Case Reports and Reviews: Open Access

When Less is More: Palliative Decision-Making in a Bedbound Patient with Advanced Illness and Bilateral Pleural Effusions

Khiem Phan, MD*, Imran Khalid, MD, Seth Sturgill, DO, Zainab Naqvi, MD, Dana Ahmad, MD, Zainab H. Farah, MD, Jyoti Chaudhary, MD, Kathleen Johnstonbaugh, MD, and David E. Martinc, PhD

Article DOI: https://doi.org/10.70620/CRROA/v7i2/159

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Abstract

Background: Pleural effusion in advanced illness presents complex challenges in balancing symptom relief with the burden of invasive interventions.

Case presentation: We report a 69-year-old bedbound male with a history of cerebrovascular accident, dementia, type 2 diabetes, hypothyroidism, malnutrition, and prior candidemia, who presented with a one-month history of intermittent non-productive cough. Imaging revealed multifocal pneumonia with large left and moderate right pleural effusions. Despite antibiotic therapy with Vancomycin and Piperacillin-Tazobactam, his overall condition remained poor, with profound malnutrition (BMI 17.5 kg/m²) and limited functional capacity. Pulmonology consultation considered bilateral thoracentesis; however, given his steeply declining health, dementia, and poor nutritional status, the family declined invasive interventions and opted for comfort-focused care. His family changed his code status to Do Not Resuscitate (DNR), and the palliative care team was consulted and provided symptom management, psychosocial support, and hospice transition planning.

Conclusion: This case emphasizes the importance of collaborative decision-making and involvement of palliative care to ensure that management aligns with the patient's goals and overall health. Choosing to avoid invasive procedures and instead focus on comfort care can better reflect the patient's wishes and uphold the principles of autonomy, beneficence, and quality of life. Keywords: Pleural effusion; Palliative care; Decision-making; Malnutrition; Dementia; Hospice; Comfort care; Cachexia.