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CASE: You are working after hours and a young mother brings her 12 month old infant with fever 104 C
Should you admit this patient and perform an infectious workup or send the patient home with close surveillance?
In any given year, 15% of visits to the ED or urgent care by children under 15 years of age are children with fever. The vast majority of these children have self-limited viral infections. Yet serious illness is also manifested by fever in children and includes meningitis, sepsis, and pneumonia. With increasing rates of vaccination against hemophilus and pneumococcus, invasive infection and meningitis have been declining. The most common serious infections are pneumonia in the less than three month group of infants and urinary tract infection in infants older than 3 months. Red flags indicating serious illness include any of the following:
- Change in sensorium
- Changes in crying/moaning patterns
- Rapid breathing and shortness of breath
- Signs of meningeal irritation
- Rashes esp petechial
This past year, the American College of Emergency Physicians have released an updated clinical policy on evaluation of the child under two years with fever. Their recommendations are summarized below:
Infants 1-3 months: consider lumbar puncture (LP) to rule out meningitis in infants 29-90 days and admitted to hospital for observation. Antibiotics are appropriate after LP until cultures are returned as negative
Children 2 months – 2 years: perform a chest radiograph in children with fever of at least 100.4F with no clear infection source but have cough, rales or hypoxia. Do not perform CXR in children with fever and wheezing and high probability of bronchiolitis. Consider performing urinalysis and urine culture especially in high risk children including girls under 1 year, uncircumcised boys, fevers lasting longer than 24 hrs. and no clear infection source. If there is a positive urinalysis (leukocyte esterase or nitrates) start antibiotics without waiting on results of urine culture. AAP recommends collecting urine samples through cauterization or suprapubic aspirate.
If the infant or child presents during the influenza season, consider performing rapid influenza testing.
If serious infection is strongly considered, the following age grouped antibiotics are recommended:
Under 1 month Ampicillin + gentamicin or cefotaxime
Over 1 month with urinary: cefotaxime or cefixime
1-3 months possible meningitis ceftriaxone
1-3 months (listeria/enterococcus) add ampicillin
3 months + pneumonia amoxicillin or azithromycin
 Annals of Emergency Medicine, May 2016; 67(5): 625-639
CASE: Mr Dooby, a 52 year old male, presents to your office with a chronic cough and shortness of breath with normal activities, worsening over the last 12 months. By history, he has been a pack per day smoker since he was 18 years of age.
Does this patient have chronic obstructive pulmonary disease?
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease characterized by chronic cough, shortness of breath with exertion or at rest. It is the 3rd leading cause of death in the United States affecting 4-9% of the population with up to 90% of COPD cases related to smoking. Diminished breath sounds, peak flow rates of under 350-l/min and a 30 pack year smoking history are 98% positively predictive. Diagnosis can be confirmed by spirometry with bronchodilators with an FEV1/FVC ratio of under 0.7 with increasing degrees of irreversibility (by bronchodilator). The GOLD classification is based on this latter index with the FEV1 % of predicted
> 80 mild
< 30 very severe
The primary differential is with asthma which is characterized by reversibility and variability of airflow obstruction. Other conditions to consider include congestive heart failure, lung cancer, pulmonary arterial hypertension, interstitial lung disease and upper airway/ vocal cord dysfunctions.
The foundations of management include smoking cessation through tobacco cessation programs and pharmacotherapy with nicotine replacement, varnenicline, or buproprion. Also includes regular use of inhaled bronchodilators starting with short acting beta agonists or anticholinergics for mild COPD with addition of long acting beta agonist (LABA) or long acting anticholingerics. With progression of disease severity, additional of an inhaled corticosteroid in combination with a LABA is indicated. Roflumilast (Daliresp) which is a phosphodiesterase-4 inhibitor should also be considered in severe or very severe COPD.
The role of oxygen has evolved with recommendations now to provide supplemental oxygen to patients with COPD who have severe resting hypoxia (O2 sat 88% or less). The key is to ensure that patients use oxygen for at least 15 hours per day to achieve target O2 saturations of 88-92%. Pulmonary rehab is also important for severe-very severe COPD patients. Mucolytics and anti-tussives are NOT recommended and provide little benefit.
As the disease progresses, consider providing or referring for palliative care. Use of the BODE Index allows you to determine the risk of dying in your COPD patients. BODE includes four variables: FEV1, six minute walk distance, MRC dyspnea score, and BMI. Scores indicate four year survival rates with 0-2 = 80% survival up to 7-10 18% survival.
CASE: Your patient brings in her grandmother (82 yrs old diagnosis with dementia) with complaints that she is up all night screaming incoherently, strikes out at caregivers, and angers easily.
What can you offer your patient to better manage her mother’s agitation?
Dementia patients commonly have behavioral and psychological symptoms that present in several clusters that include psychosis (delusions, hallucinations) and agitation/aggression, and disinhibition (agitated behaviors) Agitation and psychotic symptoms in demented patients is common, occurring in up to 30% of patients and may increase with disease progression. Dementia patients with agitation and other neuropsychiatric disorders cause significant stress on the caregivers, lead to excess hospitalizations and nursing home admissions, and carry higher mortality. Environmental and non-pharmacologic interventions are the mainstay of treatment. These include reducing ambient noise and clutter, establishing schedules of activities, periodic orientation. It is important to stay alert to possible sources of pain that the patient may be experiencing but unable to express, and manage these as appropriate. Of note 36% of patients with agitated dementia have an underlying undetected illness.
In evaluating patients with dementia presenting with agitation or other behavioral problems, consider the three main factors that contribute:
Patient-related: acute medical illness, underlying psychiatric illness, sensory deficits
Care-giver related: poor communication, emotional instability
Environmental factors: clutter, overstimulation, understimulation
Pharmacologic therapies should be reserved for severe conditions that are not well managed just by non pharmacologic therapies alone. Note that the FDA has NOT approved any medication for the management of behavioral conditions related to dementia so all of the medications discussed below are used in an off label manner.
Anti-psychotics. The atypical anti-psychotics, risperidone and aripiprazole, have been shown in 15 randomized controlled trials to be modestly effective at managing behavioral symptoms. Oddly, presence of psychosis was associated with less clinical effectiveness for agitation than in patients without psychosis. The atypical anti-psychotics are not without their adverse effects. Based on re-analysis of 17 RCTs in 2005, the FDA issued a black box warning that indicated a 1.7 fold increase in mortality risk in patients treated with these drugs. Beyond excess mortality, this class of drugs was also associated with extrapyramidal effects, hyperprolactinemia, prolonged QT syndrome (thought to be the source of excess mortality) and greater anti-cholinergic side effects. Conventional antipsychotics such as haloperidol also carry a similar black box warning.
Benzodiazepines. Curiously, there are no RCTs on clinical effectiveness of this class of drug in the management of agitated dementia, and are NOT recommended in the management of behavioral issues in dementia with the exception of acute crisis. Of particular concern with the use of benzodiazepines is the increased risk of dependency and worsening of dementia as well as excess falls.
Take home lessons are:
- evaluate the three categories of factors and address each
- Preference is for non pharmacologic strategies (environment, caregiver)
- use atypical anti-psychotics if behavior is severe and not managed well by non pharmacologic interventions
- Be cautious. Avoid benzodiazepines.
CASE: One of your patients brings in her mother who she reports is having increasing forgetfulness. She is 82 years old, with longstanding hypertension and heart disease. No history of stroke. The forgetfulness was starting to be noticed in her late 60’s and has progressed gradually since then.
Does this patient have dementia? The Alzheimer’s Association recommends looking for the ten warning signs of dementia that include:
- Memory loss that affects daily living or work
- Difficulty performing familiar tasks
- Problems with language
- Disorientation in time and space
- Poor or decreased judgement
- Problems with abstract thinking
- Misplacing things
- Changes in mood or behavior
- Changes in personality
- Loss of initiative
Dementia is very common, affecting up to 50% in patients over 85 years of age, and 10% in patients 65 years. As we all age, our memories decline. However, primary care physicians should be alert to patients who are experiencing memory loss without other signs of cognitive impairment. This is defined as mild cognitive impairment (MCI). Unfortunately up to 81% of patients who meet the criteria for dementia never receive a documented diagnosis. Up to 25% of patients with MCI progress to full dementia each year, and should be evaluated and managed.
Key diagnostic studies include a CBC, serum glucose, serum electrolytes with BUN and creatinine, serum B12 levels, liver function tests, thyroid screening with TSH and depression screening. The latter is crucial as many patients with depression present with mild cognitive impairment. At the present time, there is little evidence to screen for syphilis (unless specific risk factors exist), doing EEGs, APOE genotyping, MR or CT scans or SPECT scanning. Use of PET scans or genetic screening for Tau mutations are controversial.
If cognitive impairment exists, consider use of cholinesterase inhibitors or vitamin E in patients with mild to moderate dementia. Diagnose and treat depression and psychosis as appropriate. Many patients with dementia develop functional or behavioral problems. Consider the following:
- Behavioral modifications (scheduled toileting)
- Music especially during meals and bathing
- Walking or light exercise
- Pet therapy (yes with animals, not electrons)
- Cognitive exercise
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Completion of the Advanced Directive: When a healthcare agent or surrogate is named and a living will is completed designating what the patient’s wishes might be, the Advanced Directive is signed by the patient. In order for the Advanced Directive to become a legal document, it must either be witnessed by two people or notarized by an authorized public notary. Note that both the witness signature and the notarization only testify that the signature belongs to the patient, and not to the validity or completeness of the Advanced Directive. As noted above, the patient can elect to activate the Advanced Directive immediately upon signature and witness/notarization or can elect to activate after signature and witness/ notarization only when the patient is incapacitated.
When to Consider a Physician Order for Life Sustaining Treatment (POLST): The Advanced Directive is appropriate when a serious illness or chronic disease is first diagnosed at minimum, and updated on a regular basis as the patient ages and their health status changes. A good case could be made for starting to do Advance Care Planning, having advance directive conversations, when the patient is young. One could consider for instance, a high school graduate to receive a diploma and an advance care planning document. What is key is the recognition that advance care planning is about repeated conversation over time with an individual about their wishes. The Advanced Directive is the document that captures these conversations.
When a patient becomes more seriously ill and is approaching the last phases of a terminal trajectory, you could discuss physician orders for life sustaining treatment and complete a POLST form (capolst.org). This state approved form has four sections:
Section A: cardiopulmonary resuscitation (CPR or Do Not Attempt Resuscitation = allow natural death)
Section B: medical interventions (full, selective, comfort-focused)
Section C: artificial nutrition (long term, trial, no artificial means including feeding tubes)
Section D: Information and signatures.
This form can be signed by either a physician or a nurse practitioner/ physician’s assistant. Make copies for the patient’s medical record, provide copy to the patient and the patient caregiver/surrogate. This form should be with the patient at all times.
To learn more about POLST, the link below sponsored by the California Coaltion for Compassionate Care provides great resources.
Partnership HealthPlan Commitment: Our commitment to the seriously ill members in our plan is strong and manifest through the Partnership HealthPlan’s Offering and Honoring Choices Initiative. This is a set of 14 activities that promote, support and facilitate a spectrum of palliative care activities, including completion of advance care directives and POLST completion. Of note, PHC has included advance care planning in the Quality Incentive Program (QIP) which includes $100 per member for attestation of an advance care plan conversation and an additional $100 for submission of a completed POLST.
Counselling on Selection of a Health Care Agent (Surrogate): Anyone can be chosen by the individual to be their healthcare agent with three exceptions:
- Patient’s supervising healthcare provider unless related to the patient
- Any employee of the healthcare institution where the patient receives care unless related to the patient
- Any operator or employee of the facility where the patient lives unless related to the patient
The optimal healthcare agent should be willing and able to serve (assess the capability of the surrogate as well as the patient), knows the patients values and preferences, is able to make difficult decisions, and is willing and capable of speaking for the patient. The scope of authority of a healthcare agent includes:
- Choosing a healthcare provider
- Approving or refusing medical treatment
- Agreeing to testing
- Reviewing medical records
- Donating organs
- Authorizing autopsy
- Directing the disposition of remains
The legal standard for surrogate decision making is either in accordance with the expressed wishes of the patient (substituted judgement) or if wishes are unknown, based upon the values and preferences of the patient. This means decisions are made as if the surrogate were standing in the shoes of the patient, making the decisions the patient would have made.
To name a healthcare agent, assist the patient in writing in the name, address, phone number and other contact information (eg. email address) for the primary surrogate. Also assist the patient in considering and putting in writing a backup or secondary surrogate if the primary is not available.
If the patient has not designated a healthcare agent, should they become incapacitated, the default surrogate is activated. These default agents include the spouse or domestic partner, and adult sibling, an adult child, an adult grandchild, or an adult relative with the closest degree of kinship. In a skilled nursing facility, the default surrogate is the attending physician.
Leeway is the degree of autonomy granted to the surrogate in making decisions for the patient. A patient can decide not to grant leeway meaning the surrogate must follow strictly the wishes of the patient. In other circumstance, the patient may decide to grant partial or full autonomy or leeway to the surrogate to use their judgement.
A section of the Advanced Directive allows the patient to determine if the surrogacy is immediately active or is only activated when a physician determines there is loss of capacity of the patient. Note the term ‘competence’ is not used as it is a legal term and is determined by a court.
Counselling on Living Will: A living will is the component of the advanced directive that provides guidance to the surrogate on what values and wishes that patient has about their continuing care. It make include:
- What makes life worth living
- Where the patient wants to die
- The role of religion or spirituality in the dying process
- Desire or lack thereof for supportive treatments
- Life support including CPR, feeding tubes, dialysis, blood transfusion, artificial ventilation
- Donation of patient’s organs
- Preference for autopsy
The Case for Advance Care Planning. Advance care planning is a series of conversations that a patient and you, their care provider, have about end of life wishes. These can be captured into an advance care plan, that may include both a selection of a health care agent or surrogate, and a living will with specific guidance on desires for interventions and level of care. These two together can form an Advanced Directive. This is a legal document that has no expiration date. It is intended to provide guidance to the named or default healthcare agent on wishes of the individual for their care. Once legally completed, it is transportable across states
Why is counseling your patient on Advance Care Planning so important? Data are compelling that our population is aging, and the types and trajectories of death are changing. Whereas relatively acute episodes of untreatable disease or trauma used to be the norm which led to shortened and abrupt trajectory to death, chronic diseases, particularly cardiovascular and pulmonary disease, have become the predominant causes of death. Seven out of ten Americans die of a chronic disease. These common trajectory now is a prolonged, downhill course with occasional decompensations and recovery until a decompensation happens from which there isn’t recovery. Patients now live longer with serious illness and disability, making their life and dying decisions so important not only for the quality of their remaining lives, but also for more rationale use of healthcare resources. Healthcare costs skyrocket in the last two years of life, accounting for almost 30% of healthcare expenditures. With the aging of the population, this is only going to increase. Although the Medicare hospice benefit provides for care in the last six months of life, the average duration in hospice in only a week. A California Health Care Foundation survey found that only 20% of Californians have talked about their end of life wishes with their doctors.
Advance care planning increases patient satisfaction and fulfillment of their healthcare wishes more often but also reduces hospitalizations, ED visits and costs in the last two years of life. Advance care planning is a win for patients, a win for providers, and a win for healthcare systems.
Next in Series: Advanced Directives and Selection of a Surrogate
Written by: Scott Endsley MD, Associate Medical Director, Quality