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 in this series of questions from my client Veronica and the question last week was PART 5 of
You can check out last week’s episode by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to answer the next question from one of my clients Veronica, which are excerpts from phone and email counselling and consulting sessions with me and the question this week is
My Dad (71) is in ICU with stage 4 lung cancer & stroke, he’s on the ventilator now and in an induced coma, what are his chances of survival? (PART 6)
In the previous episode, I advised Veronica around how she should talk to the ICU consultant about her Dad’s treatment, the steroids in particular, as initially the ICU consultant was reluctant to give her Dad special treatment. In today’s counselling and consulting session, we talk about her Dad still being in an induced coma and we talk about whether a tracheostomy would be the right next step. Please see the dialogue below
Patrik: And, if for whatever reason he deteriorates, then the question needs to be raised, are we putting the breathing tube back in? If we do put it back in, the next logical step would be a tracheostomy. Okay? So, you know they’re all saying he’s not well enough for that, okay, well let’s take the breathing tube out and see what happens. Now, next question is do you know whether he’s still on the noradrenaline?
Veronica: The noradrenaline.
Patrik: The inotropes/vasopressors for low blood pressure.
Veronica: Oh okay. No, I’ll be honest.
Patrik: That’s okay. That’s okay.
Veronica: I don’t know.
Patrik: It’s not going to make or break, you know, what’s going to happen next but it may be something you can find out tomorrow. Do you know what sedation he’s on besides the Fentanyl? Is it still Propofol?
Veronica: Yes, he’s just on Propofol. Yes, 20 the whole time now, 20. And, tried for a few days of 15, but he’s teary all the time and so they, yeah.
Patrik: Okay, so 20. Do you know whether that’s 20 mls an hour or 20 milligrams an hour, do you know? Can you see on the screen, when you are at the bedside, can you-
Veronica: When I’m at the back of it? On the back of it, it’s got 20 on the screen.
Patrik: Okay, that’s good. So then, it’s actually 200 milligrams an hour. That’s okay. That’s a normal dose for an adult, nothing unusual.
Veronica: They’ve said he’s gotten so used to it…
Patrik: Yeah. And, he’s breathing by himself with obviously the support of the ventilator.
Veronica: With the support of the ventilator, and they’ve got that turned up to 50.
Veronica: 50%, yes.
Patrik: Okay, and you know, that he’s breathing by himself, I think that’s pretty good. And, do you know how much Fentanyl he’s on?
Veronica: They’ve just taken that off, but he was on Fentanyl two to three times-
Patrik: Two mls?
Veronica: No, I don’t know the dose, sorry, but they were giving it to him two to three times in the day and night.
Patrik: Oh, I see so-
Veronica: Only when he was showing signs of-
Veronica: … of discomfort, yes. And, usually it was because his heart rate was going up a lot. And, they actually didn’t pick it because he kept saying, “No, I’m not in pain,” but they said he was wincing and his heart rate was going up, and it was, it really was.
Patrik: Yeah, and are you saying that your dad is responding to questions like are you in pain, he’s responding to that?
Veronica: Yes, but we don’t really trust what he’s saying because he’s not, it’s not really consistent a lot of the time.
Patrik: Okay, no that’s fair enough. And, are you under the impression that he’s recognising you and your family when you’re there?
Veronica: He’s definitely recognising me, yes.
Patrik: Good, that’s all good. Okay, so I guess the question needs to be raised, if they do want to take the breathing tube out, again, which I think overall there’s some positive today, you know, he’s breathing by himself. He’s off the Fentanyl now. He’s at least responding to simple questions, let’s put it that way. You know, that’s all positive I would say. And, 200 of Propofol, how heavy is your dad? Roughly?
Veronica: He’s 73 kilos(=11.5 stone), but I reckon he’s gone down to at least 60(11.4) something now.
Patrik: Okay, because you know that’s okay. I mean, 200 or 20 of Propofol is sort of a fairly high dose, but again it’s nothing unusual in ICU because once you take Propofol people wake up relatively quickly and as long as he’s still responding it’s not too high, you know, it’s not too high of a dose. So, the question really needs to be raised, take the breathing tube out, yup, I think that’s a good step irrespective of what’s happening in the lungs. We know that the picture they’re painting there is not all that great.
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Patrik: But, the question still needs to be raised, if you do take the breathing tube out and he can’t breathe by himself and the mask doesn’t work and the blood gases deteriorate, then the question needs to be raised what are the next steps? And, especially in light of the meeting tomorrow, I think you should be clear on what you want if that’s the case. Because, otherwise they will make the decision for you.
Patrik: And, the question is then as well, so with the tracheostomy, do you have any idea what it’s doing, what it’s not doing?
Veronica: So far, from what the specialist said, from what the ICU doctor said, is dad would not be a candidate for it because of the amount of damage that there is from the CT scan, how fast he’s deteriorated from the third of April to the CT scan.
Veronica: And, that’s why he needs to consult with the cancer doctor, whether he thinks it’s actually the damage or whether he thinks the cancer spread that fast.
Patrik: Sure, sure. Look, okay well that’s his point of view and he’s entitled to that point of view. I still think you should know what a tracheostomy, what it can and what it can’t do, right? What a tracheostomy could definitely do is it could prolong your dad’s life, okay? If they take out the breathing tube and the mask doesn’t work, you know, depending on what you decide, you know, nature might as well take it’s course, right? A tracheostomy will enable your dad to stay on the ventilator, right, let’s just say indefinitely, not indefinitely but for prolonged periods.
Patrik: So, you know a tracheostomy won’t be a cure, but it certainly can be a facilitator to keep your dad alive for longer if that’s something you, your dad, your mom would consider.
Veronica: But, would he stay in the hospital with that?
Patrik: Not necessarily, but that would be another, you know, that would be another conversation to have. I guess for now, and the reason I’m saying that you know, and I don’t want to go overboard with this. The reason I’m saying he doesn’t have to necessarily stay in the hospital that what I’m doing as well here in Melbourne, I’ve got an in-home nursing service INTENSIVE CARE AT HOME and we’re providing tracheostomy and ventilator care at home. In essence we are providing a quality and genuine alternative to a long-term stay in Intensive Care for ventilator dependent adults& children. We are also providing palliative care at home for Intensive Care Patients. For more information have a look at https://intensivecareathome.com
Patrik: But, that would be for a whole other discussion. So, a tracheostomy can definitely prolong your dad’s life, but it won’t be a cure. The other thing that we brought up last week, you know, there are always gonna be negatives, and I’m not saying they’re wrong, but they may not be right. You know, they’ve always got the doom and gloom. They’re never going to tell you, “Yup, we’re going to cure your dad.” You’re never going to hear that
Veronica: No, no. And, he said that anyway. He said I don’t know what it is that we’re looking at from that scan. He said, could be one of three things, and we don’t even know how long that in itself is going to, you know, how much time your dad has left basically.
Patrik: That’s right. That’s right.
Veronica: He said we could actually, you know, there’s a possibility that dad might make it home. But, he said we don’t know. We definitely don’t know, but keeping him sedated like this is actually gonna make him worse in the long run.
Patrik: Yes, sedation and not “waking up” after the induced coma or even keeping him in the induced coma will not get him to where he needs to go. As long as he stays sedated he won’t get off the ventilator and extubated(=removal of the breathing tube)
Veronica: Let’s get this tube out while we still can he said.
Patrik: Right, right. And again, I think taking the tube out if he can, I think that’s great. I just think you need to be clear on what you want, or hopefully your dad is awake enough and makes-
Veronica: What is the next step?
Patrik: That’s exactly right. That’s exactly right.
Veronica: If he deteriorates.
Patrik: Exactly, and that’s why I think it’s important to find out tomorrow, as well, whether he’s still on inotropes/vasopressors, the noradrenaline/norepinephrine, because there are two major forms of life support. Number one is ventilation. Number two is the inotropes. And, if for whatever reason, and it doesn’t sound to me like he would be on a lot of noradrenaline because he probably wouldn’t take the tube out or wouldn’t consider taking the tube out if your dad was still on a lot of noradrenaline cause that would be another risk factor.
Patrik: Just, and kidneys are still working? There’s no issues there?
Veronica: No, I asked all about that they said they’re producing a little bit less, but they’re still not worried about them at all. They said, yeah, I asked them that again tonight. Yes?
Patrik: Anymore talk about the heart?
Veronica: Not at all, nothing about the heart now. But, what I have noticed is when dad was on the Fentanyl, his heart rate was really high, and as soon as they took it off him today it went down to 77. But, before oh my goodness, for the last two days it was a lot higher.
Veronica: It was like in the 90s.
Patrik: And, you’re saying he’s coming off Fentanyl and his heart rate is going down?
Patrik: Right. That’s kind of unusual.
Veronica: Yeah, and I noticed when they were giving him the Fentanyl on the weekend his heart rate was up, and I don’t know if it was just cause it was wearing off or whether they were just giving it to him, I don’t know. Whether it was the nursing staff, I don’t know, maybe he didn’t like the nursing staff that was looking after him. I wasn’t too impressed with them either. But, he was not as happy and it was on the weekend that they started to introduce quite a lot of the Fentanyl because they kept saying he’s wincing and he’s in pain.
Patrik: Did you, what was your judgement ?
Veronica: Well, they weren’t too happy with me sort of-
Veronica: Asking, touching dad, talking to dad. They just said can you please just sit here and hold his hand? They really didn’t want me. Yeah, they were very different. They were very stern, not that I have anything against anyone, but they were both Hindu, both the girls, and they just said, “Look, if you touch him, if you stroke his hand, if you stroke his face, if you do anything it distresses him. Don’t touch him. Just hold his hand.”
Patrik: Yeah, that’s terrible, typical ICU nurses. It’s terrible.
Veronica: Whereas the other nurses have been completely fine and yeah. He was uncomfortable, and I asked them to move him because his head was all slumped forward. I said, “Can you please adjust him?” And, then when they adjusted him one of his monitors came off, and they blamed me for it.
Patrik: Oh my goodness, that’s just bad.
Veronica: So, no and I’m sort of thinking maybe dad doesn’t really like them.
Patrik: Oh, look I mean no matter if patients are in a coma or not, they can certainly recognise the nuances of whether somebody’s providing good care or not.
Look out for the next counselling and consulting session in a few days, where Veronica and I continue to talk about her Dad’s situation and whether a tracheostomy will be the right next step or whether her and her family need prepare themselves for and end of life situation.
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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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