Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Gastrointestinal haemorrhage, Haemoglobin decreased, Peripheral ischaemia, Rectal haemorrhage, Refusal of treatment by patient
Clinical narrative: DISCHARGE DIAGNOSES: COVID Anemia, likely due to GI bleed Noncompliance   HOSPITAL COURSE: 69yo woman with PAD, medical noncompliance, A. fib, COPD, HTN, recurrent embolic strokes, T2DM, and GERD that presents with intermittent bright red blood per rectum, sent from her HCF due to blood draw with hemoglobin level of 6.5. Patient has been feeling fine. No lightheadedness, CP, or SOB. She has chronic issues with constipation. She does see some bright red blood in the toilet every few days, usually when she is straining to have a bowel movement. She has not had black or tarry stools.     She is on coumadin with a goal INR of 2.5-3.5 after she developed acute left limb ischemia in November 2021, underwent thrombectomy, felt to be from embolic in nature.  Unfortunately she is known to be noncompliant with history of recurrent embolic events, not from anticoagulation failure, but rather not taking her medications.   She was admitted to observation service and was seen by gastroenterology.  She was strongly advised colonoscopy and EGD to evaluate source of anemia to rule out malignancy, AVM, polyp, ulceration or upper GI pathology such as AVM, gastritis, gastropathy, but she declined colonoscopy/EGD.  Her Hgb on admission was 7.6 and it did drop to 6.9, but patient refused PRBC transfusion.  She remained hemodynamically stable without any episodes of hypotension or tachycardia.  She feels that this is all from constipation.   Had very long discussions regarding holding Coumadin versus continuing Coumadin.  She was made aware that our recommendation is that she undergo GI work-up and rule out GI source of bleed and then if it is negative, then to resume her blood thinners while she is being monitored in the hospital.  She is very clear that she does not want to do that.  I also provided her the option of stopping Coumadin given risk of GI bleed, but then she might face risk of embolic events, but she does not want to do this either.  She chose to continue taking Coumadin to minimize risk of CVA or embolic events, and accept the risk of life-threatening bleed that may or may not lead to her demise.  I reviewed this extensively multiple times and this the decision she preferred.  We also went over options with palliative care/hospice.  She met with palliative care, but unfortunately goals of care discussions were not fruitful.     Her family was also contacted and I spoke with her daughter regarding patient's decision.  Daughter feels that Pt has a long standing history of noncompliance and declining medical interventions and that we should respect and follow her wishes.  She also states that family usually does not have any influence on her decisions.   She was also found to be COVID-positive on admission.  Had prior COVID 19 in November 2021.  Suspecting this could be a new infection.  She is stable on room air and does not have a cough or dyspnea.   On day of DC, patient was seen and examined at the bedside.  She is requesting to be discharged back to her HCF.  She feels the hospital is impeding on her quality of life and does not want any further aggressive medical treatments.  We tried to review her goals of care, but patient did not want to discuss further and was frustrated.  At the request of the patient, she is being discharged back to her HCF.  Patient understands that given she chose to continue anticoagulation without undergoing GI work-up, she may face life-threatening GI bleeding in the near future.  Her daughter was also extensively updated on the current situation.  In agreement with DC plan for today.