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Quick Tip for Families in Intensive Care: 68-Year-Old Dad in ICU 17 Days After Stroke, Ventilated & Breathing Tube. ICU Team Wants One-Way Extubation!

Today I have an email from a reader who says, “My 68-year-old dad has been in ICU for 17 days after ischemic stroke. He’s ventilated with a breathing tube. Now, the ICU team wants to do a one-way extubation, and my dad may not be able to protect his airway. What are our options?”

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

So, this was an email initially, but I’ve also spoken to the client in the meantime. It’s a really difficult situation and I’m really sorry that you’re facing this situation.

Let’s start with what a one-way extubation even means. Some of you watching this video may have never heard of what a one-way extubation is. Extubation basically means the removal of a breathing tube that’s attached to a mechanical ventilator for an ICU patient, generally speaking, or for patients that are undergoing surgery. But in this case, it’s a patient in ICU, preceding that is intubation. Intubation is the insertion of a breathing tube into the mouth.

So, a one-way extubation, generally speaking, means that the ICU is planning to remove the breathing tube knowing that your dad may not be able to be reintubated either because it’s medically inappropriate. In some cases, they might say it might be “not in his best interest” which most of the time is completely inappropriate. But I just need you to understand how ICUs operate, because it’s not for ICU teams to decide what’s in the best interest of a patient or not, especially if patients want to live. I know in your situation, your dad wants to live.

The breathing tube may not be able to be reintubated because it’s technically not feasible, there might be some contraindications, but I’ll come to the options there in a minute. It’s often suggested that when a patient is unlikely to recover enough to breathe and protect the airway on their own when ongoing ventilation is considered and perceived futile. Considered and perceived, it’s just a perception. Perceptions are often not reality. So, a lot of it comes down to what the intensive care team perceives, but at the end of the day, it comes down to what you and your family wants.

So, let’s look at some options. If you were to proceed with the one-way extubation, and it’s comfort focused, i.e. it’s with a view of a patient entering palliative care. What that means is the breathing tube is removed, and your dad receives comfort care such as oxygen, pain management, or sedation if needed. The risks basically are like you’ve already pointed out. If he can’t breathe or protect his airway, he may pass away shortly thereafter. So, when is this chosen? If prognosis is poor and the goals are shifting to dignity and comfort. But again, this is something that needs to come from you, or from your dad and from your family, not from intensive care teams.

Now, now we’re coming to the second option. I know after I’ve spoken to you on the phone, the ICU team has clearly been misleading you because they never mentioned that a tracheostomy is probably an option here. You only found out by looking at our website at intensivecarehotline.com that a tracheostomy is also an option, and they never told you about it. That is also negligent because especially since your dad wants to live and because your dad is now waking up more and more. You’re telling me he’s squeezing hands at least on one side, so that means his brain is working. If his brain is starting to work and he’s slowly waking up, now is the time to find out from him what he wants. Let him make decisions.

So, what does it look like, tracheostomy and long-term ventilation? What does it mean? A tracheostomy is a surgical opening, and it’s made in the neck for a tracheostomy tube, allowing long-term mechanical ventilation.

What are the pros? It gives you that more time for recovery. Recovery allows movement out of ICU to a home care environment or potentially even rehab. One option for home care environment is Intensive Care at Home, and you can find out more information at intensivecareathome.com.

What are the cons? If recovery is unlikely and your dad is suffering, it may just prolong suffering or lead to a life that he may not want to live. That again is something that you and your family need to decide and your dad, of course, not the ICU team.

When is the tracheostomy chosen? If generally speaking, there’s uncertainty about prognosis or family wants more time to see if your dad improves, which is perfectly reasonable.

Next, you could also delay extubation for more time. So, generally speaking, a tracheostomy should be done after 10 to 14 days of mechanical ventilation with a breathing tube. Now, your dad is already in 17 days, so you could argue it’s either a tracheostomy or extubation. But if there’s a really good chance that your dad will improve, and if he’s already had spontaneous breathing trials, and if he’s getting mobilized, gets out of bed, gets physical therapy, you’re telling me he’s making progress, then a few more days may make all the difference.

Now, picture this. Your dad will get off the ventilator, he can breathe, he can cough, he can protect his airway, and he can swallow, that would be the best-case scenario. The other direction is, if he’s having a tracheostomy, he might end up on a ventilator for long periods of time. So, waiting a couple of more days and extubating him might make all the difference.

But, that’s again where we come in. You need that second opinion. Is it possible that he can wean off in a couple of days, because what does it mean? If you ask for more time to assess whether there’s any neurological improvement or breathing improvement as well and responsiveness, pros: it can help make a better informed decision if things are still evolving.

ICU teams may sometimes say that there’s a higher risk of Ventilator Associated Pneumonia, but that argument, I believe, goes out of the window. Because the reality is that, if you’re extubating too soon, and your dad can’t breathe, then he may die or he may need a tracheostomy. So, the risk for a ventilator associated pneumonia is always there even with the tracheostomy, but you know that if he’s extubated and he can’t breathe, he’s going to die. So, might as well take the risk of a ventilator associated pneumonia with a chance of him being able to be extubated.

Lastly, you need to get a second opinion and that’s what we’re here for here at intensivecarehotline.com. Let us look at the medical records.

Let us talk to the doctors and nurses directly. That is a win-win situation altogether. You would see that once me and my team ask the right questions and once we’ll have a look at the medical records, there’s probably more things coming to light. I argue the intensive care team hasn’t even told you half of the things that are going on there.

Other important questions you should be asking is, “What specific signs indicate he can’t protect his airway?” Also, another question you need to ask is, “Why has the option of a tracheostomy not even been discussed with you and your family?” What do they have to hide? Why do they want your dad potentially to die? What’s their agenda? What’s the rush to kill someone? Where’s the urgency to kill someone?

Also, what is his current neurological status? Is it improving, stable, worsening? Has Intensive Care at Home been considered as an option if he has a tracheostomy? You can check out intensivecareathome.com for more information.

So, I hope that helps you understand what are the best options here and what to look for. But most importantly, you need a second opinion. You need an advocate here on your side that can talk to doctors and nurses directly in the ICU so they know you have someone on your team that speaks the intensive care language and knows intensive care inside out just as much as they 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. I can very confidently say that we have saved many lives to our clients in intensive care.

You can verify that if you go to our intensivecarehotline.com testimonial section at intensivecarehotline.com or if you go to intensivecarehotline.com podcast section

where you can find video podcast with our clients and they will describe to you how we helped them and saved their loved ones lives because our advice is absolutely life changing, it is absolutely life changing and once again that is verified in our testimonial and podcast section at Intensive Care Hotline.com  and we have helped hundred and hundreds of members and clients over the years and you can join a growing number of members and clients that we have helped because our members make informed decisions, have peace of mind, control, power, and influence, and  their loved ones always get best care and treatment. And you can see the dynamic change in shifting your favor very quickly once you started engaging with us.

That’s why I do one on one consulting and advocacy over the phone, Zoom, Skype, 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.. I also talk to doctors and nurses directly on your behalf or with you or I set you up with the right questions to ask. When I talk to doctors and nurses directly I ask all the questions that you haven’t even considered asking but 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 as a professional advocate, again the right questions are being asked and  your loved ones gets best care and treatment always.

We also 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 closure, 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 if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly. 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 questions intensive care related. In the membership, you also have exclusive access to 21 videos and 21 e-books that only are exclusively accessible to our members. All of that will help you to make Informed decisions, have peace of mind, control, power and influence, making sure your loved one gets best care and treatment always.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

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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.