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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 one of my clients and the first question from Richard in last week’s episode was
You can check out last week’s question by clicking on the link here.
In this week’s part 3 episode of “YOUR QUESTIONS ANSWERED“, I want to answer the questions from one my clients RICHARD as part of my 1:1 consulting and advocacy service!
Richard’s mother suffered from a fractured bone due to a fall. His mother was then transferred to the ICU due to cardiac arrest and had a tracheostomy during her stay in the ICU.
In today’s episode I’m actually going to talk to the treating doctor of my client’s mother and you can see what I found out while talking to him in the dialogue below.
My mother in the ICU is unable to come off the ventilator. Is giving sedation and doing a tracheostomy going to help her?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Richard here.”
Patrik: Hi, Dr. Zahir. My name is Patrik, I’m calling in regards to Michaela Zonn, I believe you’re aware that Richard, her son, wanted me to talk to you. They’ve been very concerned in the last few days, and they’ve been talking to me on and off over the last few days. I’m just trying to get sort of an understanding of what’s been happening with her. I believe she could be in an end-of-life situation, I guess, from their perspective. They’re not medical people. I’m an intensive care nurse by background.
Dr. Smolensk: Oh you’re working in intensive care?
Patrik: I do, I do. I’m just trying to find out what’s been happening. It doesn’t sound to me like they can make any sense out of the situation. I’m trying to find out what is happening. Is she dying? What’s the situation?
Dr. Smolensk: Okay. Now, I’m sure they must have told you about her condition. She’s about 85-86 years of age with multiple comorbidities, and her background quality of life was not very good. She was dependent on home oxygen. She came into us, we didn’t have any advanced therapy, so she was fully resuscitated, everything went, and she established her circulation and all things happened, and then moved to ICU.
Now she was ventilated. An acute kidney injury happened and she’s known case of atrial fibrillation and chronic issues. Subsequently, liver damage was also there.
So it was very difficult to wean her off ventilation. Partly because of the initial sepsis and septic shock and then subsequently because of the background lung condition developed at her age.
So at this stage … Subsequently several attempts were done. Several attempts were made for weaning, which failed. Then she was subject to tracheostomy and she continues to require significant ventilatory support. There was a period where her requirement for ventilatory support was relatively less, but she never reached a stage that she could be weaned off the ventilator.
So she is sort of waxing and waning course, sometimes her sepsis was corrected and then again re-occurrence of sepsis and all those things. It’s almost 30-31 days now and the general view among the doctors and nurses were that probably she has come to a stage where any further meaningful progress will be … is not expected. So we were of the opinion that we should now try to keep her comfortable. So we were not thinking in terms of switching off the ventilator or withdrawing support. That is not the idea. We’re thinking that we’ll let the nature take its course.
Yesterday Richard and his wife was there who herself is quite elderly and she was using something to assist in walking. So all three of them were there. Myself and our palliative care physician who was involved and the treating physician. So they were trying to explain what has happened, what was the expectation, and how to proceed with that. So that was our conversation yesterday.
Richard had a few worries and questions, so I think we tried to answer his questions. So that was the scenario.
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Patrik: So if I may just ask, you’re saying obviously she’s not improving, you think she can’t come off the ventilator, so you’re also suggesting she’s not for any withdrawal of life support but you on the other hand wouldn’t escalate any support either.
Dr. Smolensk: I mean for example; this is what the physician under whom she was admitted … She was of the view that there’s no point in, for example if she starts dropping her blood pressure or she goes into cardiac arrest, so will it be wise to do all those measures of cardiopulmonary resuscitation and CPR and all those things, given all totality of the picture. So that is what she had spoken to Richard, also made a note in the file that it would be a futile effort to try to resuscitate at that stage.
Patrik: I understand all of that and I’ve seen those situations many times. I guess where I’m getting a little bit confused and probably where I need clarity … You know there’s one way to not escalate treatment and let nature take its course. Now when I spoke to Richard just this morning, my understanding is she is now on a morphine and midazolam infusion. That to me goes in the other direction in terms of … That to me is active palliative care, which means the minute you take her off the ventilator, depending on how much morphine and midazolam she’s off, she’s probably going to pass away very quickly because she would probably suffocate.
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Dr. Smolensk: Well we don’t plan to take her off the ventilator, we’ll let it continue. The idea was to keep her as comfortable as we can.
Patrik: So you would then consider waking her up again when she’s more stable? Why is she getting morphine and midazolam at the moment? Is there a need to sedate her?
Dr. Smolensk: When patient is on ventilator doctors try to sedate the patient.
Patrik: Not with a tracheostomy necessarily. With a breathing tube, definitely.
Dr. Smolensk: True, true, true. So the idea was that if you leave her on, try to let her breathe spontaneously … because her volumes are too low and probably she makes a harder effort to breathe and also that is not good for her nor good to the onlookers, the family members.
Patrik: Agreed.
Dr. Smolensk: They feel that she is in distress. So for that reason we need to have some amount of sedation on board. And she has got lines, tubes, catheters, all those things so there will be a certain amount of pain as well.
Patrik: Sure.
Dr. Smolensk: So we try to give painkillers and a certain amount of sedation. Normally when we are trying to wean the person off we regularly give other opiates. So generally we prefer to use remifentanil where we can have a quicker … when we are trying to wean the person off the ventilators, then we can switch off and we can give her trial of breathing and trial of weaning. If we succeed, fine, otherwise we can recommence the remifentanil. But when we don’t expect … She hasn’t come to a stage where … As of now she is not even ready for giving a trial of spontaneous breathing.
Patrik: Okay.
Dr. Smolensk: So that means we are not expecting that in next one or two or three days’ time we’ll be able to extubate her. So in that case, choice of painkiller and sedation may change, say for example we don’t have that urgent need of having ultra-short-acting painkillers on board because she’s not going to wake up and start breathing on her own.
Patrik: Sure.
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Dr. Smolensk: In that case we switch over to morphine instead of remifentanil. I’m sure you must be, where you’re working remifentanil must be in use.
Patrik: Oh absolutely, absolutely. So the morphine and the midazolam has not been started with a view of palliation, because that’s where I’m getting confused.
Dr. Smolensk: Look, palliation … People have certain wrong notions about palliation. That does not mean that person is yet facilitating death. That is not the idea.
Patrik: Okay.
Dr. Smolensk: The idea is to keep the person and the relatives comfortable when we know … It can happen in a much relatively healthier person who’s walking around. He can also be a part of the palliative care. We do have a palliative care where patients are there for years. They keep coming to the palliative unit.
But in this situation it is very … what you have just described earlier, end-of-life situation. And that also, the palliative team gets involved to make the process as comfortable as possible, both for the patient as well as the family. To help them come to terms.
Patrik: Mm-hmm (affirmative). I guess another concern was that, my understanding is she was out of bed a few days ago, she was mobilized regularly. What sort of-
Dr. Smolensk: That is … Right, right, right. All the time, in any ICUs the idea is to keep making an effort for weaning off the ventilation.
Patrik: Absolutely.
Dr. Smolensk: The idea is on our minds right after the intubation and ventilation. So we start thinking when we can do the extubation as early as we can. And that mobilization, physiotherapy, that is part and parcel of the whole process.
Patrik: Of course, of course.
Dr. Smolensk: The physiotherapist should get involved in helping her in quite early, even when the patient is lying in full ventilation or patient is on support, supported ventilation that is ventilation may be inadequate and it requires a little bit of ventilatory support at that state. And at that state we prefer that if he can safely make the person sit on the chair that will help breathing, both in terms of patient weaning as well as physiotherapy.
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Patrik: Absolutely. But how can you tell?
Dr. Smolensk: That’s all part and parcel of the process of making patient better.
Patrik: Absolutely. But how can she go??..
Dr. Smolensk: And that process it was tried but she was not off ventilation.
Patrik: Of course.
Dr. Smolensk: She was made to sit and it was quite a cumbersome … I don’t know … Have you seen her lately? When have you seen her last?
Patrik: I haven’t seen … I’m in Melbourne, Australia. I haven’t seen her. I’m just talking through the phone.
Dr. Smolensk: All right, so you haven’t seen her last few years.
Patrik: No.
Dr. Smolensk: She’s quite an elderly lady and one complicating thing was she’s quite an obese lady.
Patrik: I know that.
Dr. Smolensk: With leg ulcers.
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Patrik: I understand that, but how can she go??..
Dr. Smolensk: It was an extra burden on the physiotherapist to do all those things. And they did it a wonderful job in helping her sit out doing all those things and they did all that wonderful jobs.
Patrik: But how can she go from mobilization in two days back to morphine and midazolam? How can that happen? Did she catch an infection? What-
Dr. Smolensk: I just explained to you that we… I just explained to you that choice of painkillers and opiates can vary at the different stage of the disease process. Okay? So when we expect person that will be waking up soon we use remifentanil, it’s an ultra-short-acting opiate.
Patrik: Sure. Yeah.
Dr. Smolensk: So when we don’t expect that the person will be awake next day and start breathing and sitting and walking, then we can switch over to morphine or whatever the choice can be. Now secondly let me tell you what the general impression is, that despite massive efforts on everybody’s part, she has not responded as well as we would like her to in the last 30 days.
Patrik: Mm-hmm (affirmative).
Dr. Smolensk: And what are our expectations that what is happening, given the background of her condition, back condition, heart condition, her weight, her age, her ulcers. I was seeing yesterday in her file that ulcer problems is going on for several years and they have not been able to cure her ulcers. And she’s on regular antibiotics. So if the body has not been able to rectify all of these and after this episode of her current illness, which was quite a significant one, so that is after 30 days of strenuous involvement on everybody’s part, she’s not responding favorably.
Patrik: Mm-hmm (affirmative). Okay. That … understand. Understand.
Dr. Smolensk: The treating physician had thought that she may not … and all these activities, if these things happen if she further deteriorates, will it be wise to escalate-
Patrik: Mm-hmm (affirmative). I understand all of that. Have you asked her about her wishes?
Dr. Smolensk: Now her wishes … I really … We should have had, I think in Australia you do have, advance directives and in America, but here we don’t have those type of things, advance directives for each patient, particularly elderly patients. So I don’t think there was any advance directive.
Patrik: Not that I’m aware of.
Dr. Smolensk: The nursing staff when she was relatively sort of more cognitively aware and able to respond by gestures and nodding … So from that, not one but two, three, four people got an impression that she is now fed up and she was conveying in a way, whether they are taking this rightly or wrongly I don’t know … That she’s conveying that she doesn’t want any further treatment to escalate.
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Patrik: Mm-hmm (affirmative).
Dr. Smolensk: And that was the impression of the treating physician as well.
Patrik: Sure, sure.
Dr. Smolensk: That was the impression of more than one nurses I spoke to. Now at one stage earlier was saying when we were trying to make her sit on the chair as a part of our management, physiotherapy, at that stage the sedation was reduced significantly and that is what the idea is. Of course if you’re working in the ICU you know that we do have sort of sedation holiday, early morning we stop try to wake up the patient and at the same time keep them comfortable.
So during that stages when she was able to sit, with minimal sedation or no sedation, at that stage the nursing staff got the impression that she conveyed in that way.
Patrik: Okay. Okay. Look, that…
Dr. Smolensk: She wouldn’t speak.
Patrik: That’s fine, that’s fine. I understand where you are sitting and that’s all I needed to know for now in terms of what’s happening. I understand how you’ve made the decisions that you’ve made, I understand that. Whether I agree with them or not that’s a different story, but I understand how you’ve made the decisions. And I think I can explain it to Richard and Heather in terms of … Because I think that’s where they get lost…
Dr. Smolensk: Yes … They will feel, the son Richard will feel better if it comes from the family. I think you can appreciate and understand what would happen. Probably, in Australia, would you be ventilating such a person for that long? I don’t know. But if you understand what this has actually … If you can imagine what the actual situation of your aunt is and what are the expectations. Then if you convey to Richard that will give him much relief.
Patrik: I think where … I understand what you’re trying to achieve. I think what was Richard’s main concern was really sort of a belief … They felt like things hadn’t been explained to them properly. And again I can’t talk about that because I’m not there. It’s just how they feel I think. And I’m not in a position to change the feeling for now.
I guess they feel sort of a lack of transparency, lack of communication potentially with my aunt in terms of okay, what … And maybe she wants that but … Maybe she wasn’t in a position to properly communicate that. I guess that’s sort of where they feel, yes maybe it is the right decision but how has that been communicated, was she in support of that … I guess it’s around the communication. I guess … They can accept that at 86 she may die. I think they can accept that. I don’t think that’s the problem. I think the problem as far as I can see is how the team may have gone about it. I think that’s the main concern.
I think people accept end of life. I don’t think that’s a problem if it’s approached in the right way. And it’s never an easy conversation to have of course.
Dr. Smolensk: I know… It is very difficult to understand for a person who’s not medically oriented. And it further complicates … because people can get scattered information on the internet.
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Patrik: For sure, for sure.
Dr. Smolensk: One thing which … They see it from very narrow perspective. But whether that information is right … No doubt the information available on the internet is right generally, but how to translate that information into a real situation, sometimes people find it difficult.
Patrik: It’s never easy. It’s never easy.
Look I really appreciate your time and your explanations. So I’ll have a chat to Richard and see what I can tell him. I really appreciate you taking my call.
Dr. Smolensk: Yes. No it’s … Thank you very much.
Patrik: Thank you very much. Bye-bye.
Dr. Smolensk: I hope he will have appreciate … Because let me tell you here in this hospital ICU, I can say with clarity and with confidence that the nursing staff has been wonderful, both in terms of their professional abilities and as human beings as well. So generally they are very gentle, not only to the patients and to the relatives as well in general.
Patrik: Look, as I said I have not been there, I have not worked there, I’m not … I don’t want to question your integrity or the nursing staff. You know, I think it’s all about the feeling that they have-
Dr. Smolensk: Exactly.
Patrik: You know it’s never easy and-
Dr. Smolensk: True. Probably he will, they will feel much better if the explanation and description comes from your side, they will feel much at ease.
Patrik: Hopefully, hopefully. Okay. Thank you so much for your time I really appreciate you taking my call. Thank you. Bye-bye.
Dr. Smolensk: Bye.
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 to stop being intimidated by the Intensive Care team and how you will be seen as equals
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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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