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Management strategies Key points
• Acute management options included patient
preference for enteral feeds, medical management
of aspiration pneumonitis, and escalation of care if
further deterioration was observed.
• ICD management options discussed included
unchanged programming and inactivation of
tachyarrhythmia therapies with or without
inactivation of pacing/CRT function.
• Values elicited in discussion include decision for
do-not-resuscitate status versus comfort measures
with hospice referral.
• Decision was made to continue nutrition via
enterostomy, administering intravenous antibiotics
with supplemental oxygen and inactivating
tachyarrhythmia therapies, and maintaining pacing/
CRT programming.
• Do-not-resuscitate status was requested in keeping
with focus on quality of life.
• Advanced neuromuscular
impairment and associated
medical conditions
negatively impact quality
of life.
• Given poor overall prognosis,
focus was shifted to
maintaining quality over
quantity of life.
• Therapies targeting acute
and possible reversible
medical conditions were
planned with avoidance of
care escalation given unlikely
benefit from aggressive
measures and maintaining
palliative therapies such as
pacing/CRT.
• Involvement of hospice
medicine and palliative care
specialists may be helpful in
guiding and/or leading these
discussions, with a focus on
shared decision making.
• Management options discussed included
resumption of oral anticoagulation with warfarin
or direct oral anticoagulant, left atrial appendage
occlusion when appropriate, or observation without
further intervention.
• Values elicited in discussion included addressing
preventable causes of morbidity and mortality
and minimizing/avoidance of complications from
medical/surgical thromboembolism prevention.
• Patient's family declined resuming oral
anticoagulation and deferred left atrial appendage
indefinitely in favor of monitoring for further
clinical neurological improvement given preference
for conservative management.
• Traditional appropriate
management strategies may
be fraught with an increased
risk of complications in
patients with neuromuscular
conditions.
• Invasive strategies may be
poorly tolerated, associated
with increased procedural
risk, and less appropriate
in patients with advanced
neuromuscular impairment
and associated complexities.
• The benefit of commonly
indicated therapies may
be overshadowed by
comorbidities related to the
underlying condition.
