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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.
So, a couple of days ago, I was talking to a client and her two sisters. They have their 68-year-old dad in ICU, after he was admitted with a PE (Pulmonary Embolus). He had some thrombus in his lungs. Had difficulties in breathing, ended up on a ventilator and they gave him some thrombolytics to basically manage the thrombus, the pulmonary embolus.
As part of him having thrombolytics, the side effect from that was, he ended up with a massive brain bleed with a hemorrhagic stroke. And now he’s in ICU for about seven days on a ventilator with a breathing tube after hemorrhagic stroke and PEs. And he’s got significant brain damage. He is not waking up. He’s been off sedatives now for a couple of days. He’s also having regular seizures. He’s on Keppra to manage that, but he’s still having ongoing issues with seizures.
The ICU’s telling the family after those seven days in ICU, that there are two options. The first option is to move towards hospice and end of life for their dad or the second option is to do a tracheostomy, do a PEG tube and move the patient and their father to a long-term acute care facility. And they obviously wanted to know, what are their options? What should they do? And here is my advice.
My advice is that in such difficult circumstances, number one is, you should project yourself 12 months out from today. And you should think, if I was to look back in 12 months’ time, would I regret or would I potentially regret making such a decision? I.E. if you make a decision to end your loved one’s life, is a decision you might regret.
And as a side note here, there’s plenty of time to talk about end of life. If you wanted to prolong treatment of your loved one, and for whatever reason you change your mind, because circumstances change, maybe your loved one’s condition deteriorates, you can still talk about end of life. You can come back to it at a later point. But keep in mind that once you’ve made a decision about end of life, there is no return from that. So you got to be very careful and you got to look at timelines.
Now, the next thing that I want to mention is, seven days in ICU is not a long time. It’s not a long time, especially when it comes to a significant critical illness, which under these circumstances is a given.
So, should they then consent to a tracheostomy and the PEG (PERCUTANEOUS ENDOSCOPIC GASTROSTOMY) tube instead? Well, my next question to the client was, what would your dad want? And they think that their dad wouldn’t want to live on a ventilator, for too long, but they’re obviously happy to give him the best shot at treatment and see whether he can improve.
But they’re also concerned that if he has a tracheostomy and a PEG tube, that the next step is for him to go to LTAC, to long-term acute care. And they have done their research. They already know that long-term acute care is not a good option for someone with a tracheostomy and PEG tube and a critical illness.
So, then I advise them to potentially consent to a tracheostomy but not to a PEG because from my experience, LTACs do not take patients without a PEG tube. The alternative to a PEG tube is a nasogastric tube. And patients can have a nasogastric tube, for months to come, unless they of course, can pull it out themselves. Then maybe you need to look at a PEG tube if oral intake is not an option.
Here is number three though.
So the next step is, is there any possibility that their father can come off the ventilator and they can avoid the tracheostomy? Well, I don’t know. I haven’t spoken to a doctor yet. I have yet to look at medical records, but that’s the third option. Are they pushing for a tracheostomy because they want the ICU bed and they want their patient out of ICU to LTAC?
So those are all questions you need to consider.
Now, chances are that with a brain bleed and brain damage with a stroke, chances are that he might need a tracheostomy for some time to come, because he might not have a cough reflex, no gag reflex. He might not be able to swallow. And all of those issues need to be taken into consideration as well.
So, you got to look at longer timelines when making decisions, you can’t be pressured by intensive care teams working on their timelines because again, seven days in intensive care, it’s not a long time. You need to look at the bigger picture. You need to look at options that you have down the line. Another option is, if your loved one does need to tracheostomy and has ventilator dependency and can’t wean off the ventilator quickly. You could also look at our other service Intensive Care at Home, and you can find more information there at intensivecareathome.com . I believe that is the best option when someone is stuck in ICU long-term.
So that is my quick tip for today.
If you have a loved one in intensive care, go to intensivecarehotline.com. Give us a call on one of the numbers on the top of our website, or send us an email to [email protected].
Also, have a look at our membership for families in intensive care at intensivecaresupport.org.
We also provide medical record reviews for our clients while they’re in ICU or outside of ICU, go and contact us as well if you need a medical record review.
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Thanks for watching.
This is Patrik Hutzel from intensivecarehotline.com, and I’ll talk to you in a few days.