Podcast: Play in new window | Download

Subscribe: Apple Podcasts | RSS

Quick Tip for Families in Intensive Care: Can My Dad in ICU Have a DNR Revoked with Necrotizing Pneumonia, with Ventilation and Tracheostomy?

“The ICU team wants to limit treatment for my dad who has been stuck in ICU for a few months. How can I turn this around?”

That’s a question from one of our clients that we’re currently working with, and I will answer that question today for you.

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

I’m just reading out the medical summary for this particular client where we have access to medical records. Of course, I will not share any names here, keep it completely anonymous, but it will help families in intensive care to understand how to approach those situations because unfortunately, a lot of ICUs trying to limit treatment for patients in intensive care, even though they have stated otherwise, family have stated otherwise. So, let’s look at this in more details.

Our client’s father in ICU is actually looking ill. He opens his eyes to voice but does not respond to questions. He does have tracheostomy and a ventilator in place, and he’s got diminished breath sounds to both lungs with heart rate and rhythm regular, soft, non-distended abdomen, PEG tube (Percutaneous Endoscopic Gastrostomy) in situ, on feeding with Nepro at 35 mL an hour. No edema to the limbs. He’s currently on CPAP (Continuous Positive Airway Pressure) mode at 5, Pressure Support of 6.

Completed 6 weeks of antibiotic courses for necrotizing pneumonia. Completed levofloxacin 750 mg QID (4 x a day) for 7 days, continuing pulmonary regimen, wound care, and antibiotics, aggressive pulmonary toilet, albuterol, six-hourly, general tracheostomy care with PRN suctioning. PRN means as needed, and wound care for multiple pressure injuries, wounds and muscular contractures, followed by pulmonary and wound care team, and on pain medications like acetaminophen, oxycodone, and morphine. And just on that note, it’ll be very difficult to wean someone off the ventilator with multiple opiates going in because one of the main side effects of opiates is respiratory depression.

He also got hypotension, low blood pressure with 85/55, which may be secondary to the opiates he’s getting. He’s got high sodium, which is a sign that he might be dehydrated, and high blood urea levels. He’s been treated with increased free water boluses which makes sense given that he’s dehydrated. He also had an IV fluid bolus. Blood pressure needs to continue to be monitored. The mean arterial pressure should be above 65 millimeter per mercury to maintain adequate kidney perfusion. Close monitoring needs to be continued.

No fever, heart rate is around 110 beats per minute, in a regular sinus tachy. But that means he might be a little bit dehydrated; the high heart rate might be one of the symptoms for dehydration. Breathing rate is 29 breaths per minute, oxygen saturation 100%. They’ve decreased metoprolol to 25 mg twice per day. Metoprolol should be off in this situation because blood pressure is very low. 1.5 L of fluids ordered and administered, and blood pressure improved with fluids being given because of the likely dehydration component.

In this situation, the ICU put a Do Not Resuscitate (DNR) order on the patient, which is completely inappropriate, and the family and I are working on it to turn this around. It’s not up to a hospital to issue a Do Not Resuscitate order because it’s up to patients and families what they want. And we have helped so many families to revoke DNRs with our advocacy, with our insights, that we have about intensive care.

Now the good news is he is having some spontaneous breathing trials with the T-piece, whilst he’s off the ventilator, and that is working at least for periods of time during the day. His hemoglobin levels are at 8.4, which means he doesn’t require blood transfusions. Usually, blood transfusions are given if the hemoglobin drops below 7. But it’s not a high hemoglobin either, normal hemoglobin is sort of anything above 11 or 12, it certainly needs to be monitored, and he should have a good diet, enough feeds, iron, vitamins and minerals, and also supplements to get his hemoglobin up, also potentially an iron infusion that might be helpful. His sugar levels need to be checked at the bedside every 3 hours to early detect and treat abnormal blood sugar levels because he is diabetic and he’s on an insulin sliding scale.

Obviously, this man doesn’t need full care and support, he needs aggressive medical care management to continue with his safe healing and prevent him from further deterioration due to conservative care and management. Apart from intensive care, he also requires support from the multidisciplinary team, providing good neurological, respiratory, cardiovascular, gastrointestinal, wound care, infectious disease, nutritional support, rehabilitation medicine, physical, occupational, speech language pathology, nephrology, and others to help this patient stay safe.

And like I mentioned in the beginning, he’s got a history of necrotizing pneumonia and right-sided pneumothorax, which was resolved. He has been passing spontaneous breathing trials on the trachy shield or the T-piece. And when he’s going back on the ventilator, he is on Pressure Support at 5/5 as tolerated, with a goal of maintaining tidal volumes greater than 300 mL and a breathing rate of less than 30 per minute. If he’s unable to tolerate to switch back to full ventilation settings and he can’t continue with CPAP or spontaneous breathing trials, the backup is PRVC mode (Pressure-Regulated Volume Control) on 450 and 12/5 of pressure with 30% of FiO2 (fraction of inspired oxygen), which has been discussed with the pulmonary team.

The original reason for this man to have a tracheostomy is that he failed obeying commands, and that therefore he couldn’t be extubated and obviously with the necrotizing pneumonia, there was also a clear and strong argument to keep him ventilated for now.

Currently, the chest X-ray shows worsening multiphobic consolidation with increased lucency in the right upper lung zone consolidation concerning for new cavitation, especially given the history of necrotizing pneumonia and right pneumothorax.

It was discussed with Pulmonary Team, and he has recurrent pneumothoraces with poor prognosis, with no escalation of treatment recommended from the intensive care team. No invasive intervention is recommended given below. Recommendations below non maleficent and equally as important given risks benefits, assessment and would likely precipitate a continuous air leak which leads to critical illness with high risk of mortality overall with severe and several life limiting illnesses which are mitigated by aggressive pulmonary regimen, wound care, and antibiotics.

Here is another problem he’s also got a right heel unstageable pressure sore. He’s got muscular contractures, which is really bad because, you know, by the time the family got us involved, he was in ICU for quite some time, and at that stage, he already had contractures.

The biggest challenge for families in intensive care is 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. The sooner you get help when you have a loved one critically ill in intensive care, the sooner we can help you. By the time your loved one has contractures, it’s often too late to make sure they get the best care and treatment. And then it’s also easier for ICU teams to make an argument that patients should be on DNR. If they had done the right things from the start, he shouldn’t have any contractures. That means there has been poor nursing care, there hasn’t been enough physical therapy. Just been poor all the way around.

This man was living independently before he went into ICU. One of the issues here is that, because this man has been receiving poor care, you can’t be mobilized  with the contractures, which makes it much harder to progress further with ventilation weaning because it’s much more difficult to mobilize him, and it is inevitable that patients who want to wean off the ventilator need to be mobilized. He needs to be hemodynamically stable to tolerate the ventilation weaning, CPAP, and tracheostomy shield.

It is important that you get advocacy right from the start, because as you can see here, the longer you wait, the worse things can get. That’s not to say they will get worse, but they can get worse. The sooner you understand what’s happening, the sooner you understand what needs to happen. The sooner you understand they can’t just make your loved one DNR because they feel like it, the sooner you can counteract and the sooner you can challenge things.

That is my quick tip for today. I hope that helps you understand that you need to get help as quickly as possible.

I have worked in critical care nursing for over 25 years in 3 different countries, where I worked as a nurse manager for over 5 years in critical 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 for our clients in intensive care. You can verify that in our testimonial section at intensivecarehotline.com. You can also verify it on our intensivecarehotline.com podcast where we have some live interviews, because our advice is absolutely life changing.

And that’s why you can join a growing number of members and clients that we have helped over the years to improve their lives instantly, making sure our clients make informed decisions, have peace of mind, control, power, and influence, making sure their loved ones get the best care and treatment, always.

That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever works best for you. And I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply can’t afford to get wrong, which is clearly evident in today’s videos. If you get this wrong from the start, you’re finding yourself in a pickle.

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 because 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.

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, and 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 get exclusive access to 21 eBooks and 21 videos that I have personally written and recorded. All of that will help you to make informed decisions, have peace of mind, control, power, and influence.

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

If you like my videos, subscribe to my YouTube channel  for regular updates for families in intensive care. Click the like button, click the notification bell. Comment below what you want to see next, what questions and insights you have. Share the video with your friends and families.

I also do a weekly YouTube live  where I answer your questions live on a show, and you will get a notification for the YouTube Live if you’re a subscriber to my YouTube channel or if you’re a subscriber to my intensivecarehotline.com email newsletter at intensivecarehotline.com.

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.

Related Articles:

Quick Tip for Families in ICU: Is ICP & Tracheostomy Needed After Subarachnoid Haemorrhage in ICU? Quick Tip for Families in Intensive Care: Why Pressure Area Care (Skin Care) on ECMO is so Important! Quick Tip for Families in Intensive Care: Heart Failure After COVID ARDS Quick Tip for Families in ICU: Should You go to LTAC from ICU with Ventilation or Tracheostomy? Quick Tip for Families in ICU: What’s the Evidence for a Patient in ICU Being Brain Dead?