Acute rehab or hospice: Navigating goals of care in multiorgan dysfunction: A Case Report

Case Diagnosis: Complex multiorgan dysfunction following acute cardioembolic stroke

Case Description or Program Description: An 86-year-old-female, who was previously independent and living alone, was admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure. During her ICU stay, she was found to have multifocal subacute embolic infarcts, segmental pulmonary embolism, deep venous thrombosis, atrial fibrillation, acute decompensated heart failure, severe anemia requiring multiple transfusions, and recurrent urinary tract infections. After initial stabilization, she was transferred to the acute inpatient rehabilitation unit to improve functional mobility and activities of daily living.

Setting: Acute inpatient rehabilitation

Assessment/Results: During acute rehabilitation, her clinical course was complicated by gastrointestinal and genitourinary bleeding, volume overload, acute kidney injury with hyperkalemia, hypercapnic acute hypoxic respiratory failure, and episodes of altered mental status, significantly impeding her participation in therapy. Despite some initial gains, the ongoing medical complications and her refusal of advanced interventions such as bilevel positive airway pressure hindered her progress. These factors prompted a reconsideration of aggressive rehabilitation, leading to her transfer back to the medicine service and eventual discharge to home hospice.

Discussion (relevance): While emerging data suggests that aggressive early rehabilitation in the acute setting leads to better outcomes, it is important to recognize that not every patient should be transferred to acute rehabilitation. In some cases, the severity of the underlying pathology may inherently limit early improvement and progression, despite aggressive rehabilitation efforts. Medical stability, comorbidities, and patient participation must be considered when deciding if a patient is a good candidate for acute rehabilitation.

Conclusions: This case highlights the need for proactive and evidence-based reassessment in deciding whether a patient is a good candidate for acute rehabilitation. When medical instability prevents functional gains, early palliative care integration and reassessment of goals of care are critical to ensure the most appropriate patient care.