by rapid breathing) ~ 5 days earlier. While she had been having odd episodes of shortness of breath for several months prior to this hospitalization, her Parkinson’s had been relatively mild, with no episodes of aspiration and good functional status. She had seemed to be improving when I left town and I had fully expected that she would be discharged by the time I returned home. Things clearly had changed for the worse. Speaking with my dad did little to relieve my growing anxiety – he told me that she had developed tachypnea and respiratory alkalosis again, had exceeded the monitoring capacity of the regular medicine unit, and was being transferred to the ICU to facilitate higher benzodiazepine dosing to attempt to control what was eventually diagnosed as a respiratory dyskinesia, thought to be a rare side effect of the carbidopa/levodopa she was taking to treat her Parkinson’s symptoms.

While I had complete trust in my medicine, pulmonary and neurology colleagues who were attentively caring for my mom and monitoring the situation, I felt helpless without having eyes and ears ‘on the ground’. It didn’t take me long to reach out to my palliative care colleagues for help. Who better to quickly assess and inform me about a situation involving an apparently deteriorating clinical situation and prognostic uncertainty? I sent a text message to our palliative care advanced practice nurse – “my mom’s being admitted to the ICU, I’m out of town, can you find out what’s going on?” Reaffirming the wonderfully supportive colleagues we have in this field, she and the rest of the palliative care team quickly went to the ICU to check on my mom – and to see how my dad was doing. Their call to me was at the same time chilling and reassuring – “she looks really uncomfortable – we told the ICU team that we recommend intubation for her comfort”. I’ll bet that is one of the few times that the ICU team has heard palliative care recommend intubation. New mantra – if the palliative care team recommends intubation, the patient probably really needs it.

I stayed in close contact with the palliative care team over the next day as events evolved and I was able to work my way back to Denver from Asheville. It gave me great peace of mind to know that I had trusted eyes and ears present who were looking out for both my mom’s comfort and my dad’s well-being.