What I am going to write about tonight is something we need to have a major discussion about. Because I am convinced there is no solution to this conundrum. It's a conundrum because this terminally ill 93-year-old do not resuscitate (DNR) patient was placed on a ventilator last night.In talking to her daughter, she led a wonderful life. She never held a job in her life, but her husband had a good job, so she didn't have to work. Instead, she stayed home and took care of the kids.
She has four kids, and all of them became successful in their own right. She was so proud that all her children turned out so well. And she's even more proud of her 12 grandchildren and three great-grandchildren. The flowers all over her room are a testament to how much she was loved.
When she was diagnosed with pulmonary fibrosis (PF) at the age of 88 she decided to make herself a DNR. Yet, even before the PF diagnosis she had become a regular fixture in the hospital with fluid overload, whereas her doctor said to me once, "Even a slight weight gain of 1-2 pounds quite often put her into pulmonary edema."
She was also a lifelong smoker. As a matter of fact, she smoked about a pack of cigarettes a day since the mid 1940s, when she started because it was in fashion to do so. As one of the negative and unexpected consequences of smoking, she has slowly developed emphysema, which has now progressed so that she has become a CO2 retainer.
Considering her grim prognosis, her doctor and family had decided to make her a comfort measures only patient, which justified placing her on a non-rebreather to keep her oxygen levels up despite the fact she was a retainer. But, despite the high levels of oxygen needed, she did not stop breathing (despite what believers in the hypoxic drive theory might contend. but that's a discussion for another day.)
The family had already been informed that their mother probably wouldn't live much longer without getting her lungs cleaned out, and that the best way of doing that was via a bronch. Yet, if the bronch were to be done, their mother more than likely would have to be intubated. But with her extensive medical history, she probably would need to stay on the vent at least over the weekend.
After a brief family conference, the family made the difficult decision to go ahead and allow the surgeon to do the bronch and risk the vent.
While the anaesthesiologist used a minimal amount of sedatives during the procedure, the patients sats consistently stayed low even on 100% FiO2, and the patient was not breathing over the vent when provided the opportunity. So the choice was made to send the patient upstairs to critical care, and to call RT to set up a vent.
As you know, when someone has to go to surgery they wave their right to a ventilator, at least temporarily. Even while a bronch is a simple procedure, it involved placing a tube in her throat, and the doctor peeking around her lungs with a bronchoscope.
As I was setting up the vent, the surgeon told me the right lung was completely filled with pneumonia, and he suctioned copious amounts of thick brown pneumonia not just from the right lung but from the left lung too.
The poor lady. My initial impression was that I'd keep her on the vent a few hours and wait for her to wake up and hopefully extubate her by morning, as I would any other post-op patient. But then I learned the story I just reported to you.
The problem with this case, as the Internist reminded me when he arrived on the scene to manage the ventilator, is that this patient is not weanable. He said, "How do we wean someone off the vent to respect a DNR order when she was on 100% to begin with. I know she's a DNR, but how do we ethically get her off the vent?
This lady was a true medical and ethical conundrum.
Did the family make the right decision? If they did nothing, there mother probably would have died soon. If they did the bronch, it might be possible to resolve the pneumonia, but still, the chance of her ever leading a normal productive life is gone. She is frail and has a terminal illness.
While the family assured me that they perfectly understand modern medicine cannot stop the inevitable, it might buy her some time, "so she can make it to her grandson's wedding in June."
Still, as one of the doctors said to me afterwords, "Are we prolonging life, or delaying death?" That is the question up for debate. What do you think? What would you do?
6 comments:
This is one of the main reasons I want to work in pediatrics. I don't see it as saving a life, I see it as avoiding the inevitable.
I agree totally with you. There are times when you just need to let go, Really if I live to be over 90, don't you dare do anything to me, just leave me at home with my family.
I guess it doesn't really matter what you or I think at this point. It's all up to the family and possibly your hospitals ethics people. This woman is certainly not going to attend any wedding.
In my experience so far, it seems like MD's do not always tell the family the cold hard truth about what is going on untill it is too late. We terminally extubate people all the time. I think that with the DNR from earlier you could extubate after 48 hours or whatever the clause is that she agreed to before surgery that took away her DNR.
I personally do not feel that the bronch was warranted from what you've told me. Old people die from pneumonia all the time, she had a long life many people would be jealous of. To let her go now should not make anyone feel bad.
I do have an update on this case. As soon as this discussion phase has worn down I'll post it.
I hate this kind of situation and I see it all the time. Tonight, for example. What the ER doc told my little lady's husband was that "you could always withdraw". That way the blame isn't felt by the doc anymore it is felt by the family. Way to pass the buck!
The ethical dilemma is always more apparent in retrospect than in real time. Putting myself in your shoes, and in the family's shoes, I do not think that anyone made irresponsible decisions. You all opted for a chance at saving your patient, which was possible, given what you knew at the time you had to make the decisions. Yes, it was a long shot, but it was not unreasonable. Tragically, it turned out badly. That does not mean that you did less than your best for your patient.
It would be interesting to read a post from an attorney in your state as to whether the patient can be terminally extubated on the basis of her DNR request.
These are always difficult judgment calls with fuzzy boundaries. They seem clear after the fact, but they are not at the time one has to make them. You served your patient skillfully and contentiously. You did the best anyone could in a world of unpredictable outcomes. Be gentle with yourself.
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