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Patient Care Vignette

TG, who goes by the name “Tom,” is a 43-year-old man with metastatic rectal cancer. He was brought to the hospital by Fire Rescue due to difficulty breathing (respiratory distress). He was receiving second-line chemotherapy for his rectal cancer due to cancer recurrence after completing first-line therapy. He was admitted through the emergency department and had an endotracheal (ET) tube placed to connect him to a mechanical ventilator as he needed substantial help managing his breathing. Because he was placed on a ventilator, he was transferred to the ICU.

Tom had involuntarily lost 30 pounds in the last 3 months, reducing his weight to 125 pounds. This weight indicated severe malnutrition for this 5 foot, 9 inch man. Social work was consulted upon admission to assist with future planning and family support. Tom has been married to Nikhila for about 15 years. They are first-generation children of Indian immigrants and practice the Hindu religion. Tom has a PhD in economics and Nikhila is a PhD-trained pharmaceutical scientist. Their socioeconomic status is middle class and they are in their early 40s. They own their own house but have spent their savings cushion after Tom was no longer able to work. During that time, Nikhila had to take additional time off from work to get Tom to his multiple doctor’s appointments.

They have an 8-year-old daughter who does not come to the hospital due to Nikhila’s fears of traumatizing the child. This continues to be a strain for Nikhila because she has struggled with guilt between being wanting to be with her husband and needing to care for their daughter. She tells the social worker that balancing her daughter’s needs in school and at home while trying to be present in the hospital has been difficult. She feels as if she is torn between two competing worlds.

Before this unplanned admission, Tom and Nikhila’s life was marked by concerns for each other. Tom was not eating and losing weight, and Nikhila increasingly became responsible for everything at home. Nikhila’s fears about Tom’s future featured prominently in her discussions with the social worker. Throughout surgery, chemotherapy, and radiation they had focused on recovery as they hoped combination therapy would take care of the cancer. Accordingly, they had neither completed Advance Directives nor a living will. The social worker also noted that Tom and Nikhila never had a clear discussion about what would be important, or what goals of care they would value. Relatedly, Tom had not been evaluated by Palliative Care Medicine at any point in time—a consultation that the social worker suggested would be ideal during this ICU admission.

The social worker was initially consulted upon ICU admission to provide multiple services. The first step was to a provide support and develop a rapport with Tom and Nikhila, assess Tom’s medical and social situation, and clarify who would serve as Tom’s medical decision-maker. In the ICU, Tom did not have ...

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