{"version":"1.0.0","segments":[{"startTime":0.434,"endTime":3.058,"body":"[upbeat intro music]"},{"startTime":3.058,"endTime":5.615,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.058,"endTime":5.615,"body":"to Harrison's PodClass,"},{"startTime":5.615,"endTime":8.638,"body":"where we discuss important"},{"startTime":5.615,"endTime":8.638,"body":"concepts in internal medicine."},{"startTime":8.638,"endTime":9.96,"body":"I'm Cathy Handy."},{"startTime":9.96,"endTime":11.668,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.96,"endTime":11.668,"body":"Wiener, and we're coming to you"},{"startTime":11.668,"endTime":13.84,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.808,"endTime":17.474,"body":"[Dr. Handy] Welcome to episode 88,"},{"startTime":17.474,"endTime":20.02,"body":"a 79-year-old with pneumonia."},{"startTime":20.02,"endTime":24.72,"body":"[Dr. Wiener] Hey Cathy, well"},{"startTime":20.02,"endTime":24.72,"body":"today's case is a 79-year-old"},{"startTime":24.72,"endTime":29.063,"body":"former IRS auditor who has"},{"startTime":24.72,"endTime":29.063,"body":"advanced Alzheimer's disease."},{"startTime":29.063,"endTime":30.84,"body":"As background, she was living at home"},{"startTime":30.84,"endTime":32.87,"body":"with her eldest son"},{"startTime":30.84,"endTime":32.87,"body":"and her daughter-in-law"},{"startTime":32.87,"endTime":35.18,"body":"and despite notable"},{"startTime":32.87,"endTime":35.18,"body":"decline over the past year"},{"startTime":35.18,"endTime":37.01,"body":"she still had a good quality of life,"},{"startTime":37.01,"endTime":39.04,"body":"including visiting with"},{"startTime":37.01,"endTime":39.04,"body":"her great-grandchildren"},{"startTime":39.04,"endTime":40.48,"body":"and her grandchildren,"},{"startTime":40.48,"endTime":42.57,"body":"and she particularly"},{"startTime":40.48,"endTime":42.57,"body":"enjoyed the Price is Right"},{"startTime":42.57,"endTime":45.237,"body":"every day, starring Drew Carey."},{"startTime":45.237,"endTime":46.73,"body":"Because of her advanced disease,"},{"startTime":46.73,"endTime":49.33,"body":"she developed aspiration"},{"startTime":46.73,"endTime":49.33,"body":"pneumonia with sepsis"},{"startTime":49.33,"endTime":52.44,"body":"and was admitted to the"},{"startTime":49.33,"endTime":52.44,"body":"intensive care unit with sepsis."},{"startTime":52.44,"endTime":54.3,"body":"[Dr. Handy] Okay, let's"},{"startTime":52.44,"endTime":54.3,"body":"stop there for a moment."},{"startTime":54.3,"endTime":57.15,"body":"It sounds like she was a"},{"startTime":54.3,"endTime":57.15,"body":"very high functioning woman"},{"startTime":57.15,"endTime":60.6,"body":"who unfortunately had declined"},{"startTime":57.15,"endTime":60.6,"body":"due to Alzheimer's disease"},{"startTime":60.6,"endTime":61.95,"body":"over the last year"},{"startTime":61.95,"endTime":64.64,"body":"but she was still enjoying"},{"startTime":61.95,"endTime":64.64,"body":"a good quality of life."},{"startTime":64.64,"endTime":66.89,"body":"The cognitive changes"},{"startTime":64.64,"endTime":66.89,"body":"of Alzheimer's disease"},{"startTime":66.89,"endTime":69.31,"body":"tend to follow a characteristic pattern."},{"startTime":69.31,"endTime":70.91,"body":"They begin with memory impairment"},{"startTime":70.91,"endTime":74.12,"body":"and progress to language"},{"startTime":70.91,"endTime":74.12,"body":"and visuospatial deficits,"},{"startTime":74.12,"endTime":76.882,"body":"and then that's followed"},{"startTime":74.12,"endTime":76.882,"body":"by executive dysfunction."},{"startTime":76.882,"endTime":80.01,"body":"In the end stages, people"},{"startTime":76.882,"endTime":80.01,"body":"can become rigid, mute,"},{"startTime":80.01,"endTime":82.05,"body":"they can have incontinence or be bedridden"},{"startTime":82.05,"endTime":84.44,"body":"and oftentimes will need help with eating,"},{"startTime":84.44,"endTime":86.166,"body":"and dressing, and toileting."},{"startTime":86.166,"endTime":90.133,"body":"Hyperactive tendon reflexes and"},{"startTime":86.166,"endTime":90.133,"body":"myoclonic jerks can also occur."},{"startTime":90.133,"endTime":92.56,"body":"Unfortunately, aspiration"},{"startTime":90.133,"endTime":92.56,"body":"is a common cause"},{"startTime":92.56,"endTime":95.31,"body":"of death for patients with"},{"startTime":92.56,"endTime":95.31,"body":"advanced Alzheimer's disease"},{"startTime":95.31,"endTime":97.51,"body":"but other causes will"},{"startTime":95.31,"endTime":97.51,"body":"include malnutrition,"},{"startTime":97.51,"endTime":101.46,"body":"secondary infections, pulmonary"},{"startTime":97.51,"endTime":101.46,"body":"emboli, or heart disease."},{"startTime":101.46,"endTime":103.69,"body":"So keep going with the case."},{"startTime":103.69,"endTime":105.812,"body":"[Dr. Wiener] Okay. She"},{"startTime":103.69,"endTime":105.812,"body":"was admitted to the ICU"},{"startTime":105.812,"endTime":109.18,"body":"but unfortunately after four"},{"startTime":105.812,"endTime":109.18,"body":"days of mechanical ventilation"},{"startTime":109.18,"endTime":112.353,"body":"it was clear that her condition"},{"startTime":109.18,"endTime":112.353,"body":"had only deteriorated."},{"startTime":112.353,"endTime":114.452,"body":"She was still requiring"},{"startTime":112.353,"endTime":114.452,"body":"mechanical ventilation"},{"startTime":114.452,"endTime":117.435,"body":"with an inspired oxygen tension of 70%."},{"startTime":117.435,"endTime":118.877,"body":"She was on vasopressors"},{"startTime":118.877,"endTime":121.36,"body":"and she developed acute kidney injury."},{"startTime":121.36,"endTime":123.606,"body":"After a number of family"},{"startTime":121.36,"endTime":123.606,"body":"meetings over those days,"},{"startTime":123.606,"endTime":125.33,"body":"her son who was her designated"},{"startTime":125.33,"endTime":127.3,"body":"medical decision maker made it clear"},{"startTime":127.3,"endTime":129.61,"body":"that his mom had never"},{"startTime":127.3,"endTime":129.61,"body":"wanted prolonged mechanical"},{"startTime":129.61,"endTime":132.11,"body":"therapy, would not want dialysis,"},{"startTime":132.11,"endTime":134.335,"body":"and if she was unable to"},{"startTime":132.11,"endTime":134.335,"body":"enjoy the Price is Right"},{"startTime":134.335,"endTime":136.57,"body":"would really not want to prolong her life."},{"startTime":136.57,"endTime":139.69,"body":"He therefore requested that"},{"startTime":136.57,"endTime":139.69,"body":"the team stop intensive care,"},{"startTime":139.69,"endTime":142.955,"body":"in effect he said, I'd"},{"startTime":139.69,"endTime":142.955,"body":"like you to withdraw care."},{"startTime":142.955,"endTime":143.913,"body":"[Dr. Handy] Quick comment about that,"},{"startTime":143.913,"endTime":145.56,"body":"because this is one of my pet peeves"},{"startTime":145.56,"endTime":147.48,"body":"when medical professionals use this"},{"startTime":147.48,"endTime":150.52,"body":"but we should not use the"},{"startTime":147.48,"endTime":150.52,"body":"expression withdrawal of care."},{"startTime":150.52,"endTime":152.54,"body":"Especially in this case,"},{"startTime":150.52,"endTime":152.54,"body":"we're not withdrawing care,"},{"startTime":152.54,"endTime":153.88,"body":"we're really transitioning her"},{"startTime":153.88,"endTime":156.92,"body":"from intensive care to comfort"},{"startTime":153.88,"endTime":156.92,"body":"care or palliative care."},{"startTime":156.92,"endTime":158.137,"body":"[Dr. Wiener] That's a great point."},{"startTime":158.137,"endTime":160.002,"body":"Okay, so in this case,"},{"startTime":158.137,"endTime":160.002,"body":"the patient was treated"},{"startTime":160.002,"endTime":162.41,"body":"with fentanyl and midazolam intravenously."},{"startTime":162.41,"endTime":165.66,"body":"She was extubated and"},{"startTime":162.41,"endTime":165.66,"body":"her NG tube was removed."},{"startTime":165.66,"endTime":167.343,"body":"The family was at the bedside."},{"startTime":167.343,"endTime":169.081,"body":"[Dr. Handy] Transitioning"},{"startTime":167.343,"endTime":169.081,"body":"to comfort care is a common"},{"startTime":169.081,"endTime":171.25,"body":"occurrence now in intensive care units,"},{"startTime":171.25,"endTime":173.88,"body":"surprisingly more than"},{"startTime":171.25,"endTime":173.88,"body":"90% of Americans die"},{"startTime":173.88,"endTime":176.83,"body":"without performance of"},{"startTime":173.88,"endTime":176.83,"body":"cardiopulmonary resuscitation."},{"startTime":176.83,"endTime":178.33,"body":"And that has changed dramatically"},{"startTime":178.33,"endTime":180.51,"body":"over the last one to"},{"startTime":178.33,"endTime":180.51,"body":"two decades as patients"},{"startTime":180.51,"endTime":183.16,"body":"and families really better"},{"startTime":180.51,"endTime":183.16,"body":"understand the limitations"},{"startTime":183.16,"endTime":185.26,"body":"of intensive care and more conversations"},{"startTime":185.26,"endTime":188.05,"body":"about goals of care occur,"},{"startTime":185.26,"endTime":188.05,"body":"not only in the ICU setting"},{"startTime":188.05,"endTime":190.24,"body":"but even more importantly"},{"startTime":188.05,"endTime":190.24,"body":"in the outpatient setting"},{"startTime":190.24,"endTime":192.763,"body":"with the primary care"},{"startTime":190.24,"endTime":192.763,"body":"physician. Now that being said,"},{"startTime":192.763,"endTime":195.07,"body":"when a family decides to"},{"startTime":192.763,"endTime":195.07,"body":"transition to comfort care"},{"startTime":195.07,"endTime":197.43,"body":"the treating care team"},{"startTime":195.07,"endTime":197.43,"body":"of doctors, nurses, and"},{"startTime":197.43,"endTime":200.12,"body":"respiratory therapists really"},{"startTime":197.43,"endTime":200.12,"body":"must work together to ensure"},{"startTime":200.12,"endTime":201.89,"body":"that the dying process will be comfortable"},{"startTime":201.89,"endTime":203.67,"body":"for both the patient and the family."},{"startTime":203.67,"endTime":205.48,"body":"[Dr. Wiener] Yeah. That's"},{"startTime":203.67,"endTime":205.48,"body":"the context of this question"},{"startTime":205.48,"endTime":206.83,"body":"because you are urgently called"},{"startTime":206.83,"endTime":210.07,"body":"to the bedside 15 minutes"},{"startTime":206.83,"endTime":210.07,"body":"after the patient is extubated"},{"startTime":210.07,"endTime":212.69,"body":"because the patient's"},{"startTime":210.07,"endTime":212.69,"body":"daughter-in-law is distraught."},{"startTime":212.69,"endTime":214.72,"body":"She states that her mother is drowning"},{"startTime":214.72,"endTime":217.27,"body":"and struggling to breathe."},{"startTime":214.72,"endTime":217.27,"body":"When you enter the room"},{"startTime":217.27,"endTime":218.824,"body":"you hear a gurgling noise that is coming"},{"startTime":218.824,"endTime":221.765,"body":"from the accumulated"},{"startTime":218.824,"endTime":221.765,"body":"secretions in the oropharynx."},{"startTime":221.765,"endTime":223.727,"body":"You suction the patient"},{"startTime":221.765,"endTime":223.727,"body":"for liberal amounts"},{"startTime":223.727,"endTime":226.959,"body":"of thin salivary secretions"},{"startTime":223.727,"endTime":226.959,"body":"and reassure the daughter"},{"startTime":226.959,"endTime":229.784,"body":"that you will make her mother"},{"startTime":226.959,"endTime":229.784,"body":"as comfortable as possible."},{"startTime":229.784,"endTime":232.043,"body":"Which of the following"},{"startTime":229.784,"endTime":232.043,"body":"interventions may help"},{"startTime":232.043,"endTime":235.335,"body":"with the treatment of this"},{"startTime":232.043,"endTime":235.335,"body":"patient's oral secretions?"},{"startTime":235.335,"endTime":236.813,"body":"And the options are,"},{"startTime":236.813,"endTime":240.001,"body":"A. increase the infusion rate of fentanyl;"},{"startTime":240.001,"endTime":244.36,"body":"B. nebulized N-acetylcysteine;"},{"startTime":244.36,"endTime":247.83,"body":"C. pilocarpine drops;"},{"startTime":247.83,"endTime":251.038,"body":"D. placement of a nasal"},{"startTime":247.83,"endTime":251.038,"body":"trumpet and oral airway"},{"startTime":251.038,"endTime":254.238,"body":"to allow easier access"},{"startTime":251.038,"endTime":254.238,"body":"for aggressive suctioning;"},{"startTime":254.238,"endTime":256.84,"body":"or E. a scopolamine patch."},{"startTime":256.84,"endTime":259.15,"body":"[Dr. Handy] The issue of"},{"startTime":256.84,"endTime":259.15,"body":"respiratory secretions is common"},{"startTime":259.15,"endTime":261.662,"body":"and can be very distressing"},{"startTime":259.15,"endTime":261.662,"body":"for family members."},{"startTime":261.662,"endTime":264.91,"body":"These sounds are sometimes"},{"startTime":261.662,"endTime":264.91,"body":"referred to as a death rattle."},{"startTime":264.91,"endTime":267.182,"body":"I'm going to presume that the"},{"startTime":264.91,"endTime":267.182,"body":"patient appears comfortable"},{"startTime":267.182,"endTime":268.7,"body":"on fentanyl and midazolam"},{"startTime":268.7,"endTime":271.21,"body":"and in fact is likely not responsive."},{"startTime":271.21,"endTime":272.385,"body":"[Dr. Wiener] Yes, that's exactly right."},{"startTime":272.385,"endTime":273.71,"body":"The patient appears comfortable"},{"startTime":273.71,"endTime":275.19,"body":"but there are a lot of secretions."},{"startTime":275.19,"endTime":276.631,"body":"[Dr. Handy] Right, so it's"},{"startTime":275.19,"endTime":276.631,"body":"important to understand"},{"startTime":276.631,"endTime":278.409,"body":"that fentanyl and midazolam"},{"startTime":278.409,"endTime":280.43,"body":"which are a narcotic and a benzodiazepine"},{"startTime":280.43,"endTime":283.9,"body":"are great for sedation,"},{"startTime":280.43,"endTime":283.9,"body":"anxiolysis, pain, and dyspnea,"},{"startTime":283.9,"endTime":285.8,"body":"but will have little or no effect on"},{"startTime":285.8,"endTime":288.43,"body":"oropharyngeal or respiratory secretions."},{"startTime":288.43,"endTime":290.308,"body":"And remember, this"},{"startTime":288.43,"endTime":290.308,"body":"woman's primary event was"},{"startTime":290.308,"endTime":293.42,"body":"an aspiration pneumonia,"},{"startTime":290.308,"endTime":293.42,"body":"so secretions are an issue."},{"startTime":293.42,"endTime":295.32,"body":"And further the secretions can produce"},{"startTime":295.32,"endTime":298.038,"body":"or exacerbate agitation"},{"startTime":295.32,"endTime":298.038,"body":"and labored breathing."},{"startTime":298.038,"endTime":300.41,"body":"[Dr. Wiener] Okay. So which of"},{"startTime":298.038,"endTime":300.41,"body":"those is the treatment though?"},{"startTime":300.41,"endTime":302.039,"body":"[Dr. Handy] Treatments for"},{"startTime":300.41,"endTime":302.039,"body":"excessive oropharyngeal"},{"startTime":302.039,"endTime":305.247,"body":"secretions are primarily"},{"startTime":302.039,"endTime":305.247,"body":"anticholinergic medications"},{"startTime":305.247,"endTime":307.43,"body":"which would include scopolamine delivered"},{"startTime":307.43,"endTime":309.92,"body":"either transdermally or intravenously."},{"startTime":309.92,"endTime":312.907,"body":"You could also use"},{"startTime":309.92,"endTime":312.907,"body":"atropine or glycopyrrolate."},{"startTime":312.907,"endTime":316.34,"body":"[Dr. Wiener] Okay. So the answer"},{"startTime":312.907,"endTime":316.34,"body":"above is E. a scopolamine patch."},{"startTime":316.34,"endTime":318.044,"body":"[Dr. Handy] Yes, that's"},{"startTime":316.34,"endTime":318.044,"body":"what I would try next."},{"startTime":318.044,"endTime":319.87,"body":"Titrating the midazolam and fentanyl"},{"startTime":319.87,"endTime":321.756,"body":"are important components"},{"startTime":319.87,"endTime":321.756,"body":"to the comfort approach"},{"startTime":321.756,"endTime":323.643,"body":"and may also help with dyspnea."},{"startTime":323.643,"endTime":325.94,"body":"[Dr. Wiener] Okay. What about"},{"startTime":323.643,"endTime":325.94,"body":"the other options quickly?"},{"startTime":325.94,"endTime":327.41,"body":"[Dr. Handy] While placement"},{"startTime":325.94,"endTime":327.41,"body":"of a nasal trumpet"},{"startTime":327.41,"endTime":330.07,"body":"or oral airway may allow"},{"startTime":327.41,"endTime":330.07,"body":"better access for suctioning"},{"startTime":330.07,"endTime":332.32,"body":"of secretions, these can"},{"startTime":330.07,"endTime":332.32,"body":"be very uncomfortable"},{"startTime":332.32,"endTime":334.34,"body":"or even painful interventions."},{"startTime":334.34,"endTime":335.78,"body":"So these are typically discouraged"},{"startTime":335.78,"endTime":337.84,"body":"in a palliative care situation."},{"startTime":337.84,"endTime":340.077,"body":"My experience is also that"},{"startTime":337.84,"endTime":340.077,"body":"families prefer to see"},{"startTime":340.077,"endTime":342.95,"body":"their loved ones without"},{"startTime":340.077,"endTime":342.95,"body":"these types of devices."},{"startTime":342.95,"endTime":344.56,"body":"N-acetylcysteine can be used"},{"startTime":344.56,"endTime":347.64,"body":"as a mucolytic agent to thin"},{"startTime":344.56,"endTime":347.64,"body":"lower respiratory secretions"},{"startTime":347.64,"endTime":351.07,"body":"but it's seldom useful in a"},{"startTime":347.64,"endTime":351.07,"body":"palliative or comfort situation."},{"startTime":351.07,"endTime":353.23,"body":"And pilocarpine is a cholinergic stimulant"},{"startTime":353.23,"endTime":355.76,"body":"and will increase salivary"},{"startTime":353.23,"endTime":355.76,"body":"production and secretions."},{"startTime":355.76,"endTime":357.94,"body":"So that's a bad idea in this case."},{"startTime":357.94,"endTime":359.82,"body":"[Dr. Wiener] Okay, so the"},{"startTime":357.94,"endTime":359.82,"body":"teaching point in this case"},{"startTime":359.82,"endTime":363.2,"body":"is that most deaths in"},{"startTime":359.82,"endTime":363.2,"body":"the ICU are not unexpected"},{"startTime":363.2,"endTime":365.07,"body":"and that a comfort care approach requires"},{"startTime":365.07,"endTime":367.117,"body":"a multidisciplinary care that is sensitive"},{"startTime":367.117,"endTime":369.065,"body":"to the patient and the family's needs."},{"startTime":369.065,"endTime":371.728,"body":"Use of multiple medications"},{"startTime":369.065,"endTime":371.728,"body":"that can enhance comfort"},{"startTime":371.728,"endTime":374.277,"body":"are indicated in these situations."},{"startTime":374.277,"endTime":376.085,"body":"[Dr. Handy] And you can read"},{"startTime":374.277,"endTime":376.085,"body":"more about this in Harrison's"},{"startTime":376.085,"endTime":378.718,"body":"chapter on palliative"},{"startTime":376.085,"endTime":378.718,"body":"and end of life care."},{"startTime":378.718,"endTime":382.73,"body":"[outro music]"},{"startTime":382.73,"endTime":385.42,"body":"[Mr. Shanahan] This is Jim"},{"startTime":382.73,"endTime":385.42,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":385.42,"endTime":387.01,"body":"Harrison's PodClass is brought"},{"startTime":387.01,"endTime":389.18,"body":"to you by McGraw Hill's AccessMedicine,"},{"startTime":389.18,"endTime":391.268,"body":"the online medical resource that delivers"},{"startTime":391.268,"endTime":394.428,"body":"the latest trusted content from"},{"startTime":391.268,"endTime":394.428,"body":"the best minds and medicine."},{"startTime":394.428,"endTime":397.063,"body":"Go to accessmedicine.com to learn more."}]}