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A PATIENT I cared for recently reminded me that actions can sometimes be more empathic than the most empathic words. The hospitalist asked me to see a man in the ICU with progressive refractory lung cancer who experienced respiratory failure and required mechanical ventilation. Prior to intubation, his dying wish was to return to his hometown, a 4–5-hour drive from our hospital. After compassionate extubation by the ICU team the day before, a Sunday, to prepare him for transition to hospice, his family was determined to get him back home no matter what. When I arrived on the scene a few minutes after receiving the consultation request, the man's family was so irate that they literally would not let me into the room to see him. Multiple daughters and granddaughters, some of whom were nurses with strong opinions about his care, filled the hallway, where they loudly directed a barrage of grievances toward me, barely pausing for breath. They were so angry and frustrated that I was unable to get meaningful information from them, so I stood there silently and allowed them to vent for several minutes. They eventually calmed down enough to explain thatthe ICU team had assured them that they could make the trip back home the next morning, only to find out that several logistical details were delaying discharge and making it increasingly likely that the man would die before making it home. To compound the problem, his family had already paid several thousand dollars for a ground ambulance that was non-refundable. The hospitalist coming on service that day asked our supportive care team to facilitate transition home to hospice at the 11th hour, even though we had never met the patient before.

After my initial hallway encounter with the family members, I excused myself to review his medical record in more detail and spoke with his hospitalist, case manager, ethicist, social worker, and the hospice medical director in his hometown who had accepted his care. After extubation the day before, the ICU team had implemented their typical comfort care orders, which included high-dose opioid and midazolam infusions. All with good intentions, the case manager, intensivist, and the previous hospitalist had arranged home hospice to meet the family's timeline, not understanding the intricacies and complexities this entailed. They were trying to discharge him home on midazolam and fentanyl infusions at doses that neither the hospitalist nor I were comfortable prescribing. In addition, no one had adequately addressed several practical details, such as how the ambulance crew would administer infusions in transit or where the pumps would be obtained for the infusions, since our pharmacy was unable to send hospital pumps with him. Other reasons for concern included the high doses of both medications and the hospice agency's ability and willingness to continue them in the home hospice setting. After my initial evaluation, I told the family that we would do everything in our power to ...

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