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If you want to know if the intensive care team can force you to give consent to a tracheostomy when your loved one is critically ill in intensive care, stay tuned. I’ve got news for you.

My name is Patrik Hutzel from intensivecarehotline.com and I have another quick tip for families in intensive care today.

So last week, I had a client call me up and he said, “Hey, can the intensive care team force me to give consent to a tracheostomy for my mom?” and I said, definitely not. No one can force you to give consent to a surgical or medical procedure if you don’t want to, if you don’t think that’s in the best interest of your family member.

Now, first things first, I do believe that tracheostomies have their time and their place. They absolutely do but you need to approach this subject and the question with much discernment, which is what our client has done here. So, he’s done the right thing.

But keep in mind, no one can force you to do anything, really, and that’s a good thing. But what is important when you have a loved one critically ill in intensive care, you do want to make the right decisions, and you do want to make the right decisions in a timely manner.

So, let’s break the situation down and see whether tracheostomy is even an option for our client’s mom. So, this is an 86-year-old lady with a significant medical history of hypertension, rectal cancer on current radiotherapy. She was admitted into ICU on the 29th of November for acute hypoxic respiratory failure and sepsis due to COVID-19. The hospital course was complicated by worsening respiratory status and increasing oxygen requirements, admitted to the ICU on the 1st of December. Now, the time of the recording of this video is actually the 5th of January 2025.

Now, the patient eventually was intubated after a DNI reversal. DNI means a Do Not Intubate reversal and treated with evidence-directed treatments for COVID-19 and ARDS with dexamethasone, Tocilizumab, and episodes of proning. She was also treated with heparin which was transitioned to Lovenox therapeutic dosing for presumed acute pulmonary embolism and treated for superimposed bacterial pneumonia. The patient had a persistent shock state with high oxygen requirements, with unrevealing work up to date. Septic workup including fungal workup and RUQ (right upper quadrant) ultrasounds were unremarkable.

On the 22nd of December, patient was started on high doses of methylprednisolone for possible organism pneumonia, and then she was transitioned to prednisolone, 60 milligram per kilo with slow taper.

On the 25th of December, patient noted to have abnormal CT chest imaging with pneumomediastinum, CT surgery was consulted. CD to evaluate for esophageal perforation, didn’t show any evidence of extravasation of oral contrast from the stomach or proximal small bowel, but did show interval increase in the pneumothorax.

Next, the let’s look at ventilator settings for this particular lady. She’s on a PEEP of 6, increased multiple times to 100% for asynchrony related desaturation. So FiO2 or (fraction inspired oxygen) was increased to 100% on a number of occasions. Levophed or noradrenaline is now off. She is, however, requiring vasopressin. Midodrine was started, persistent low-grade fevers and high dose prednisolone, and broad coverage with recent Posaconazole added. The morning, chest X-ray per radiology with right 4-millimeter apical pneumothorax and worsening subcutaneous emphysema.

Now, her ventilator settings are that she’s in a pressure control ventilation mode and she is on a PEEP of 6 with a respiratory rate of 24. FiO2 (fraction inspired oxygen) 60% but going up to 100% at times. She’s on a pressure control set at 28 centimeters of water. So, that’s a fair amount of support.

But also, this is where I keep saying over and over and over again, that the biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care and that is exactly what this family is up against.

How can the intensive care team possibly ask the family to give consent to a tracheostomy when she’s not even ready for a tracheostomy? She’s on 60% to 100% of FiO2 of oxygen and that is a contraindication for a tracheostomy. Also, she’s got a pneumothorax and a surgical emphysema, that is also often a contraindication for doing a tracheostomy.

That doesn’t mean tracheostomy is off the cards, not at all, but it means there’s going to be a delay and there needs to be some time that goes by between now and this lady having a tracheostomy. She’s simply too sick to have a tracheostomy. Her lungs are too sick to tolerate a tracheostomy because the risk of doing a tracheostomy while she’s on 60% to 100% of FiO2 is simply too high.

Now, this lady would have definitely benefited from having a tracheostomy by now already, but she’s simply been too sick and too unwell to have a tracheostomy. Why would she benefit from a tracheostomy? Quite frankly, she would benefit from a tracheostomy because she could be liberated from sedation. At the moment she’s still on Precedex as well as hydromorph and she’s not really waking up. One of the main purposes of a tracheostomy is simply to minimize and wean off or stop sedation and opiates because a tracheostomy is so much easier to tolerate compared to a breathing tube.

But here’s another question, why would the intensive care team even ask to give consent to a tracheostomy if she’s clinically simply not ready for it? Well, this time is in the U.S. and my theory is that by having consent for a tracheostomy and also for a PEG (Percutaneous Endoscopic Gastrostomy) tube, the minute they can do that, they can send her out to an LTAC (Long-Term Acute Care). 

So, I’m all for this lady needing a tracheostomy if she can’t come off the ventilator, but then the next question is would she be sent to an LTAC? I argue that without a PEG tube, she won’t be going anywhere. She’ll stay in ICU, which is where she should be staying anyway.

So, what did we advise this family to do? We advised to hold off to give consent to a tracheostomy for now while she’s on 60% of FiO2, but the minute the FiO2 is coming down and gets less than 40%, then probably a tracheostomy needs to happen unless she can wake up smoothly, she can pass spontaneous breathing trials, and then maybe extubate.

But in this situation, because she’s been in an induced coma for so long, and she’s most likely also deconditioned, it is probably not advisable to do a tracheostomy just right now, but you most likely would need a tracheostomy.

So, I hope that answers this question today.

Now, I have worked in critical care nursing for 25 years in 3 different countries, where I worked as a nurse unit manager for over 5 years in intensive care and critical care. I’ve been consulting and advocating for families in intensive care since 2013 for intensivecarehotline.com. I can very confidently say that we have saved many lives for our clients in intensive care. You can verify that by going to intensivecarehotline.com and check out testimonial section, or you go to intensivecarehotline.com and you check out our podcast section where we’ve done some client interviews who vouch for what we’ve done for them.

That’s also one of the reasons why we help hundreds and hundreds of members and clients over the years to improve their life instantly when they have a loved one critically ill in intensive care.

That’s also why I do one-on-one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. I also talk to doctors and nurses directly. When I talk to doctors and nurses directly, I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensity and today is actually such an example. This family didn’t know what they didn’t know, they were asking, “Should we give consent to a tracheostomy?”, and my answer was, “Well, it all depends”, but they wouldn’t have even thought about that she’s simply not ready for a tracheostomy. Now, I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also do a medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecareholine.com if you click on the membership link, or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 videos and 21 e-books that I have personally written and recorded, once again, so that you make informed decisions, you have peace of mind, control, power, and influence when you have a loved one critically ill in intensive care.

All of that, you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.

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