My name is Patrik Hutzel from intensivecarehotline.com, and this is another quick tip for families in intensive care.

Here at intensivecarehotline.com, we instantly improve the lives of families of critically ill patients in intensive care so that you can make informed decisions, have peace of mind, control, power, and influence — making sure your loved one always gets the best care and treatment, even if you’re not a doctor or a nurse in intensive care.

Today I have an email from Grace who says:

“Hi Patrik,

My mom had aspiration pneumonia which led to pleural effusion. Why does she have this, and are they missing something when they say it just won’t go away, and there’s nothing they can do? She has no known heart conditions except AFib, which is atrial fibrillation — which, by the way, is a heart condition. Her nutrition status is low, protein at 1.6 when it should be at 4, but when they push her feedings in her tube up to a certain level, she desaturates and her heart rate goes up, so they can’t get her nutrition to improve. She’s on BiPAP (Bilevel Positive Airway Pressure) in the ICU, but she does well on high flow oxygen for a couple of hours, a few times a day. She is alert and talking and only complains of her butt hurting but not really anything else, so it just doesn’t make sense that she’s dying and they can’t do anything” — and she puts that in quotes — “The only option is to take her home and let her die because ventilating her wouldn’t do anything to help her to be better. Is there really no hope for this talkative, feisty, alert woman? If she really is not going to recover, then we want to take her home, but she would need to be weaned from the BiPAP except at night and naps in order to go home on hospice and live for any length of time to actually enjoy being at home. She has been in a nursing home for 1.5 years, and we have always promised that we will take her home if she isn’t going to live. She’s still on IV (Intravenous) antibiotics — 2nd round of them for this infection — 2 more days for one and 5 more days for the second one. So, we don’t want to just take her home to hospice and remove the IV antibiotics if she might have a chance, but we also don’t want to wait if she’s going to decline because then she can’t enjoy being at home. Surely there’s a way to get her nutrition up. Every time a new doctor comes in, it is like starting all over again. They want to meet with us and ask us the plan,” — again she puts that in quotes — “and push us to tell them we are willing to ventilate and tell us how she’s not going to get better. But we see with our very own eyes that she is getting better — fever gone, much more alert, respiration rate has gone from the 40s most of the time now to the lower 20s, and even in the teens on BiPAP. I think they’re missing something. We saw her way sicker than this 1.5 years ago, and she recovered, but this pleural effusion just won’t let up.

Thanks in advance for any advice you can give.”

Grace

Thank you so much, Grace. I can absolutely feel your frustration and pain coming through your message, and honestly, you have every right to question what’s happening here. Let me break down what I’m seeing and what you need to be focusing on.

Number one: The pleural effusion that won’t go away.

When you have a pleural effusion that keeps recurring, the ICU team must investigate the underlying cause. They can’t just say it won’t go away, and there’s nothing we can do. That is simply not acceptable.

Common causes of recurrent pleural effusions include:

• Heart failure — even with just AFib, there could be underlying cardiac dysfunction. Get an echocardiogram, get an ejection fraction, which shows you how good the contractility of the heart is.
• Liver failure — which would explain low protein and albumin levels. Definitely check albumin levels. Pleural effusions can be caused by low albumin levels.
• Kidney failure — causing fluid overload.
• Malignancy — which needs to be ruled out, i.e., cancer.
• Infection — parapneumonic effusion or empyema.
• Malnutrition and low albumin — creating a vicious cycle.

Your mom’s protein level at 1.6 — I’m assuming you mean albumin — when it should be around 4, is critical. Low albumin means low oncotic pressure, which means fluid leaks into the pleural space. But here’s the catch-22: she can’t get adequate nutrition because of desaturations, which keeps the albumin low, which perpetuates the effusion.

However, what you can do here is albumin infusions. The ICU can give an albumin infusion over a few days, and the albumin should come up.

Next: The nutrition crisis and high CO2 (Carbon Dioxide).

This is where things might get tricky. When they increase her tube feeds, and she desaturates with an elevated heart rate, this could indicate:

• Aspiration risk, even with tube feeds
• Gastric distention affecting diaphragm function
• High CO2 from overfeeding, especially with high-carbohydrate formulas
• Pulmonary mechanics are being compromised

The medical team needs to optimize her nutrition strategy:

• Consider peptide-based or elemental formulas for better absorption
• Use lower-carbohydrate, higher-fat formulas to reduce CO2 production
• Trial continuous slow feeds versus bolus feeds
• Assess gastric emptying and consider post-pyloric feeding

What that means is: every 4 hours, the ICU team should check the residuals in the nasogastric tube in the stomach and see how much is left. If it’s greater than 300 to 500 mL, your mom is not absorbing. That could mean they need to start her on a PPI — a proton pump inhibitor — they might need to start her on Maxolon, they might need to start her on erythromycin, or they might need to consider post-pyloric feeding, which means they might need to use a naso-jejunostomy tube.

As mentioned before, add IV albumin to help with oncotic pressure while building up nutrition. Consider TPN — total parenteral nutrition — if enteral nutrition continues to fail. And TPN, by the way, can also be given at home.

Next: Liver failure, ammonia, and treatment options.

You mentioned high CO2, ammonia, and liver failure in your question. If your mom has elevated ammonia levels, this is absolutely critical. Treatment options for high ammonia include:

• Lactulose to reduce ammonia absorption
• Rifaximin — an antibiotic — to reduce ammonia-producing bacteria
• Low protein diet initially, but this conflicts with her malnutrition
• Treating the underlying liver condition
• L-ornithine L-aspartate in some cases

If liver failure is a contributing factor, the team needs to address: What’s causing the liver failure? Can it be reversed? What’s the MELD (Model for End-Stage Liver Disease) score? Is there hepatorenal syndrome — i.e., is your mom potentially going into kidney failure as well?

Next: BiPAP and weaning strategy.

Here’s what I love — your mom is alert, talking, feisty, and can tolerate high flow oxygen for a couple of hours and BiPAP. This tells me your mom is alive and there is potential here. The ICU team should be pursuing gradual BiPAP weaning protocols — not all or nothing:

• Overnight BiPAP with daytime high flow trials, increasing duration
• Addressing the root cause of her respiratory failure — effusion, nutrition, possible liver issues
• Physical therapy and mobilization to improve respiratory muscle strength
• Speech therapy assessment for swallowing and aspiration risk

And why are they saying nothing can be done?

Grace, when you’re seeing improvement with your very own eyes — fever resolved, increased alertness, respiratory rate improving from the 40s to the low 20s — but the doctors keep having the talk about goals of care, something is seriously disconnected. This happens for several reasons:

• Different doctors, different perspectives, and different opinions — there’s no continuity
• They’re looking at lab values, monitors, and imaging — not the whole patient
• Defensive medicine — preparing families for worst-case scenarios instead of best-case scenarios
• They may be missing something, as you suspect
• Communication breakdown between shifts and specialties

What you must do right now:

Get access to all medical records immediately. You need complete access to all lab results — especially albumin, liver function, ammonia levels, kidney function — but everything: electrolytes, everything. All imaging reports: chest X-rays, CT scans, and ultrasounds. All consultation notes: pulmonology, nutrition, infectious disease, ICU doctors, ICU nurses, everyone’s progress notes, medication lists, and treatment plans. Daily progress notes from everyone, ventilation charts, and fluid balance charts. Leave no stone unturned — the devil is in the detail. Without complete medical records, you are flying blind. You can’t make informed decisions, and neither can anyone advocating for your mom.

Next, schedule a consulting call with me or one of my team members at ntensivearehotline.com. We need to have a consulting call with you and the ICU team as soon as possible to get absolute clarity on:

• What they’ve investigated and what they are missing
• Why the pleural effusion keeps recurring
• What the actual treatment plan is for nutrition
• Whether liver failure is confirmed and what’s being done
• What the realistic prognosis is based on facts, not assumptions
• What questions need to be asked and what advocacy needs to happen

During our call, we question the ICU team’s approach, advocate for your mom, and push for answers to the critical questions that aren’t being addressed.

And don’t rush into hospice if there are unanswered questions. You’re absolutely right to wait until the antibiotics are finished. If she’s still improving on antibiotics, pulling them now could be premature — and quite literally deadly.

Key questions before transitioning to hospice:

• Has the infection been adequately treated?
• Has the pleural effusion been properly drained and investigated — i.e., root cause analysis?
• Has the nutrition issue been truly optimized, or just given up on?
• Have all reversible causes been addressed?

Next: Consider Intensive Care at Home as a long-term solution.

Grace, here’s something the hospital probably hasn’t told you. Even if your mom needs long-term ventilation — invasive with a tracheostomy, or non-invasive — she does not have to stay in the ICU. Intensive Care at Home provides solutions for adults and children who need:

• Long-term invasive and non-invasive ventilation, including BiPAP at home
• Invasive ventilation with tracheostomy at home
• Tracheostomy at home without ventilation
• Complex medical and nursing care that keeps patients out of ICU — predictably and permanently
• Palliative care in the comfort of your own home, with dignity, if that is the appropriate option

If your mom can’t be weaned off the ventilator or if she needs ongoing BiPAP support, Intensive Care at Home can help you create a plan where she can be home, comfortable with family, and receiving the medical support she needs. This could be the solution that allows her to leave the ICU, be at home with family, and have quality of life — even if she needs ongoing intensive care and respiratory support. You can find more information at intensivecareathome.com

The bottom line, Grace: Your instincts are right. When you’re seeing improvement, but the medical team is pushing end-of-life discussions, there’s a disconnect that needs to be investigated and challenged before making any decisions about hospice or withdrawal of treatment.

Once again:

• Get all medical records
• Schedule a call with myself and the ICU team — you and I talk beforehand
• Demand answers
• Push for aggressive nutrition optimization
• Explore all options, including Intensive Care at Home

Your mom is talking, alert, feisty, and showing signs of improvement. That deserves a full investigation, proper treatment, and clear answers — not just “there’s nothing we can do.”

I have worked in critical care nursing for 25 years in three different countries, where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy. You can verify that on our testimonial section.   at intensivecarehotline.com and on our podcast section, where we have done client interviews.

The biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for, they don’t know what questions to ask, they don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care. That’s why we help you improve your life instantly — making sure you make informed decisions, have peace of mind, control, power, and influence, ensuring your loved one always gets the best care and treatment.

That’s why you can join a growing number of members and clients we have helped over the years, saving their loved ones’ lives. I do one-on-one consulting and advocacy  over the phone, Zoom, or WhatsApp — whichever medium works best for you. I talk to you and your families directly. I handhold you through this once-in-a-lifetime situation that you simply cannot afford to get wrong. When I talk to families directly, I also talk to doctors and nurses directly — asking all the questions that you haven’t even considered asking, but that must be asked when you have a loved one critically ill in intensive care. I also represent you in family meetings with intensive care teams. We do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care — if you have unanswered questions, if you need legal advice, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care. You can become a member by going to intensivecarehotline.com and clicking on the membership link, or by going directly to intensivecaresupport.org. In the membership, you have access to me and my team 24 hours a day in the membership area and via email, and we answer all intensive care-related questions. You also have exclusive access to 21 e-books and 21 videos that I’ve personally written and recorded — all of which will help you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets the best care and treatment, always.

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Thank you so much for watching.

This is Patrik Hutzel from IntensiveCareHotline.com, and I will talk to you in a few days.

Take care for now.