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 question in last week’s episode was
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 the next questions from one of my clients Natasha stating that the DNR has been issued to her Dad without the family’s consent, winding down life support leading to her Dad’s eventual death.
The ICU team issued a DNR to my Dad without our consent, slowly winding down life support! Is this murder?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Natasha here.”
Patrik: That would have been the conversation that would have been going on during their board rounds. That could have well been that even on admission, somebody might have thought, “Oh, maybe it’s best if we’re not using the Zosyn and well maybe it’s best if we’re not going full steam ahead.” And maybe down the line they were thinking, “Maybe it’s best if we’re not using any Fluconazole to treat the yeast.” Having said all of that, this is where I believe there is also a leverage point. We can’t turn the tide back, your dad unfortunately is not here anymore. But here is where I think there is some leverage. Now, we’ve talked about this there was no DNR.
Natasha: No. Listen to what happened, though. My sister, she did not read the doctor’s progress report when he came in around six … What time did he come in? … I don’t remember, it was 6:30ish or something. When he came in, she didn’t read … Usually, I start typing something on the subject line that’s a part of the body of my email. And you know she’s a doctor, she’s a very smart doctor — she went to excellent schools. I started typing on the subject line but she didn’t see that. All she saw was, “Confirmed placement with endoscope, tube in adequate location, continue to bag patient.” Blah, blah, blah. Then I sent her the actual screen shot, I did a screen shot of the PDF. It actually reads, “Call to see patient regarding hypoxia. Chest x-ray showed ETT high – pushed in ETT and confirmed placement with Ambu Scope – Tube in adequate location.”
He actually pushed it in, it wasn’t pushed in. Then she kind of got all weird because that’s not what happened. He didn’t tell us that he pushed anything in. He just said that it was in place. He just said that it was in place, that there was nothing wrong with it, right? And then she also did a comment that before he actually did that, the nurse and the patient care technician, Patrik, they were taking an obscenely long time to change my dad’s diaper.
Patrik: Why …
Natasha: He shouldn’t even have diaper in ICU.
Patrik: No, no.
Natasha: He’s supposed to have a diaper sheet underneath him.
Natasha: They put an actual diaper on him, Patrik.
Patrik: So inhumane.
Natasha: Yes. You are not supposed to do that and I know that because my dad’s been in two other ICUs. They put a diaper on him, okay? Two other times they put a towel on his penis and a cloth. They’re disgusting, right? You’re not supposed to do that in ICU. Put a diaper, right? You’re not. You put the diaper..
Patrik: I certainly don’t do that because I think it’s inhumane. I think it’s humiliating, I think it’s a disgrace. There are some nurses who do that. I think it’s an absolute disgrace. It’s just humiliating.
Natasha: Also, when you have a pressure ulcer it’s worse to do that. You can’t-
Patrik: Absolutely. Makes pressure sores worse.
Natasha: Even at the regular floors at the two other hospitals … The hospital in New Jersey I keep telling you about, Hackensack University Medical Center, even in the regular floors they would not put a diaper on him. They just put that pad underneath him, the diaper pad. Because they’re like, “Oh, it’s not good for the skin.” He can do that in a nursing home but in the hospital we just like to take extra precautions. So, my sister said that maybe the nurse dislodged the mucus plug or something.
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Patrik: Could be.
Natasha: And that’s why that happened. It literally took them 25 minutes to just change his diaper. They didn’t have all the supplies, they were laughing and giggling. She did something, she was so careless. This was a nurse that wouldn’t wear gloves, she had these long fingernails, she would touch my dad’s IV. They didn’t give a shit, Patrik. They didn’t give a shit about my dad.
Patrik: When they were changing the diapers, you were waiting outside of the bedside or the cubicle?
Patrik: Okay, and you could hear the conversation?
Natasha: Yeah. I was on my chair with my laptop right by the glass door, I was just waiting there. “Ahaha”, they’re just laughing and taking their time going to the room to get the clean linens. Just really an obscene amount of time to change him. You should do it in five minutes and just boom, boom, boom and that’s it.
Patrik: Okay, look you should do it in five minutes. I can tell you that I’ve changed patients where it took half an hour and simply the reason for that is number one if they’re had large bowel movements. It can take time to clean that up. That might have been the case. Just to put some perspective around that.
Natasha: The time that they were talking, the way that they were acting … It was just so … Not having all of your supplies and I’m gonna tell you this, Patrik, that CCU, there was like nobody there. There was only like three patients in the whole CCU. It can hold up to, I think about, 13 or 15 beds. Like 15 people. There was only like three people. So, it wasn’t busy when my dad was there. Yeah.
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Patrik: Right. Two questions or two things. As I mentioned to you before, once they’ve … You know, you keep talking about that the ET tube position has been confirmed with a fluoroscope which is basically with a bronchoscope but I can tell you that even that … Again, after a bronchoscopy or after the ET tube has been moved, there needs to be a follow-up chest x-ray so we can confidently tick that box.
Natasha: Yeah. That’s what I thought.
Patrik: Here is another question. With that three patients in that CCU, do you know what your dad’s nurse to patient ratio was? By that I mean, do you know whether he had one on one nursing 24 hours a day, or it was one to two nursing? You know what I’m asking, there?
Natasha: So, I think that day maybe they got a couple more patients. But throughout his stay, it was as low as three and maybe as high as six. That night, I think that that nurse only had my dad and then there was another patient, I think he came … I think she was sharing a patient with somebody else. She helped out somebody with something. I saw her go over to another patient but she was rarely ever going there. And I talked to that patient — that patient was up. He was actually talking and eating by mouth. He was like, “Can you get me some tissue?” My dad was literally the most critical. That’s how I felt. Out of everybody there. Sometimes there would be … She had like two nurses on my dad. They were just not really …
Natasha: Not all the time. To help out if they couldn’t do something. They couldn’t draw blood for the life of them. I don’t know. They couldn’t do that and stuff like that.
Patrik: Sounds horrible. It sounds like you’ve had a really bad experience. On top of that whole bad experience with staff, your dad passed away. That’s the worst sort of possible outcome you can have, really.
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Natasha: The way they treated him, the way they just acted like he never …
Patrik: Coming back to those chest x-ray that are missing, do you think they haven’t done those x-rays or do you think they just haven’t put the x-ray results into the documents? What’s your feeling?
Natasha: I have a feeling they didn’t put them into the documents, because I-
Patrik: You think they have been done but they just haven’t put it in?
Patrik: That would be my feeling, too. And the reason I’m saying that, as I said, ICU patients who are ventilated and are very critical, they tend to have daily chest x-rays and also that, I hate to say it, it’s money-making for them.
Natasha: What I’m concerned about is how can the chest … If he has a chest x-ray then on the 6th, how can he legitimately say there’s no pleural effusion and then … Do you know what I’m saying? It’s kind of like …
Patrik: Yeah. Look, I don’t know how he can say it. Maybe there wasn’t an effusion. I don’t know. We would have to look at the x-rays.
Natasha: Yeah. Covered it up, the clouds. I don’t know.
Patrik: It also depends on how big was this effusion when it first showed up. Right?
Patrik: Was it an old effusion, was it a big one? It’s hard to say, without looking at the report or seeing the x-ray film.
Natasha: Then it starts making me think maybe is that why they never did a CAT scan because … I don’t know.
Patrik: Quickly going back, there was no DNR? There was no do not resuscitate? It was never point of discussion, was it? It was in the end, I believe, but there’s no document that you have seen that he was DNR?
Natasha: Not until that doctor came at 6:35, or whatever, and when all that stuff happened. The timing is weird, though. Because, I could have sworn that they stopped working on him around like 6:47 but then it’s documented at … It seems like it was earlier that they put a DNR. Maybe they just retroactively put it in? I don’t know. In the notes or something.
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Patrik: Have you seen a DNR in the notes?
Natasha: Yeah. Towards the end, that last day.
Patrik: Okay. Here’s another leverage point. With that DNR, do you remember what it says? Is there a section where you would have to sign as next of kin, as medical power of attorney?
Natasha: No, it was literally the day that he was dying — that morning.
Patrik: Well, yeah. I understand that.
Natasha: Oh my god, though. Wait, though. It was right at that moment when he came. That’s the thing that’s weird. Do not … Okay, no, go ahead. Continue.
Patrik: Before I continue, what would be good to know … When was that DNR issued? On the last day or on admission or somewhere halfway through?
Natasha: No, the last day.
Patrik: Okay. Did you know at the time that it was issued?
Patrik: Okay, that’s more than enough information to tell you where I believe this is going. A DNR, number one, with issuing or even discussing a DNR, they need to follow policies and procedures. And the hospital or the ICU would have a policy or procedure around how to issue a DNR. And I can tell you, from experience, that this policy would say something along the lines of, “If we think a DNR is in the best interest of the patient, or needs to be discussed, we need to sit down with the family and we need to give consent.” We need to get consent from the family. Okay? Now, that’s the theory and that’s the policies and procedures. That’s the theory. In practice, this is what happens; doctors are writing out DNRs because they think that it’s “in the best interest of the patient” to let them die. Now that, as far as I’m concerned, is murder.
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Natasha: See, this is the thing. It’s right when a doctor came, the note was made when the doctor came.
Patrik: But they didn’t tell you, did they?
Natasha: No, they didn’t. Not at that time.
Patrik: Let’s put this in a different frame, for a moment. So I think-
Natasha: No, it’s wrong! It’s wrong. Exactly.
Patrik: It’s completely wrong.
Natasha: I just don’t know when he had that time … Did they go back … Did they do it pre-emptive … Did he just put it in, right before he came into the room? I thought he just came into the room. I don’t remember him going to the nurse’s station and writing something down or …
Patrik: Doesn’t matter. It’s the principle. They’re not informing you to make a life or death decision. Right? And I …
Natasha: He didn’t, because he didn’t tell me …
Patrik: That’s right. That’s what’s happening across the board. They’re not transparent what’s happening in the last 24 hours or sometimes 48 hours, before a patient is dying. Because basically what’s happening is, and it happens nine times out of ten, they issue a DNR without informing the family. And they’re slowly but surely winding down life support without … You wouldn’t see … I would see straight away, what’s happening because I’ve seen it over and over again. Right?
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Natasha: You would have known.
Patrik: As far as I’m concerned, this is murder. The patient might well die but if you are winding down life support and you’re not telling the family, that is highly questionable.
Natasha: That’s the thing. It’s like it was issued right when he came. Not when me and my sister decide okay, let’s just take him off because they can’t do anything else, he’s dying.
Patrik: DNRs have their time and their place. If it’s openly, transparently and mutually agreed upon. Then they have their time and their place. By doing what they’re doing, they’re doing what other ICUs are doing, too, and I believe it’s shocking. Some families don’t even know that this exists.
Natasha: Yeah, I got really confused with timing. I was like, “What happened?” I was like, “No, that’s not what-” Yeah.
Patrik: Here is what you can do. It looks to me like you might get in touch with the hospital anyway, because you think there are some chest x-ray films missing. You can also ask them for their DNR policy. I would probably put that in writing. I don’t know how you went about getting the medical records. Whether you had to put that in writing or whether it was just a simple phone call. You may have to state in writing what you exactly want.
Natasha: Yeah, they usually want you to do that. Medical records would have them. Yeah, they have that.
Patrik: What you may want to do as well is … They also must have a policy in the ICU around when an ET tube is moved, what we discussed before, there must be a policy around that, too. Whether they need to follow-up with a chest x-ray or not. They must have a..
Natasha: I’ve been looking at the notes, his chart. From what I’m seeing, apparently, they’ve been doing the auscultation capnometry. I don’t know when they’ve been doing this stuff. I’ve been with him 24 hours. Unless it’s that cuff, if the capnometry, is that on the cuff? I’ve never seen them bring any equipment to check to see if his ETT tube is in the right place. They have something with the auscultation. Is it auscultation? Is that how you say it? Auscultation.
Patrik: Yeah, you said it but it doesn’t make sense that they would use an oscillator on your dad, unless …
Natasha: Auscultation bilateral breath?
Patrik: Just remind me, he was on a study, wasn’t he? What was that study again?
Natasha: Yeah, the COPD study. I just got to page 700, so I have about 400 pages to go. I still have not come across the COPD study.
Patrik: The only thing I can think about oscillation ventilation is usually used for ARDS for lung failure. I haven’t come across any other oscillation ventilations besides the ARDS, so I don’t know why they would be doing that on your dad.
Natasha: No, over here. It says, when it talks about the ETT status. Ventilation status maintained, airway device ET insertion position right, secured at 24 centimeters size, 7.5 whatever that is. Cuff pressure 20, secured by holder, endotracheal tube placement confirmation, auscultation bilateral breath sounds and capnometry.
Patrik: Oh! Okay. No, what that means is somebody had a listen to your dad’s chest with a stethoscope. That’s just confirming that they could hear air entry, that’s all. It’s got nothing to do with equipment.
Natasha: And they wrote capnometry, too. Capnometry?
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Patrik: Okay, yeah. Natasha, I’ve got about three more minutes and then I’ve got to go. What I’ve done this week, just to let you know … Because, if you do want that review of the medical notes, I won’t do that myself because I have people working in the background. Just to let you know. And I’ve touched base with some of them. They’re pretty much ready to go whenever you want that.
Natasha: Really? They could do it? Okay.
Patrik: Oh, yeah. Absolutely, because I wouldn’t have the time to look at … Even if you only want to review half of those pages, right? I wouldn’t have the time to do that. I’m talking to people all day long. So-
Natasha: Yeah because I know that you have your own … You’re also viewing other peoples’ notes.
Patrik: Oh, absolutely. That’s why I have never done that myself, because I just don’t have the time. This is part of the services where I employ people.
Natasha: Okay, so you have other medical experts do it, because I was gonna finish making the notes. I would want to finish over this weekend. I really want to get working on this but …
Patrik: Of course. You do it in your own time and when you’re ready you let me know.
Natasha: And they do help file complaints, do they help you do that, or do you often..
Patrik: I’ll tell you what we do from there. Once we’ve reviewed the notes, basically what we will do is we will document our findings. With those findings, we will recommend whether we have concerns that medical negligence has been happening. A yes or no. What are the findings. We can only give you that opinion. Whether medical negligence has been happening from our perspective or not. We will find that relatively quickly. That is the advice that we can give you. I would imagine that if you went to a lawyer or to an attorney, for example, with that type of issue, they would probably review medical notes as well but they would probably be way more expensive than we are. Right? So we can do that. I need to look at the notes first, to give you an indication how much, but they will be charging you probably $250 an hour. Ours will be way more cost effective.
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Natasha: All right, then they’ll give me a price quote, though, once I send it and ask them. As if I write up my own notes and then let them take it from there?
Patrik: Yeah. For sure. The person that is most likely reviewing your notes, I will debrief them on what you and I discussed today.
Natasha: Thank you
Patrik: Have an overview of what’s the background story and all of that. You know?
Natasha: Okay, good. How long do you think it could take? Approximately, do you think? Once I give it, how long do you think it would take to review this many notes.
Patrik: I would think that if you want 1,200 pages reviewed, the person who will be reviewing that most likely is somebody who is still working in intensive care. That person is in the trenches. They have done other cases. They probably have a turnaround time of maybe, let’s say, 2 to 4 weeks. Do you think that’s too long?
Natasha: Okay, that sounds wonderful. No, that sounds pretty normal. That sounds-
Patrik: Because they do still have a full time job. But I want people to work in ICU because they know what they’re looking for. They have lots of experience. So, the turnaround time would probably be 2 to 4 weeks.
Natasha: All right. That sounds about normal. Because, this is taking a long time for me even.
Patrik: Oh, of course.
Natasha: I’m not a medical professional, but I just want to make sure I don’t just … because I remember certain stuff. All right, I’ll let you go because you have to go. I’ll get back to you, when I finish doing this.
Patrik: Okay, so watch out. There will be another webinar on Sunday. Sunday evening, for you. Watch out for that, and we’ll probably talk then.
Natasha: Yeah, hopefully I can finish this.
Patrik: Okay, all right. And I’ll hope you have a good weekend.
Natasha: You too.
Patrik: And I’ll talk to you next week.
Natasha: Thank you for the chat. Thank you, as always.
Patrik: You’re most welcome. Take care.
Natasha: You too.
Natasha: Bye, bye.
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- How to ask the doctors and the nurses the right questions
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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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