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
When Will My Mom in ICU Wake Up After Being in an Induced Coma?
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, Isabel, as part of my 1:1 consulting and advocacy service! Isabel’s mom is critically ill in the ICU, and she is asking why she is being pressured by the ICU team to withdraw treatment for her mom in ICU.
Why Am I Being Pressured by the ICU Team to Agree to Withdrawal of Treatment for My Mom in ICU?
Isabel: Hello, Patrik?
Patrik: Yes, I’m here, I’m here. Leon?
Leon: Hi Patrik.
Patrik: Hi Leon. Hi Isabel. How are you?
Isabel: We are tired and worried. There has been a lot going on. Thank you for asking.
Patrik: I understand. Do you want to call the hospital now or…?
Leon: Yeah, I am calling them now. (Phone ringing)
Patrik: Maybe let’s go through those numbers first while waiting for the hospital to pick up the phone and then probably makes more sense to you when we call them.
Leon: Okay.
Patrik: You had the update from the nurse 7:00 PM, low 80s; 10:00 PM, high 50s; 11:30, low 70s. That’s oxygen saturation. Then the ABG, PO2 50, PCO2 54, was in the low 70s prior to that. 100% oxygen on the ventilator, 40% maximum on nitric oxide, heart rate 110.
The only missing information there is her blood pressure. But that’s okay. We can find that out. Let’s just quickly look at the ABG (arterial blood gas). So PO2 50 is very low. The PO2 (partial pressure of oxygen) should be above 65 at least. Bear in mind that she’s on 100% oxygen in the ventilator, which means it can’t get any higher. On top of that, she’s on nitric oxide. If they would take away the nitric oxide, chances are that her PO2 would drop even further.
CO2 54, I’m not too concerned about. Normal CO2 range is 35 to 45. Given that she’s asthmatic, I’m not worried about a PCO2 54. Everyone with asthma generally speaking has a higher baseline PCO2 (partial pressure of carbon dioxide). But what’s happening in this situation is her oxygen levels are really, really poor.
Now, if her oxygen levels keep deteriorating in the ABG in particular, eventually her organs won’t get enough oxygen and that will eventually lead to death, right. That’s what those numbers mean generally speaking.
Now if you look at the numbers that you sent, oxygen saturation, low 80s, definitely concerning; high 50s, incredibly concerning; and then 11:30, low 70s, incredibly concerning. So those numbers are all concerning. But was there anything else the nurse said?
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Isabel: She just said that they were adjusting the ventilator. That’s how they got those numbers to change-
Patrik: Okay. She said they would do that after you spoke to her or were they in the process of doing it or…?
Isabel: I think they had been doing it since earlier today or yesterday. Yeah.
Patrik: Right. Okay. And the nurse is helpful? Are they happy to share information?
Isabel: Yeah, she was sharing information.
Patrik: Good.
Isabel: This wasn’t the nurse practitioner. It’s just like the nurse that’s taking care of her as at 7:00 PM.
Patrik: Right. The nurse practitioner you are referring to was during the daytime?
Leon: There were two. I spoke to two. During the daytime, there was a male, and he was the one who was kind of pushing us to make a decision. The nighttime… night person, she was the one who was saying that they were running out of options.
Patrik: Right. The nurse practitioner, are they from ICU or are they from palliative care?
Leon: That’s a good question. I actually don’t know.
Patrik: I do believe they’re from palliative care, but I could be wrong. Most of the nurse practitioners are from palliative care, but especially if they’re pushing towards the end of life, most of the time they’re from palliative care. But we can find that out when we talk to them.
The connection over the phone at the moment is fairly average. I can hear what you’re saying, but it’s a little bit average. I’m worried that if we dial a fourth person in that, the connection might get a little bit wobbly.
I am wondering whether I could set up a Zoom link for the two of you and we could get a Zoom call and then you could dial them in, and I could talk over Zoom because I think that would be a better connection than what we’re having at the moment. Is that an option for you? Or if not, we just carry on, but I’m just trying to work out how we can get a better connection.
Leon: We are okay with the Zoom.
Patrik: Okay, good. While we’re waiting, do you have access to an online medical records chart for your mom?
Leon: I don’t know if we have any for this one. For the previous hospital we had to get them physically mailed to us.
Patrik: Right. Have you heard of a website called MyChart?
Leon: No. What is that?
Patrik: Yeah, most hospitals now have medical records on a website called MyChart. It’s pretty much centralized from all hospitals. And if you wanted access to the medical records, they should give you a username and a password through MyChart, and you should be able to look up blood results, progress notes, medications, almost like in real time.
Leon: Oh, nice.
Patrik: That could be an alternative. So, I assume one of you, or both of you, is the power of attorney for your mom?
Isabel: Yes. I mean, we’re just kind of all, myself and my brother and my dad, we’ve kind of just… making decisions.
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Patrik: Yeah. Yeah. Look, one of you should be able to access the medical records on her behalf, especially since she can’t make decisions. You shouldn’t have an issue in getting… you go back to them and say, “Hey, we want to look up medical records,” and they should be issuing you with a username and a password.
Isabel: Okay. (Ringing the hospital)
Patrik: I’m pretty sure that if we keep trying, we will get through to them eventually. They might just be having a tea break. I’m sure we’ll get through to them eventually. Do you want to try-
Leon: So, in just what you’re seeing with these primary numbers and stuff, what do you…
Patrik: Life threatening. Life threatening.
Leon: Right.
Patrik: She won’t be able to sustain those numbers for long.
Leon: Right.
Isabel: Okay.
Leon: What adjustments can be done?
Patrik: I can’t see them making any adjustments, besides potentially trying one more… a nebulizer called Flolan or Epoprostenol. That might be an option. I do believe that proning would help her if she can tolerate that, but it sounds to me like she can’t tolerate it. They’ve tried that. If your mom was younger, but that is really hypothetical, if your mom was younger, ECMO would be an option. But ECMO usually cutoff is at 65, I’m afraid. Do you know what I mean by ECMO?
Isabel: Yes.
Leon: Yeah, yeah. We’re familiar with ECMO.
Isabel: We’ve asked about it before.
Patrik: Yeah. Unfortunately, the cutoff is at 65 years of age, rightly or wrongly. And the cutoff was at 65 before the pandemic, before COVID, and it’s still at 65 now, because the demand for ECMO with the pandemic has gone through the roof. And ECMO can be a lifesaver. There’s no guarantee.
But if proning doesn’t help, if nitric oxide doesn’t help, generally speaking, with ARDS (acute respiratory distress syndrome), you would be going on to ECMO as a next step. The challenge with ECMO as well is not every ICU is offering ECMO. It’s a very specialized treatment. They may have ECMO where she is. Probably look that up on the website. But I almost argue it’s irrelevant because of her age, unfortunately.
Leon: Is there a way to try to advocate for them to try it regardless, or is that kind of just up to their discretion?
Patrik: Look, I’m a big believer that everything in life is negotiable. I’m a big believer in that. What I will say is many COVID patients that end up in ICU end up with ARDS. And if ARDS is refractory to treatment, or to conventional treatment I should say, then the next step often is ECMO (extracorporeal membrane oxygenation). Right?
Leon: Right.
Patrik: In the current environment, what we are seeing is, I hate to say it, what we’re seeing in the current environment, only young patients get ECMO because it’s so limited. There’s only a limited number of machines. And also, even if there was a machine, you also need the staff that can operate those machines.
Isabel: Right.
Leon: Right.
Patrik: So, you need two things. You need a machine, and you need staff that can operate that machine. So, it’s a very… ICU is a specialized area, and that is even setting up ECMO, and then using the ECMO is, again, another specialist skill in and of itself.
Leon: What about other medications? Do you think that-
Patrik: Yeah. Other medications could be epoprostenol. Right? I do understand… excuse me. That’s the only other thing that I can think of at the moment. Your mom’s heart sounds like it’s been healthy before, is that correct?
Leon: Yeah. Right.
Patrik: Right. Because of that, sometimes when people have a little bit of heart failure, they’re often using Viagra. That can be used for treatment for ARDS. But it’s only really in combination with heart failure. And I can’t see that for your mom. Proning can be very effective, but I’m also well aware that she may not be able to tolerate it. One way for patients to tolerate proning is if they paralyze them. And it sounds to me like that has happened. It doesn’t quite add up to me that even though they paralyzed her, she still can’t tolerate proning.
Leon: That was at the other hospital, that I remember that they would tell me that she wouldn’t tolerate it. I don’t know if they did it while she was paralyzed. Because I know at the other hospital, they took it off. They took off the paralytic after some time. It was after maybe a few days.
Patrik: And she was proned during that time?
Leon: They would try to prone her, but then they would see how her oxygen saturation would go down, so they would just put her back on supine.
Patrik: Sure.
Leon: But I don’t know if they did that after they took off the paralytic, or if it was during the paralytic too.
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Patrik: Right, right. Okay. I tell you one of my most important questions in all of this is, I mean, you’re telling me you felt pressured to potentially agree to a withdrawal of treatment. The most important question to me is, are they doing everything they’re supposed to be doing? Now, they are by law, because you have not agreed to withdraw treatment. If they withdrew treatment without your consent, that is potentially murder. Simple as that.
But I also know how hospitals operate, and I know that sometimes they’re not quite playing by the rules. That’s why I would love to talk to them, to find out what they are doing, what are they potentially not doing? Do you know if she’s on any blood pressure medication?
Leon: I know they put it on back on today, on blood pressure medication to keep her blood pressure up.
Patrik: Okay, that’s good to hear, because that’s telling me they’re firing on all cylinders, which that’s what they’re supposed to be doing. And especially if she’s still on dialysis and they’re giving nitric oxide, I do believe they are firing on all cylinders. But have they considered, for example, epoprostenol as a treatment option?
Leon: And what is that medication?
Patrik: It’s a nebulizer. The easier name to remember is Flolan. F-L-O-L-A-N.
Leon: F-L-O-L-A-N?
Patrik: Yeah. What else? Was there anything else they said when you were last talking to them?
Isabel: No. I called for the updates. What I sent earlier, but Leon, I mean, what else did you…? Pretty much kind of this little downward spiral that she had recently. It began when they switched kidney dialysis from the CRRT, the continuous dialysis, to the conventional dialysis.
Patrik: Yeah.
Isabel: Just didn’t respond well to that.
Patrik: Right. Did she respond well to that?
Isabel: She didn’t.
Patrik: She didn’t. Okay.
Leon: Not to the conventional.
Isabel: Yeah. And they don’t have her on dialysis right now until tomorrow.
Patrik: Did they elaborate on that, in terms of not responding well? Did they elaborate on what that meant?
Leon: So, he didn’t really elaborate. He was just saying whenever the dialysis was done, when they took off the machine and everything, he saw that my mom was a little more stable. Her numbers weren’t going crazy. And he was like, “Okay, I guess she just didn’t like conventional dialysis.” Because they were doing the slow one. I don’t know what the name of that one is, but it’s the one that runs very slow and it’s 24 hours.
Patrik: CBHTF?
Isabel: Yeah, the CRRT or something.
Patrik: Oh, CRRT (continuous renal replacement therapy)?
Isabel: Yeah, that one, CRRT.
Leon: And so that he was going to put in a note for tomorrow, today now, today’s nurse practitioner and or doctor to potentially put them back on the CRRT dialysis machine instead of the conventional.
Patrik: Okay. Yeah. Well, one of the reasons it might be advantageous for them to keep the CRRT going, is simply anyone on a ventilator with high oxygen requirements needs a dry lung. And if they can remove fluids… now, let’s just say she’s fluid overloaded, and she might be fluid overloaded, one of the first lungs that does get fluid overloaded is the lungs. And it would not be a bad thing if part of her needing high oxygen is potentially fluid overload. Because if they can take off fluids, maybe then it’s salvageable. Right?
Isabel: I don’t remember if we mentioned, Patrik, that she had a… What is the name of that, Leon? The pneumothorax?
Patrik: Oh, pneumothorax?
Leon: Oh, the pneumothorax. She has chest tube.
Patrik: She does?
Leon: Yes.
Isabel: From the first hospital, yeah.
Patrik: And she still has that chest tube in?
Leon: Yes.
Patrik: Okay. Both sides or just one side?
Leon: Just one.
Isabel: The right lung. And the right lung on the x-rays is the one that’s the most inflamed, I guess is the-
Patrik: Right.
Isabel: … term, right? At that time, they had her at a PEEP of 16.
Leon: At the other hospital.
Patrik: I see.
Isabel: Continuously. Yeah.
Patrik: Do they think the PEEP (positive end expiratory pressure) caused the pneumothorax?
Isabel: They didn’t say that. The second hospital said that they like to keep it at 8, is what they started her on.
Patrik: Yeah.
Leon: 10. 10.
Isabel: To prevent things like that from happening. 10. 10.
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Patrik: Right. Well, with ARDS, it is often running at a PEEP of above 10, very often. But it depends a little bit. At the moment, I think all you need to focus on, I believe, is obviously what’s happening with the lungs, what’s happening with her blood pressure, and what’s happening with the kidneys. They’re probably the most important things at the moment, because all systems are dependent on each other.
If her blood pressure is stable and the kidney machine is going and it’s working, then hopefully it’s, “only the lungs,” and hopefully they can rectify that. If there’s more than one system failing, let’s just say the heart would be failing too, and the kidneys would be failing, and they can’t operate the dialysis machine for whatever reason, that’s when it could become even more tricky.
Leon: Okay.
Patrik: Has she had blood transfusions in recent days?
Leon: No, not that I know of.
Patrik: Okay. All right. Do you want to try ringing them again?
Isabel: Yeah, I’m trying them right now.
Patrik: Yeah. Yeah.
Leon: What is your take on Ivermectin?
Patrik: Look, I’ll tell you what my take on Ivermectin is. I don’t know enough about the drug, but what I do see as a bigger picture, is there are pharmaceutical interests that go way beyond what might be in the best interest of a patient. And you can interpret that in any way you want, what I just said.
Isabel: (Phone ringing) Hello…
Patrik: But what I do believe is that the system, to a degree, is corrupted.
The 1:1 consulting session will continue in next week’s episode.
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- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!