The ambulance was called for a 69 year old female in a nursing home who was having difficulty breathing.

The ambulance was called for a 69 year old female in a nursing home who was having difficulty breathing. She has a medical history that includes advanced ovarian cancer, COPD, asthma, anxiety disorder and depression, and severe abdominal and back pain. She was admitted into the hospital and medical records were available for her.

Following procedure, it was decided that she should be intubated. Soon she was able to be weaned off the respirator and then moved to the medical floor. Though she was suffering from abdominal and back pain, she was unable to withstand surgery due to her current condition. To treat other conditions she was prescribed Neurontin and Xanax and since she could breathe on her own she was sent back to the nursing home. 24 hours later she was back at the hospital suffering from emesis and nausea along with back and abdominal pain. She was treated with Dilaudid and Darvocet and the oncologist came to see her. Within a few hours she was comfortable.

During her first admission at the hospital her family asked for only comfort care and a DNR was signed. The patient gets a grave prognosis as she declines. Her breathing is getting shallow as she is dying. At this time the attending physician has chosen to discontinue giving morphine. The patient stops responding and this causes the family to panic and they want to rescind the DNR. Due to this, the patient is sent to the ICU after intubation. There is nothing listed on the chart that shows anyone realizes that the patient in now in the dying process. 

After being seen by 15 physicians and suffering various conditions and treatment, on the 51st day of her stay, the family signed a DNR again and she died the next day in ICU.

1) How should have this case been handled? Do you see that there was a plan of care for this patient? Why is a plan of care important?