Severe Community-Acquired Pneumonia Complicated by Acute Respiratory Distress Syndrome in a Geriatric Patient and Limitation of Life-Sustaining Treatment

Abstract

Introduction: Severe community-acquired pneumonia (CAP) frequently progresses to acute respiratory distress syndrome (ARDS), imposing high morbidity and mortality rates in patients in advanced stages of life. The confluence of biological frailty, exposure to environmental toxins, and prior corticosteroid use significantly worsens the respiratory prognosis, necessitating careful consideration of the ethical boundaries of futile organ support. Objective: To describe the clinical evolution of a geriatric patient with severe CAP and refractory ARDS, analyzing the utilization of non-invasive monitoring scales and the protocolized transition toward the limitation of life-sustaining treatment (LLST) and terminal palliative sedation. Case Report: A 92-year-old male with a history of smoking and chronic biomass smoke exposure was admitted due to severe hypoxemic respiratory failure (SpO2​ 78%) and bilateral pulmonary consolidation syndrome. Advanced oxygen therapy via high-flow nasal cannula (HFNC) was implemented, monitored through the ROX Index. Total parenteral nutrition and empirical broad-spectrum double antibiotic coverage were initiated due to the risk of multidrug-resistant (MDR) pathogens and Pneumocystis jirovecii secondary to poorly tapered corticosteroid therapy. Following refractory HFNC failure, neurological collapse (Glasgow Coma Scale 3/15), and the presence of advanced signs of hypoperfusion (such as the Schölein-Henoch/Stenon-Louis ocular sign), an interdisciplinary medical consensus meeting was held with the immediate family. Invasive endotracheal intubation was declined, and a legally binding Advance Directive document was signed to transfer the patient to the general ward under a comfort care protocol. Conclusions: The terminal palliative protocol—based on continuous infusions of Midazolam, Morphine, and Dexmedetomidine, combined with strict maintenance fluid restriction (Hartmann's solution at 10 mL/h)—completely alleviated refractory dyspnea and prevented terminal respiratory secretions (death rattles), achieving a dignified end-of-life transition. Timely integration of advance directives and monitoring for clinical futility preserve the dignity of terminal geriatric patients.