Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was
Is it Possible to Wean My Dad Off the Ventilator and Avoid a Tracheostomy in the ICU?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients, Iyah, as part of my 1:1 consulting and advocacy service! Iyah’s dad is in the ICU, and she’s wondering if they will allow the Ethics Committee to step in when she and her siblings disagree on end-of-life decisions for him.
Should We Allow the Ethics Committee to Step In When We Disagree with Decisions About Our Dad in the ICU?
You can also check out previous 1:1 consulting and advocacy sessions with me and Iyah here.
Nurse Ron: No.
Iyah: But with a PEG feeding tube he would’ve to be sent to a long-term care facility.
Nurse Ron: That’s not true. It has to do with his body being stable. Is his blood pressure stable? Can he tolerate being on dialysis?
Dr. Shelby: We’ve had patients at home with both kinds of tubes before. It just depends on the situation. But what’s keeping him in the hospital right now is being on the ventilator and the dialysis for the time being.
Iyah: That’s all I got.
Nurse Ron: And just because he’s stable enough to go to a facility, it still takes days to get it arranged.
Nurse Ron: It’s going to take days to actually get access to a room. Everybody is so full. So, it is not like he’s going to be gone in five days.
Dr. Shelby: And to find one that could actually do dialysis too would also be really hard.
Nurse Ron: Correct. He may stay here no matter what-
Iyah: Yeah. That’s why my concern is that I want him to stay in ICU or stay in the hospital instead of being sent to a facility.
Nurse Ron: … because of the accessibility of things.
Dr. Shelby: That could be a long-term problem too.
Nurse Ron: So, leaving a nasal tube in as opposed to a PEG tube is not going to stop any of that. It all functions the same way. But with the nasogastric tube, he’s at risk of developing abscesses in areas that we have a very hard time healing because they’ve got moisture all the time. They’ve got mucus. And the air is coming in and out, so they have access to getting infections over and over and over.
Dr. Shelby: We don’t want to cause erosion in his throat because that would add just too many more problems… to his list of problems.
Nurse Ron: Yeah. Right. He has enough problems right now with his body.
Dr. Shelby: What would be your thoughts at this time, Ann?
Ann: It’s kind of tough to say. I want him to live, but at the same time, I don’t think my dad would want all this to be done to him. Those are my thoughts.
Dr. Shelby: Has he had talks with you in the past, or kind of said things, or just who he is as a person.
Ann: There’s a lot of stuff. He’s just going through a lot of stuff already, just his condition already right now, or before this. So those are my thoughts for him.
Michael: I see what you mean.
Dr. Shelby: Michael, what are your thoughts?
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Michael: That’s the same. I don’t believe he would want to keep going through all these procedures if he had the choice.
Dr. Shelby: So, if it came to needing a trach next week, you would err on the side of not putting him through that?
Michael: Yes.
Dr. Shelby: And again, these are all right now hypotheticals because we don’t know what’s going to play out in the next few days. But I think it’s good to get just a starting position, feeling of where people are, give you guys time to both think on your own offline, and also talk to each other offline. I mean, away from us.
Michael: Yeah.
Ann: So, what happens if we can’t come to an agreement? What would happen?
Dr. Shelby: Ideally, we’d be able to get there, to an agreement. But if not, sometimes we bring in an ethics consult, and they bring in a team that helps weigh in from the outside and tries to figure out how to proceed.
Ann: Objectively?
Nurse Ron: Yes. They’re very objective.
Dr. Shelby: An outside mediator.
Nurse Ron: Yes.
Iyah: And they would make the decision?
Dr. Shelby: They would try to figure out the best way to bring resolution with, hopefully, everyone not being very upset.
Iyah: Right. Okay.
Nurse Ron: They would help you work through it.
Dr. Shelby: But oftentimes, not everyone is pleased with outcomes.
Iyah: Can a scenario be trying the tracheostomy, and if he’s still declining, then can possibly do the end-of-life route?
Dr. Shelby: There are different scenarios, so yeah, all these things are possible.
Nurse Ron: Yes.
Iyah: There can be scenarios. Okay.
Nurse Ron: Yes.
Dr. Shelby: But if we feel there’s a high chance that someone is not going to be able to recover, we try to avoid putting them through more procedures-
Nurse Ron: Right.
Dr. Shelby: … if there’s not a good decent chance of actually making use of that and getting better.
Nurse Ron: Yeah.
Dr. Shelby: It’s a tough balancing act.
Iyah: Yeah.
Nurse Ron: It’s tough, because, even for some patients, if their blood pressures are so unsteady, it doesn’t matter how much pain they’re in, we can’t give them much pain meds. So how he responds to things is how we respond to treating him. And unfortunately, in medicine, there’s nothing that’s complete black and white, because human beings are different. If I’m not stepping on your toes, I would like you guys to think about not having CPR (cardiopulmonary resuscitation). If his heart stops then…
Ann: Yeah. I agree with that.
Nurse Ron: Because CPR is going to break ribs. It’s going to cause his lungs to be bruised. The tissues get really inflamed, full of fluids. Every breath would be painful.
Ann: Yeah.
Nurse Ron: As opposed to, you know what I mean?
Ann: His body’s already fragile right now as it is.
Nurse Ron: Right. Right.
Ann: So, it is already broken.
Iyah: I disagree. I do want for him to be resuscitated.
Liza: Well, my question is, I’m kind of not sure if I’m following you. So, what would the scenario be under trach, and if he has a heart attack?
Dr. Shelby: This is kind of separate from the trach question. This is just, if while here in the hospital, in case that he actually passes away, goes into cardiac arrest, do we subject him to CPR with the hope of bringing him back to life, or do we let him pass peacefully at that point and not try to do those things that probably would not work, given how sick he has been?
Liza: And I’m not following the scenario we’re on. Is it the one-week breathing trials, or not?
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Nurse Ron: No, no, no. This is just whether we do CPR, which is chest compressions. If his heart stopped, do I rush in there, smack the button, and start pushing on his chest to force his heart to pump?
Liza: In what conditions would his heart stop in? I’m not following this scenario.
Dr. Shelby: So normally, if someone becomes so sick that their heart became really unstable, like if he got worse, sepsis and his blood pressure dropped too low, cutting out blood flow to his heart, or the AFib (atrial fibrillation) turned into a more dangerous rhythm and his heart went into cardiac arrest because his body’s so sick the heart stops.
Iyah: When can the medications cannot help maintain it?
Nurse Ron: Well, Liza, he’s at that sick level, where his heart could stop for any reason, and there’s any number of reasons that would make it stop.
Liza: Right.
Nurse Ron: But he is sick enough that his heart could stop at any time.
Liza: Right.
Dr. Shelby: For most emergencies, CPR is useful when what caused the problem can be fixed, like a car accident or a major trauma. But if someone is gravely ill or has advanced cancer and they’re already on maximum treatment, there’s no higher that you can go than that. So, if they die and you bring them back, they’re in the same boat they were before but now worse because of all the trauma from the CPR.
Nurse Ron: Yes, much.
Dr. Shelby: Or brain damage from a blood flow to the brain.
Nurse Ron: Right.
Dr. Shelby: So, when someone’s sick, CPR becomes a very important question to think about, because it’s not so straightforward as it is if someone’s healthier.
Nurse Ron: And the point is when they’re not sick, it’s rarely successful anyway. So that’s why we kind of talk about whether it’s worth putting him through the pain. That’s-
Liza: Right. I understand. My question is the ribs breaking, what is the chances of that actually happening?
Nurse Ron: It’s almost a hundred percent. We have to push on your chest at least two inches deep, and we have to do it 60 times a minute or a little more.
Liza: Right. So, is it mainly because his bones are so fragile?
Nurse Ron: No, it’s just the force.
Dr. Shelby: Anybody getting CPR, it’s a lot of force to put on someone’s chest.
Nurse Ron: Yeah. It’s a natural occurrence from pressing down on that chest two inches or more to make the hard pump.
Liza: Right. Yeah.
Dr. Shelby: But if you’re older and you have osteoporosis, then you’re probably going to break even more ribs, like 10 or 12 ribs vs 5 ribs, kind of thing.
Nurse Ron: Right.
Dr. Shelby: Yeah.
Liza: So, what is that diagnosis of heart failure?
Dr. Shelby: No, this would be cardiac arrest.
Liza: Cardiac arrest. So that’s not-
Nurse Ron: That’s just a fancy name for saying your heart stopped pumping.
Liza: Right, right. Okay. So yeah, I understand now. I feel that would be his natural way of going, so I would be comfortable with not doing CPR. That would be in him, and between his and God.
Nurse Ron: Okay. So, you’re the only one. What do you think?
Iyah: Yeah. Yeah, the only one. Remember this is what dad wants, not what you want.
Liza: Last question is, what is the timeframe that his bones would recover from the break?
Nurse Ron: Because he’s so sick, it would take quite some time, in my guess, in my experience of being in ICU for over nine years and being an RN for over 16 years and being in healthcare since I was 18.
Liza: Right. So, the average time for bones to heal is four to six weeks. So would it be more than that, or would it-
Nurse Ron: It would very likely be more because his body is so taxed already, trying to fight off the infection. So, it could take longer. Yes.
Liza: Right. Well, I do feel that it would be his natural way of passing away, so I’m not quite sure if I’m ready to make that decision right now. However-
Iyah: Yeah. So, let’s sit on things.
Liza: … I don’t fully understand all the circumstances that would lead to him having cardiac arrest.
Nurse Ron: Okay.
Dr. Shelby: What I would probably recommend is me doing the consult for ethics, just because there are already kind of discrepancies and some pretty big decisions. So, it’d be good to have that mediation earlier rather than later.
Michael: I agree.
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Iyah: How early would you project?
Dr. Shelby: I’ll ask them to put the consult in now, but they may not talk to you for a day or two, I imagine.
Nurse Ron: It is the holidays. It’s a matter of what’s already on their schedule. We can’t predict exactly when, but they would be coordinating with you.
Dr. Shelby: So, I’d probably advise keeping code status the way it is for the moment until we get their input.
Nurse Ron: Yeah.
Iyah: So, this were to happen this week, whatever, what decision are you guys going to make?
Nurse Ron: Well, right now, he’s full coded until you guys agreed to make him-
Iyah: So fully resuscitation?
Nurse Ron: Correct.
Iyah: Until we make a decision, basically.
Dr. Shelby: Either from the consensus or ethics weighs in and-
Iyah: Just regarding the CPR part?
Patrik: Well, I guess as a health professional myself, I guess, if you wanted to bring in the ethics committee, I do believe that the family would need to give consent to that step. So, I guess the question is, would the family give consent for you to refer that to the ethics committee?
Nurse Ron: They don’t have to give consent for the ethics committee.
Patrik: Show us your policies around that, please.
Nurse Ron: I don’t know the exact policy on that. It’s just-
Patrik: Well, then how can you make such a statement then? How can you make such a statement that-
Nurse Ron: Because it’s a protocol that it would happen.
Patrik: Yeah. Then just show it to us and make it transparent. That’s all. If you have nothing to hide, just show it to us.
The 1:1 consulting session will continue in next week’s episode.
How can you become the best advocate for your critically ill loved one, make informed decisions, get peace of mind, control, power and influence quickly, whilst your loved one is critically ill in Intensive Care?
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- How to ask the doctors and the nurses the right questions
- Discover the many competing interests in Intensive Care and how your critically ill loved one’s treatment may depend on those competing interests
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- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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