Contrast: February 19, 2008
Posted by keepbreathing in Career Advice, Coming to an ER near you, ICU, asinine, death, ethics, life, medical ethics, respiratory therapy.trackback
“Mr. D came in last night, somethin’ wrong with his bowels or somethin’. He was a DNR but the ER doc talked the family into trying to resuscitate him and now he’s intubated. He’s septic or somethin’ cuz he’s breathing fast.” I nodded and looked at Mr. D, who was breathing a phenomenal fifty times a minute. His thick and distended abdomen heaved as he worked against the ventilator. His mouth opened in the classic “guppy breathing” posture as he worked.
“Do you know anything else about him?” I asked the night therapist. She eyeballed me quickly and shook her head.
“Nope. I’m off. See you tonight.” I nodded back at her and went to work.
Over the course of the morning, I spent a couple of hours with Mr. D. I put him on our ARDS protocol, ran mixed venous blood samples. I put in an arterial line, which was something of a personal triumph for me because even the Intensivist couldn’t insert one on this gentleman. The nurse and I played with PEEP and pressors and tried to balance oxygenation with perfusion. It was an uphill battle. Finally, at noon, the family asked us to cease our efforts. Mr. D died within three minutes after I extubated him. I was standing outside his room when his wife pulled the curtain back. Her eyes were blooshot. She grabbed me by the arm and began sobbing.
“Is he supposed to turn blue? What should I do?” She burst into tears and began sobbing hysterically all over my sleeve. I looked over her shoulder. Mr. D was bright purple, and as I watched he heaved his last breath and gave up the ghost. He was a family man, worked diligently in his church, served his country in the army for twenty years. Within twenty hours of coming to the ER for serious sudden abdominal pain he was dead. His family was devastated.
Down the hall, I had another patient, a middle-aged ex-IV drug user, unemployed woman who had come to the hospital more than two months ago because she didn’t feel right. She progressed into respiratory failure and got intubated in mid-December. Her family refuses to give her a tracheostomy because “she wouldn’t want that,” yet they refuse to let us withdraw support because she “wants everything done…” except for a trach, evidently. We’ve explained to them how her tube is surely eroding her throat, but they won’t listen. This woman has been on and off the oscillating ventilator, she has been in and out of surgery a number of times, and she is not neurologically intact in any meaningful sense–yet she is not brain-dead. She emits a smell that could stun a musk ox at a hundred yards. She absolutely refuses to die, and her family absolutely refuses to let us withdraw support. She never worked, she spent her life abusing drugs and grunting out babies, and she sits in our ICU and wastes your tax dollars to the tune of 5,000 dollars a day so that her high-quality life of staring into the middle distance and having tubes and lines inserted into her can continue indefinitely. We are no longer treating her for any curable condition; we are now keeping her alive for no reason. If she was aware of what was going on, I’d call it torture, but luckily for her she’s in a persistent vegetative state.Her family visits for about five minutes a day and then pronounces that “The Good Lord will make her better!” and leaves. I suspect that they are attending the church of the idiot pastor, but I can’t prove that.
Sometimes the contrast between my patients astounds me.
sometimes i wonder if we could ship people like your second story somewhere, like the moon or some random island or something…but i guess that wouldn’t be very humane.
I suppose that would be considered inhumane, but I don’t think it’s any less humane than what we’re doing to her in the ICU.
A wonderful world we live in, hey. I hope my family would let me go the way of guy #1.
Its amazing to me that no one can clearly define why its moral to keep a person with no hopes on a ventilator only to let them died alone in a nurseing home. Out of there mind and laying in there waste. I only hope when my time comes i can go out like the first person. Then agian this america we live in so i shall not hold my breath.
You use oscillators in adults? I thought we just used them in the NICU (and the odd sick-as-shit kids in the PICU)!
oh man, I hear you. We had someone somewhat like the second person where the family believed that God was punishing them through him and that if only they could repent of their specific sin, God would let this person in a vegitative state walk out of the hospital. I didn’t know where ther to cry or smack them.
Beth, we oscillate adults frequently. It’s more common in the NICU or with peds, but we will oscillate adults from time to time.
She will eventually erode and bleed out. A horrible way to go but we can blame her family for that. It shouldn’t be too much longer.
So sad, for both of them.
But also a reminder of why it’s so important to have a living will…hopefully you live in a state where they’re legally binding (I know in some places and in some circumstances they’re not…), and if you don’t, sit your family down and talk to them…I’ve told my family that if I’m kept alive by machines for no reason for an extended period of time, when I do finally die I will come back and haunt their asses forever.
Does your facility not have an Ethics Committee? We actually had a case similar to this not long ago, although it didn’t progress quite this far. After our physicians exhausted all hope and the family still wasn’t satisfied (they were a little slow), they took it to Ethics and got permission to withdraw support, as it was considered abusive to the patient and wasteful of healthcare resources that could go to patients with hope.