Answer 1
The immediate goals of therapy are to control variceal bleeding and, in conjunction with Mr. Appleton’s primary care doctor, develop a plan---to the extent possible---to prevent future episodes of bleeding. The process of sclerotherapy should be discussed with the patient but, given the possibility of a bad outcome, there is a need to ask Mr. Appleton what should be done if the bleeding cannot be controlled, would he want very aggressive therapy to be continued even if he was doing poorly, and if he had an advance directive.
Answer 2
Mr. Appleton’s family is meant to illustrate the axiom that if there were problems in a family prior to the illness of a parent, they do not get better with that illness. Given a history of alcoholism and divorce, there probably are a number of chronic issues in the family. The ICU staff needs to communicate with them but also not be immobilized. There are several possible courses of action to limit family interruptions during the day: 1) involve social work early on for a family meeting to set the ground rules and, if Mr. Appleton will give permission, discuss his case; 2) as part of that meeting, ask the family to appoint a spokesperson who will speak to the doctor daily and then relay information to the rest of the family.
Answer 3
A large, angry, dysfunctional family and a critically ill, likely dying patient are a difficult combination. Hopefully, the physicians have a sense of what Mr. Appleton would want for care and can communicate this to the family. The staff and physicians caring for Mr. Appleton need to do their best to keep communication open with the family while helping them in their disarray and grief. Social workers and chaplains can be extremely useful in this type of scenario.