To think about this case in the broader context of this woman’s life, we needed to think about her illness trajectory. She was 94 with multiple chronic conditions. This event most likely heralded the beginning of a steady decline, punctuated by trips to the hospital and rehab, with possibly a short trip home, only to be repeated until her death.

1. Standard approach: Intravenous antibiotics, admit to floor, and default full code.
2. Palliative approach: Discuss her prognosis, goals of care, and trajectory of illness and fill out a physician order for life-sustaining treatment (POLST) form with patient and power of attorney (POA).

While we waited for her primary physician to call back, we asked a few basic questions. What had her life been like the past few weeks? Why didn’t she want to come to the hospital? Who will make decisions for her when she is no longer able? Does she have an advance directive or living will? We found out that she had been very independent until the last couple of months when she had required more and more assistance. She did not want to come to the ED because she knew she would be admitted, and she hated being in the hospital. She did not want us to “do anything” to her. Her goals were to remain as independent as possible at home. Her niece was her POA, and she, indeed, had a living will but not with her. We asked what her living will said, and she said that she did not want to be on life support or on any machines.

We explained to her that we would not do anything to her that she did not want us to do and that we would make sure her wishes would be followed in the event she worsened. We gave her our prognosis: she would probably improve from this infection, but she would most likely not be able to function at the level she had before and would likely need more help.

She and her niece were visibly relieved. The patient was admitted with a code status of do-not-resuscitate/do-not-intubate. Although it would probably not be relevant during this admission, we filled out a POLST form and explained that it would follow her to every facility to help ensure her wishes were followed. Our discussion and plan laid the groundwork for her admission and subsequent care because now future providers can see the POLST and take into account her goals of care.