CLINICAL CASE Planning End-of-Life Conversations: Hospitalist and Primary Care Physician Roles

At the end of a busy day in her pediatric clinic, Dr. Smith was going to visit the Johnson family. Even though she and her partners now admitted their patients to the pediatric hospitalist service at the nearby children’s hospital, Dr. Smith still visited her patients there whenever her clinic schedule permitted. She had been notified by the emergency department earlier that day that Claire, the Johnsons ’ third child, had been admitted with a fever and dehydration. Dr. Smith knew the Johnson family well—she had taken care of their older children, both healthy, for the past 7 years, and had gotten to know Mr. and Mrs. Johnson even better during Claire’s first year of life. Claire was born healthy, but stopped making developmental progress at age 6 months. By the time Claire was 1 year old, an extensive workup showed that she had a rare, progressive metabolic disorder. Despite strictly adhering to a special diet and routinely seeing subspecialists, Claire continued to decline. Feeding problems resulted in the need for placement of a gastric tube and Claire’s development never progressed beyond that of a 6-month old. Now 4 years of age, Claire had bee