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Monday, May 19, 2008

More on the agony of end of life issues

A few days ago I presented you, my faithful readers, the end-of-life story of one of my favorite patients. She had led a wonderful life, was terminally ill, was a self declared DNR, had a bad case of aspirtion pneumonia and, as per her families wishes, was set up on comfort measures only.

She was on a non-rebreather to provide her 100% oxygen in order to help her breathing, and she was even on morphine. She felt no pain. However, her breathing was mildly labored.

In my opinion, and the opinion of most people I have had the privilege to discuss this case with the past few days, this was the humane and ethical thing to do in this case. It was time to let nature take its course with this lovely 93 YO lady. It was time for her to go to her maker.

Yet, the doctor provided an option to the family, that he could have the surgeon do a bronch, and that this might buy her some time by cleaning out her lungs. And the family came to the difficult decision to allow the bronch.

So, yada-yada-yada, the surgeon sucked a bunch of brown crap from her lungs, and she was placed on a vent. This is where I left you guys off.

That first night her breathing was SO comfortable on the vent she wouldn't do any breathing on her own. The doctor had conceded she might be a major conundrum to get off this vent. In fact, he said something along the lines that she might be a terminal wean.

But he didn't know I was working.

Without an order I weaned the lady off 10 of PEEP and placed her in CPAP and PS. She did not fail the weaning attempt as I had surmised. After a half hour of the wean I did weaning parameters, and her numbers weren't good by any means, but probably good for her considering her terminal lung status.

Her NIF was only -17. We like it to be at least -20 to consider extubation. Her RSBI was 120, and statistics show 75% of patients with a RSBI under 100 do not get reintubated. Since she was over 100, her odds were not so good. Yet, despite these stats, the Internist on duty wisely decided to give the order to extubate -- after all, she was a DNR.

Now, 24 hours later, she is on BiPAP. She is miserable. She hates the mask. She looks so frail and unhappy. When I go into her room she wants me to hold her hand and talk to her. When I tell her I have to leave, her voice is muffled through the BiPAP mask: "Please, don't leave me alone."

She keeps asking me to take the mask off, but when I do her sats sink fast.

Now the Internist on the case does not want to give her too much morphine as to not knock her drive to breath out. And he doesn't want to put her on 100% oxygen because she is a CO2 retainer.

That ticks me off, considering she was on 100% non-rebreather for five days before she was placed on a vent and she did not stop breathing then. She tolerated the high oxygen quite well as a matter of fact.

Yet now, while her PO2 remains in the 40s, we are allowed to go no higher than 50%. Go figure.

Despite that, I was rather impressed with this doctor. When he was provided an opportunity to yank her tube, he didn't hesitate as some doctors have in similar situations I have experienced.

People, this is a perfect example of why sometimes it is NOT a good idea to take advantage of modern technology. Sometimes it is best just to follow the wishes of the patient, and let nature take it's course.


Iron Lung said...

The key here might be "comfort measures only." If the mask isn't comfortable, that needs to be pointed out to the family. If it's not comfort, it shouldn't be a measure.

Bob Kacmarek gave a great presentation at the last MSRC Spring Conference, including categorizing NIPPV patients into 3 categories (one of which was comfort-only) so that the family and the healthcare team (ie, all the docs involved or potentially involved) would be on the same page with goals, probable outcomes, etc. It sounds like now that the tube is out, this would be a good time for this to take place.

Lucky said...

Enjoyed reading this. It's unfortunate she didn't go along with the peaceful path.

Anonymous said...

I wouldn't post on the internet that I was practicing medicine without a license by changing vent settings without an order. Be careful.

Freadom said...

Correct anonymous. We have a vent protocol is what i meant, we don't need a specific order.