You are called to see a 49-year old female in the general surgical ward who has become profoundly hypotensive (75/40 on auscultation). She is now 5 days after palliative surgery for a perforated malignant gastric ulcer.  She is barely rousable and the pulse oximeter saturation is 85% on face mask oxygen (10L/min).

(c)        Please discuss your plan for her definitive care.

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College Answer

At this stage definitive information is required regarding her prognosis and expressed wishes. The palliative operation may have been performed to provide months of more comfortable existence, or to prevent severe discomfort during the last weeks of life.

Priorities for “comfort only” measures or limitations in therapies should be introduced when considered appropriate (with input from family, parent unit etc.).

If appropriate after all information is available, specific treatment to treat the potential underlying causes should be implemented. Specific therapies depend on the diagnosis (drainage/surgery/antibiotics for intra-abdominal sepsis; antibiotics/ventilation for pneumonia; anticoagulation ± surgery for pulmonary emboli; etc.).

Nonspecific supportive care should also be discussed (including DVT prophylaxis, GI bleeding prophylaxis, feeding, pressure area care, support for family etc.