Is it okay to keep patient alive until family arrives?

So there's a patient who is going to die soon, and the family is aware of it.  She is on a BiPAP or ventilator, and is nonresponsive.  The family wants to keep the machine going, to keep the patient alive, until a family member arrives from California.  Is this ethical? 

This is a question that plagues me.  I personally think it's unethical.  Yet, it is a personal decision, not for the doctor to make.  You offer it up to the patient, let them know the facts, and the family has to make these decisons.  What can you do? 

"We want to keep her alive until our daugher arrives from California.  Her plane will land in a few hours."

So we get to play God?  What do you think?

Is there really such a thing as patient autonomy?

Is there really such a thing as patient autonomy?  You know, that's that thing where you, as the patient, get to make medical decisions for yourself.  Chances are, that while you may think you're choosing your own course through life, this may not be true as far as your health is concerned.

To further this discussion, let's allow for a few definitinos:

1.  Autonomy:  independence or freedom, as of the will or one's actions: the autonomy of the individual.(From Dictionary.com)

2.  PatientAutonomy:  The patient is allowed the freedom to make the best medical decision based on the best available information about all possible options.  The desire of caregivers to treat the patient as an individual person

Yet the truth is, there really is no such thing as patient autonomy.  The reality is the following:

3.  Real Patient Autonomy:  The patient is lead down a certain path, given one or two options, and lead to believe he made the best decision on his own.  Most people are naive about medical options and trust their physician to make the right choice for them.

I see examples of real patient autonomy on a daily basis at my work.  I walked into a room and the patient said to me:  "I don't think those breathing treatments do me any good, and I don't want them anymore."  I said, "That's fine.  They're meant to treat symptoms you no longer have, so you can refuse if you want."

As I was leaving the room the doctor walked in, and the patient said, "You can discontinue the breathing treatments if you want, because I don't need them."  The doctor said, "You need those treatments so everything else works better."  The patient said, "Oh, Okay."

So here you have to doctor ignoring the wishes of the patient and convincing him based on a statement that was completely not true.  Yet the medically naive (and other wise highly intelligent) patient had no way of knowing this, and so he bought into the physicians logic.

Perhaps better examples come at end of life care.  Here you have people who maybe even have advanced directives, yet because of the ethics of end of life care, the wishes of the patient are often overruled by the physician.

I have seen several younger patients who had DNR orders who were ultimately intubated and put on a ventilator because "The person was only 42 and too young to be a DRN."

I have seen a DNR patient put on a BiPAP machine, and even though the patient did not like nor want to be on the BiPAP, the doctor ordered:  "Do not take the mask off the patient no matter what."
Then you have the DNR patient who does not want to die but also wants to die comfortably.  This is where it gets really touchy.  This is where end of life ethics really comes under fire.  The patient doesn't want life saving efforts, but is gasping for air, cyanotic, and his lungs are full of secretions to the nipple line.

Does the doctor follow the wishes of the patient and do nothing, or does he treat the symptoms with BiPAP?  So now the doctor orders for the BiPAP, and it works so good the patient is awake and alert and insisting the mask comes off.  So you take the patient off the BiPAP and he can't breathe off of it.  So now what do you do?  ( I wrote about this here.) You have no choice but to put the patient back on.  Once again, the patient thinks it was his decision.

The patient's autonomy takes a back seat here.  Now consider the comfort of the patient.  Say the patient wants to be a DNR under comfort care only?  In other words, the patient has already accepted the futility of his disease.  Does being on the BiPAP make the end of life more comfortable, or does being on the BiPAP delay the inevitable?  Is the order for BiPAP complying with the wishes of the patient, or trumping the wishes of the patient?

In this sense, the patient isn't really making any decision, he is simply being lead in one direction and made to think he decided what was best for him.  Yet once the patient makes the decision to accept BiPAP (something most patients don't understand until they try it) it's difficult for a doctor to order for it to be discontinued so the patient can either sail without it or die.

Yeah.  You can debate such end of life medical ethics until you're blue in the face and there is no right or wrong answer.  That's why I think it's important for patients to be well educated about their medical conditions and end of life options.

Or, as one of my coworkers defined recently:

4.  Do not resuscitate:  I want to live, but I understand the futility of my medical condition, and I don't want you to make rescue efforts to save me if I stop breathing or if my heart stops.

5.  Do not intubate:  Load me up with medicine, do chest compressions on me, but, by God, do not you dare put a tube in my throat so I can breathe.

Related readings and references:

• Whitnack, Jeff, "NPPV Does Not Have a Positive Role to Play in the Care of DRN/DNI," RT for Decision Makers in Respiratory Care, August, 2006
• Silverman, William A, "The Myth of informed consent in daily practice and in clinical trials," Journal of Medical Ethics, 1989, 15, pages 6-11
• Also see my end of life lexicon

Why paralyze when you could just extubate?

Sometimes I'm glad I'm not a doctor. They have a responsibility on their shoulders that I would never want to have. There are a lot of times I opine that this should be done or that, but it's the doctor who has to bolster the brunt of the responsibility for that person's life.

So when this 47-year-old male came in after overdosing for the second time, he was placed on a ventilator to support his breathing and to protect his airway. But this came a little too late, as he had already aspirated. So, when he started waking up the next day, and went ballistic, the doctor decided to paralyze (and sedate) him instead of taking him off the vent.

Do you see the problem my co-worker and I have with this. We had already sucked a ton of brown shit from this guys lungs, so there isn't a lot of it left. He was breathing fine on his own even with a load of sedatives in his system, and when they let those wear off, he went ballistic again. But, instead of yanking the tube and letting him fly on his own, the doctor decided to paralyze him again.

Yesterday my co-worker told me he went ballistic himself because, "there is no f#%%ing reason not to extubate that patient."

How inhumane is it to keep paralyzing someone because they are "TICKED" that they have a tube up every orifice.

To be fair, however, we have to look at the doctor's end of this. The patient did aspirate. He did OD before and ended up on a vent that time too, and he did develop ARDS that time. But still, there are no signs the patient is in ARDS now.

Due to the drug he overdosed on ( I can't remember what it was), there were some complications to watch out for, but the patient, according to the nurse, "is fine other than the fact he's paralyzed."

Are we missing something here? Are we right that this patient is inhumanely paralyzed, or is the doctor right? We may never know. And that is why doctors make the big bucks and we don't.

To be honest, it's easy taking care of a paralyzed vent patient. But is that what's in the best interest of the patient? It's not our decision to make.