Dr DALEY: Mrs J is an 88-year-old widow who has had multiple recent episodes of congestive heart failure [CHF] requiring hospitalization. She lives alone in an assisted living center for senior citizens in a suburb of Boston, Mass. She has 1 daughter, Mrs V, who is very involved in her care. She has Medicare insurance and a supplemental Medigap insurance policy.
Mrs J has long-standing essential hypertension, coronary artery disease with stable angina pectoris, aortic stenosis, and an elevated alkaline phosphatase suggestive of Paget disease of the bone. She has chronic CHF, paroxysmal atrial fibrillation, 2 to 3 episodes of angina per week relieved by nitroglycerin, and recurrent episodes of flash pulmonary edema, necessitating 4 hospital admissions in the previous 10 months. Within the past year, Mrs J refused needle biopsy for evaluation of a multinodular goiter. Functionally, she needs assistance only with bathing, but notes fatigue and some shortness