Are we prolonging life, or delaying death???

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?

No Vent, DNR, or full code: what's your choice?

The decision of whether or not you want to be placed on a ventilator, or whether or not you want to make a decision for your loved one, is one of the most difficult decisions one can make. In fact, this is the basis of some very deep ethical discussions, and one of which may never be answered by society, only by the person who has to actually make that decision.

First let us note here that a majority of patients who go on a ventilator do so only for temporary purposes. If you have surgery, if you have severe asthma, pneumonia, or failing heart, you may need to be placed on a ventilator short term.

If a person is involved in a trauma, or if CPR is performed, then a person may be intubated and placed on a ventilator.

Those are easy decisions, especially when we are in emergent situations and are trying to save a life. However, there are also times when the decision to intubate or not to intubate can be complicated as complicated can get, and very stressful, and often disappointing if not discouraging.

In some cases you can plan ahead and write in your advanced directives that you do not want to be placed on a vent, however, sometimes I have seen this declaration over-ruled at the point of impact when a person is in the emergency room and the person has to decide, "Do I want to risk dying now, or do I want to let these good people here in the emergency room help me breathe by placing a tube into my airway and assisting me with my breathing. Do I want to do that? Do I want to allow them to place me on a ventilator?"

Here I will provide some examples for you. All of these come from real life examples as I have actually seen them in my eleven years as a registered respiratory therapist.

One of the most frustrating examples to me is when a person has decided they do not want to be placed on life support because "I don't want to spend the rest of my life on one of those things," or "because I don't want to become a vegetable." In thinking this way, many people choose the following in their advanced directives: Full Code, Do Not Vent, or Do Not Intubate.

I have to cringe when I see that. I cannot believe any lawyer or doctor or advisor would recommend that option, because when a person's heart stops, and we have to do CPR on the patient, we also have to pump in quite a bit of medicine, and 99.9% of the time the patient does not survive a code breathing on his own: he has to be placed on a ventilator. Thus, if we do CPR, we have to put you on a vent -- there is no other option.

What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having CPR performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was Chuck, but Chuck's friend with the broken arm.

It does not work this way in real life. The majority of the time when CPR is done on a person, that person buys himself a ventilator. That is, unless you are a DNR. In short, DNR means Do Not Rescucitate. That means if your heart stops we will not try to restart it. And, if you stop breathing, we will not place you on a ventilator. We will let nature take its course.

However, if the people working on you don't know you are a DNR, you will end up on a vent regardless. Not only is that the ethical thing to do, it's the law.

However, I do think the decision not to become a vegetable on a vent is a valid issue for most people. Yet, one also has to consider the definition of a vegetable. Are you a vegetable when you have no body, but your brain is fully functional as would be the case with ALS (Lou Gehrig's Disease) or multi-system atrophy, which is a disease my grandma suffered from at the end of her life, and is a disease like ALS in that the person loses control of his muscles and basically becomes a brain without a body.

Some people value life so much that they would want to live so long as they have control of their brain. That was my grandmas wishes, and I totally understood those wishes. However, there is also the issue of depression and humiliation as you are fully aware that you have a tube up every orifice, and some strange person wiping you every time you have a bowel movement. Not only that, but you have to have someone assist you every time you move anywhere. Basically, you are a mind without a body. Do you want to live like that? Do you value life that much? Some people do. And we medical workers respect that.

Then you have the people who have Alzheimer's. These people will have fully functioning bodies but no mind. No mind no matter, no matter no mind. I would imagine that this might be the best way to end your life on a ventilator, if one had to choose between the two. If I were an elderly person diagnosed with Alzheimer's, I would simply make a wish to be a DNR just so that I wouldn't become a ward of the state, a useless blob of skin on a bed taking up space and absorbing taxpayers money. However that would be my decision, I have to respect the wishes of others who think otherwise. Thus, life is very precious no matter how fragile, and each individual has to decide for himself.

Then, let us consider the COPD patient who decides that he does not want to be placed on a ventilator. He is not necessarily end stage, but he is to the point that he cannot go without using his oxygen. However, he has a quality life to the extent that he is not one of those people who simply sits around and feels sorry for himself. He loves life. He loves living. However, he was also scared by the prospect that he might be placed on a ventilator and have to stay on it the rest of his life. So he makes the decision one day that he will make himself a d0 not vent patient.

Then one day he is having trouble breathing. His wife drives him to the hospital and by the time he arrives there he is severely short-of-breath; his work of breathing is labored. The doctor looks the patient straight in the eyes and asked the question no one wants to ever hear, "If something happens to you, do you want to be placed on a ventilator?"

Of course now the patient is not in the planning stages. He is actually miserable, gasping for every breath. His oxygen levels are falling. His CO2 levels are rising. He is pooping out. He has a feeling of impending doom. He, however, does not want to die; he is not quite ready.

Then again, he does not want to go on one of those things; he does not want to be intubated. So, he asks the naive question that is really not so naive because the only people who truly know the answer were standing in the bright room around him. Of course there were other COPD patients who knew the answer, but they were not in the room. His life, his destiny, was in the hands of the fine medical workers in the room.

"So," he says, huffing and puffing, barely able to get the words out, "How long would I have to be intubated for?"

"Well, the goal would be a day or two, but we really can't guarantee," the doctor explains.

Of course she doesn't want to give false hope, but she also doesn't want the patient to simply give up hope at the same time. This is the ironic twist that we often face in the emergency room. "The goal is basically to rest your lungs and allow them a chance to heal. That's the goal. I can't guarantee anything, but that's the goal."

I stand there thinking, as I am getting my intubation equipment ready just in case the patient makes the decision, that the doctor made a good presentation. In fact, I couldn't have worded it better myself. The key words there were "help you get over the hump" and "I can't guarantee anything."

By these short phrases the doctor threw the ball completely in the patient's corner. And, if the patient were to pass out, into the wife's corner. And if the wife were not there, the medical staff would have no choice but to make the patient a full code and do everything for the patient, unless they were 100% positive the patient was a DNR.

Another case I've seen is the elderly man with a chronically failing heart come into the hospital in respiratory failure secondary to the failing heart. The patient is non-responsive, and he is also not a declared DNR. The wife now is forced to make the decision of whether or not to allow nature to take its course, or to allow the medical staff to intubate her husband and place him on a vent.

"What should I do?" the patient's wife asks the Doctor.

"Well," the doctor says, "I know this is a difficult decision. Since you are in a very stressful situation right now and you want to make sure you don't make the wrong decision, perhaps it would be best to let us intubate your dad, and you can see how things progress, allowing yourself some time to spend with your family and to think, and then in 24 hours you can see how things are going with your dad. Either way, I can't make any promises. It's your decision.

The doctor pauses, allowing the patient time to think, before continueing. "Technically speaking, the goal of going on a vent is short term therapy to allow your husband's heart and lungs to rest. If things work out, he might come off in a day or two. However, I can't honestly say those odds are very likely right now. But, if things don't work out, he very well could be dependent, that's always a possibility. But if it comes to that, you can make a decision to terminate the vent if you wish."

After another pause, the doctor solemly states, "However, if he doesn't go on a vent now, there is very little chance he will survive this."

In this case, the wife decided to place her husband on the vent and the patient came off two days later with full mental capacity. Of course he was limited in what he could do, and had to go home with oxygen. And while his heart remained severely fragile, he was able to spend another two years.

Thus going on a vent "to get over the hump" bought this man two years to say good-bye to those he loved, and allowed those he loved to say good-bye to him.

I talked to the wife a year after he died, she told me she was very pleased with her decision to place her husband on the vent.

One time we had a lady on a ventilator with ARDS, and as she was on the vent for the fourth week, it was becoming evident that she wasn't going to make it. The patient had already been given a slim 10-20% chance of surviving by the doctor.

But the family stood firm with their hope, and prayed the patient would not only come off the vent but have some quality of life thereafter. Even the family was starting to give up hope after a while, though. Then one day, as though by some miracle, the patient woke up and was eventually discharged.

I know that's a rare instance, but patients with grim chances of survival can survive. And while it might be fine to say, "I've seen people like this survive before," you still don't want to give a family member false hope.

Likewise, I have seen many cases similar to my above examples go in different directions. In the medical field, you just never know what's going to happen. And, when you are making end of life decisions, you never know what the right answer is.

There are times, though, where I would definitely recommend a DNR status. These would be elderly people over 90, and any person who has a terminal end stage illness. If you have an 80 year old lady dying of cancer, it would be kind of foolish to place that person on a vent, when all the vent would do is delay the inevitable, and cost the family insurance and taxpayers thousands of dollars in the process.

Yet, I see these people going on ventilators all the time. In many cases it becomes quite frustrating to see these people on the vent for weeks on end. And, this can quite possibly be one of the most frustrating parts of the medical field. Sometimes I even feel sorry for these people, especially when it appears to me they are trying to die, and their family members keep pushing for them to live.

Recently I placed a cerebral palsy patient on a ventilator. He is off now and back at home in the care of his family. The quality of life for this person was already pretty low, but the family loved this young man and truly valued the sanctity of life. We had to respect those wishes, and we took care of him as we would any other patient.

So, if you are wondering whether or not you want to be a full code or DNR should your heart stop, or whether or not you want to go on a ventilator should you stop breathing (and many times those two come together in the same package), you should take some time to consider the what ifs.

It might be a difficult thing to stop and think about, but it could save you and/or your family members a ton of stress in the end.

As you can see, this is not an easy subject matter for anyone, including us in the medical field. And this has been and will continue to be an important ethical discussion for years to come.

What's it like to be intubated?

As I was looking at my blog statistics, and checking the recent keyword activity that landed someone on my site, I noticed one person had typed in the query, "What's it like to be intubated."

I remember waking up from a surgery once, and this person pulling something out of my mouth. I had no idea until I went to RT school what had actually transpired at that moment: I was being extubated.

So because I was medicated, I had no memory of being intubated, and had no memory of my time on the vent during the surgery. Thankfully, I must add, I have no memory.

Fortunately, I think that is the case for most people who are intubated. I think that we keep them sedated enough that they do not remember much. However, on occasion, we do have to intubate people under emergency situations where there is no time to medicate the person, and usually that person gags and groans during the process. There is no doubting the this is not a pleasant procedure to have done.

Which is why Succiconine is such a great drug, because it paralyzes a person just long enough to get the job done. And then, while the patient is serving time with a ventilator doing all the breathing or assisting with it, a patient is sedated enough with some good meds to allow the person to rest comfortably. And, while the patient is often awake, the meds are good at causing amnesia.

Lots of times I have to communicate with a person on a vent. Of course they can't talk, but you get pretty accustomed to lip reading after a while. Then, a few days after the patient is over the hump and is extubated, you ask them if they remember being on the vent, and they will tell you they have no memory of it. That's not always the case, but most of the time it is.

Occasionally, a patient remembers everything. Some patients are awake, alert and orientated the entire time they are on a vent. It's these people where you can learn the most from of what it's really like to be intubated.

It doesn't always suck either. I remember this one chronic end-stage COPD patient who was extremely short-of-breath. She told me she felt like she was suffocating. The next time I saw her she was on a vent, and she looked at me with eyes of joy. She smiled. She took in a deep comfortable breath. That vent was her savior.

That patient did not want to get off that vent.

I like to explain to my vent patients, if they are at all comprehensive, that they have not been placed on a ventilator permanently, it's just short term until their lungs get better. It's more or less to allow their bodies time to get over the hump. That's the case most of the time. And, usually, the person is off the vent in a day or two.

While I can honestly say that I have experienced much of the things I do for patients on a daily basis, I have never been on a vent; and I have never been suctioned.

One of my co-workers and good friends and fellow asthmatic was placed on a vent once, and she said she remembers the whole thing. She remembers being awake and alert and looking out the window and seeing a Burger King, which sucked because she was starving. And, she said, that wasn't even the worse part. The worse part was getting suctioned. She said there is absolutely nothing worse than that.

That in mind, a fellow blogger who used to be an RT, and who is unfortunately a victim of severe persistent asthma, was placed on a ventilator recently. I thought his story was very inspiring, and I would like to link you to his blog: The Bay City Walker.

The five different types of COPD patients

In RT school we are taught that there are three different types of COPD patients: emphysema, chronic bronchitis and asthma.

In the hospital we tend to leave asthma out of the COPD definition, and the general consensus is that if they smoke it's not asthma.

However, some doctors still diagnose smokers with asthma. I suppose that's their prerogative.

Personally, I am under the belief that if you are an adult with asthma, it is chronic asthma, and falls under the category of COPD.

Emphysema patients are referred to as pink puffers, because they tend to have smaller frames are are not cyanotic. Chronic bronchitis patients are referred to as blue bloaters, because they tend to have larger frames and are often cyanotic.

However you want to define COPD patients that's up to you. Based on my experience working with COPD patients over the years, I have come up with a list of the five different types:

Happy: About 80% of COPDers fit this category. These patients tend to be among the most pleasant of all patients, more so because they are professional patients with a chronic illness and have accepted it. They rarely ask, "Why me?" Happy COPDers generally are of two types: they are either talkative or phlegmatic.

Talkative: About 80% of Happy COPDers are talkative. Some of the best conversations I've ever had with a patient have been with a talkative COPDer. Before their "time is up" they want to share as much of their experiences and knowledge as possible.

When you give a treatment to one of these patients they might not let you leave. They will talk openly about their illness and family life. By the time the patient is discharged you will have a pretty good idea of what kind of a person he was, and what kind of a life he led, prior to getting sick. Usually they are very interesting and intelligent.

If you are talking with a COPD patient, and the patient starts describing an event that occurred in 1945, he is probably a talkative COPDer.

Phlegmatic: About 20% of Happy COPDers are phlegmatic. Whatever you want to do, they don't care. They talk little and have very pleasant and modest dispositions. The majority tend to be men.

If you walk into the room and find the patient has his feet up on the end table while watching TV, you know he is a phlegmatic

If you walk into the room and find the patient is moderately labored and still appears cool and calm, he is most probably a phlegmatic.

Melancholy: About 20% of COPDers fall into this category. They love to be waited on hand and foot. These patients have not accepted that they are sick, and have a tendency to be unpleasant
and very bossy.

When this patient wants a drink, she will say something blunt like, "Drink!" or, "Gimme a drink." Many might pretend they are incapable of lifting the glass so you have to do it for them. If you hear the words like please or thank you, you are probably not dealing with a melancholy COPDer.

Exaggerated: Would you believe it if I told you that a certain percentage of patients actually WANT to be in the hospital. The exact percentage is unknown, but it is estimated to be around 20%, and includes both Happy and Grumpy COPDers.

What happens here is that family members are tired and need a break, so the patient feigns his symptoms to get admitted.

If you need to give a series of Duoneb treatments in ER, but once the patient is on the floor she declines a treatment because she wants to sleep, then you should think exaggeration.

If she is lying in low fowlers and appears to be in no respiratory distress when you walk into the room, but as soon as you grab your stethoscope you hear an audible forced expiratory wheeze, you should think exaggeration.

If she is so bored the day after her admission that she is assisting her elderly room mate walk to the bathroom, then you should think exaggeration.

There are two different types of exaggeration of COPD. When emphysema and chronic bronchitis patients are faking it, the diagnosis is generally exaggeration of COPD. Faking asthma patients are referred to as exaggeration of asthma.

It is important that exaggeration of COPD not be confused with exaggeration of asthma. The differences may not be easily identified once the patient is in the hospital, but must be obtained through questioning, or it may simply be assumed.

Now, I know your science teacher told you not to assume, because when you assume you make an A-S-S out of U and ME. But in this rare instance, it is often necessary in order to make a proper diagnosis of the type of COPDer.

Exaggeration of COPD is when the patient is faking because their family members taking care of them are tired and need a break. So it may be assumed that 100% of exaggeration of COPD patients do not come from nursing homes or assisted living centers.

Exaggeration of Asthma is when the patient is faking because he is stressed and in need of a break from his family. He loves it that when he comes to the hospital he receives special attention and sympathy, and gets waited on hand and foot.

Now, while most of my opinion in establishing this data was obtained at one small town hospital, I believe my sample size and length of study (12 years) was large enough to obtain an accurate stereotype of all COPDers.

However, it must be noted that their is a +/- 6% margin of error on my percentages.

If you disagree with this assessment, or you have an observation of your own, please feel free to let this RT know.