When a Patient Declines Curative Care: Management of a Ruptured Aortic Aneurysm
A 72-year-old female ex-smoker with a past medical history significant for hypertension, abdominal aortic aneurysm, severe chronic obstructive pulmonary disease, and lung cancer presented to the ED with progressively increasing left-sided abdominal pain over 24 hours. The patient was tearful and anxious. Her vital signs included blood pressure of 150/90 mmHg, oral temperature of 36.5°C (97.8 °F), pulse 120 beats/minute, respiratory rate 26 breaths/minute, and 97% oxygen saturation by pulse-oximeter. She was adherent to her albuterol inhaler and labetalol regimen. Physical examination revealed a slightly distended abdomen with guarding and significant tenderness over the left lower quadrant. The rest of her examination, including bilateral pulses, was normal. A bedside FAST (focused assessment with sonography for trauma) examination was positive for free intra-peritoneal fluid. Computed tomography imaging revealed an 8 cm (transverse diameter) aortic aneurysm with evidence of contained rupture and displacement of abdominal organs by the large left sided peri-aortic hematoma (). The patient informed staff that she was aware of her diagnosis and condition and had refused surgery 5 years prior. During her initial resuscitation, the patient had a discussion regarding operative management with the vascular surgeon and ED clinician. She again refused any major surgical interventions due to her concern that she could be ventilator dependent for some time, an outcome she felt was unacceptable.\nTherefore, we present a framework for shared informed decision-making, exploring the pathway of our patient’s transition from a curative (disease-directed) to a comfort care (symptom-directed) approach.