My First Terminal Wean July 28, 2007
Posted by keepbreathing in Doctors, death, ethics, health, health and wellness, hospital, mechanical ventilation, medical ethics, respiratory therapy, terminal wean.trackback
I’ll never forget that first terminal wean.
It was the dead of winter here in the Great North Woods. The grimness of the middle winter had sent many patients our way. The psyche patients were depressed and cabin-fevered, the oldies were slipping and breaking bones on the ice, and the lungers were feeling the sting of the sharp winter air.
But it was for none of these reasons that the weaning patient was brought to us. No, he was brought to us for other reasons. He had come in to have elective throat surgery in an effort to correct his sleep apnea without losing any of his much-treasured body fat. But something went wrong. When he came back to the ICU from the OR, we were all horrified by the mangled mess that was his airway. Where his throat used to be was an enormous, gaping stoma. An anesthesia tube jutted out at an awkward angle, held in place by sutures covered in sterile gauze. Somebody had slipped. Things were not looking well for this mans throat.
Over the course of a week, he was brought to and from the OR countless times. He was infected, debrided, closed up, reopened. They got his throat to close but he couldn’t breathe on his own. He remained intubated for days and days; the ENT people and the pulmonary people and the maxillofacial people tinkered with this mans body, but to no avail. His long downward spiral had begun.
Eventually they were able to close his throat, but he had suffered a couple of minor MIs and a stroke. He was septic. His heart was giving out slowly, and it was looking unlikely that he would make it. The ICU physicians called a meeting with the family and the hospital ethics committee to discuss the course of action. It was decided that the best course of action was to end his life before it was taken from him.
And that duty fell to me. I was working with a therapist named Jeff, a guy who lived far away but made the drive to Our Lady for reasons not clear to anybody. Whenever questioned about it, he’d simply say “I used to be a trucker” and change the subject. Jeff and I were told by the day shift that the family was at the bedside, and that at 8:00 the physicians would write the order and discontinue supportive measures. Jeff turned to me.
“Have you ever done this before?”
“No.” Jeff looked at me from behind his hermit’s beard.
“It’s time you learned.” I didn’t object, and so the decision was made that I would do the primary work of extubating the man.
8:00 rolled around. The ICU doc of the evening strolled in with a cup of coffee and spoke with the family, making sure that they understood that there was no turning back now. The chat went on for fifteen, twenty minutes. I sat nervously in the fishbowl behind the nurses desk, watching with interest and wondering about what I’d have to do. Finally, the time came. The family left. The doc came up to me and showed me the order:
“Discontinue: (1) mechanical ventilation, (2) ET tube, (3) all pressors, (4) parenteral feeding. Do not resuscitate. Comfort measures only.”
I called Jeff and he came in with me. The man lay supine on the bed, the tube sticking out between his cracked lips. The ICU nurse moved about the room, removing lines and turning off drips and preparing the patient. Jeff coached me.
“Just make one smooth move. He won’t even feel it. Deflate the cuff, pull the tube back, and turn off the vent.” He passed me a 20-cc syringe, and I drew the air out of the cuff. The ventilator beeped in alarm as the breath it tried to deliver slipped around the cuff.
“Cough for me, sir.” I said it more out of habit than out of any hope that he would cough. I pulled the ET tube out, carefully laying it on the Chux pad that the nurse had thoughtfully put beneath his chin, cautious not to dribble tube slime all over the fresh sheets and the patients chest. Nobody wants to hug grampa goodbye and get a chest full of mucous. The ventilator screamed in protest, and I reached over to flip it off. A question burned in my mind.
“How long before…?”
“Depends. Sometimes they go for hours. Sometimes they go for minutes. C’mon, let’s get this vent out before the family comes back.” We made sure the RN didn’t need anything else from us and then skedaddled out of the ICU, abandoning the vent in the dirty room until we could get it cleaned up later on.
I went back and sat in the fishbowl, watching the patients monitor. The nurse let the family back in, and within ten minutes of the discontinuation his heart slowed down and stopped. It was over: he was dead.
:::
For all the fuss they made in RT school about this sort of thing, and about the ethics of these situations, it was remarkably easy to do. I thought about it a lot over the next few days, turning over the situation in my head again and again, thinking about the man and his family. It took me a while to sort everything out in my head, but ultimately I came to realize that it wasn’t my decision. I didn’t decide to take him off life support, and I didn’t decide to send him to that botched surgery. Indeed, the only decision I made was to carry out an order that I could have easily asked someone else to do. Further, the man’s life was likely to end in a horrific code, and this way his family got to say goodbye.
Sometimes, death isn’t so bad. On that note, check out this hilarious video about coping with death. I’m not sick, it really is funny. Seriously, check it out!
I remember my first time to do the “compassionate wean” alone…it’s a breeze with someone else, but the first time I did it alone, I went to the supply cabinet to get the setup for a trach collar, (I work in a vent weaning facility) and as I was walking back to the room with it I felt as if I were the one getting the pre-filled syringes ready for the “midnight execution” at the prison. Actually that patient lived for 3 weeks after. By then, all the feelings I had on the day I removed that patient from the vent had long since disappeared. I have done quite a few since then, and some didn’t last 10 minutes off the vent, but I wonder sometimes that under the “cocktails” of comfort drugs, can the patients hear what’s going on in the room, are they screaming inside, “I’ve changed my mind, help me, somebody please, I don’t want to do this” and of course you don’t see that, but I do wonder…..hmmm…
The terminal wean from the nurses point of view can be quite an adventure, as well. I’ve had some like what you described, and I’ve had some worse. It is interesting to examine my feelings about them. Most of the time I am actually glad that my patient isn’t suffering anymore (if they were), and sometimes, especially if the injury/illness was preventable, and they were young, I get pretty sad at the waste. . .
People really don’t give this much thought, and it’s something I never thought I would do. However, while in school I was told to go to a patient’s room and do it. The therapist told me that it was something I needed to do alone and coordinate with the nurse, then she promptly left. The nurse told me to go ahead and pull the tube, she would be in in a minute. I must have checked the patient’s nameband 20 times hoping the nurse would come in. I didn’t want to be the only one in the room. After stalling as long as I could I untaped the tube and just waited. Finally the nurse came in and didn’t raise any sort of alarm. I half expected her to freak out and tell me I had the wrong patient. I proceeded to extubate and just watched the nurse go about her work. I waited…and waited…and waited. The heart just kept putting along at 70 beats per minute for like 10 minutes. The nurse finished up and almost as an afterthought laid a large magnet on her chest. The heart just stopped. I didn’t understand at the time.
The first one is hard. It made me question what I was getting myself into. Later, when I had students of my own I made sure to be as supportive as I could. Noone should have to go through it alone. Thanks for sharing the story of your first. It’s always nice to hear from others who have gone through what you have.
RT
Thanks for all of the insightful comments, guys. I always like hearing what other people have to say about things.
Good Sunday morning the 29th to you Anonymous Therapist!
Just came by to say hello and see what was new with you !
Today is “thank-you’s” on my blog, and you are mentioned with a link !
*cyber hugs and smiles*
Loving Annie
p.s. Better to have someone like you doing what you have to, than to have someone suffer longer and unnecessarily. Doesn’t make it easy to do, and it was still the right thing for the family to do.
R.I.P.
p.s.s. I must have no sense of humor. The video went right over my head…
I’ve done about a dozen now, and like you in this instance, I’ve always had another RT in the room. Mostly because, as a real therapist I’ve never caught a terminal extubation but as a student in clinicals I had so many as sign off extubations they called me the Queen of Death. None of the ones I’ve done have ever bothered me. Made me stop and think, but not bothered me. I think it’s because mine so far have all been either very riddled with painful cancer or very old, very bedridden, very much gone from this world before we ever pulled the tube. In all of those cases I felt good about what I was doing, feeling like I was releasing my patient from a decaying body to go on to whatever’s next.
I’ve just stumbled on your blog while looking for information on ventilator weaning. Very sad, my MIL is lying in a Greek hospital with her family at her bedside and tomorrow they will extubate her. I just hope and pray that her passing will be swift. When faced with a decision two years ago to put my mother on life support I chose not to do it. She was already in a coma caused by I think septic shock and there was no brain activity. When I removed the oxygen and with a little help from morphine she died relatively peacefully in my arms…ciao
I found this to be a very interesting subject. In December of 2007 my grandfather had been on a vent only for a day and a half. He had been so sick before that time with cirrhosis of the liver, diabetes, CHF, and many other minor illnesses. He had ended up in the hospital with pneumonia and a few days later he became septic. He was filling up with so much fluid, his kidney’s were failing, and his body was too weak to do dialysis on him so it was just his time. It was very hard for me to deal with the fact of removing the tube that is keeping him alive though. But in the end I knew that it was the right thing to do. The tube was removed and he passed away about two minutes later. He was ready to be released from all the suffering he had done. I never thought how hard it would be on the person removing the ventilator though. Thanks for sharing and listening to my story.