My name is 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, control, power, and influence, making sure your loved one always gets best care and treatment, even if you are not a doctor or a nurse in intensive care.

Today I’m going to answer a question from Angela, who’s one of our clients, and she has a very important question about her mother’s options after cardiac arrest and hypoxic brain injury. Angela says in an email.

“Hi Patrik,

My mom remains ventilated, sedated with a breathing tube after the cardiac arrest and the hypoxic brain injury. There are three options that the ICU doctor gave me for my mom. Number one, extubate, which means removal of the breathing tube, and if she fails, BiPAP or CPAP ventilation and reintubate if needed, but would need to consider a tracheostomy then in two or three days after the failed extubation. The second option he’s given me is the tracheostomy. And the third option he’s given me is extubate and not to reintubate in case extubation fails. I’m leaning towards number one. The ICU doctor told me I can think about it and talk tomorrow. I want to buy my mom some more time, but should we do it tomorrow? I need your advice. What do you suggest?

 From Angela.

Angela, I want to start by saying that I’m really glad you reached out because this is one of the most difficult decisions families face in ICU and you shouldn’t have to make it alone or without proper support and advocacy. Let’s look at first understanding your mom’s situation. Your mom has had a cardiac arrest with hypoxic brain injury and she’s currently on a ventilator, sedated with a breathing tube. The ICU doctor has given you three options, and I can tell you are trying to do the right thing for your mom, which is why you’re reaching out for help.

Let me break down these three options for you. Option one, trial extubation with reintubation if needed. This is the option you’re leaning towards, and I understand why you want to give your mom a chance to breathe on her own, but you also want the safety net of being able to put the breathing tube back in if she can’t manage. The doctor mentioned BIPAP (Bi-level Positive Airway Pressure) or CPAP as a bridge and potentially considering a tracheostomy in two to three days if needed. This is a reasonable approach if the assessment shows your mother has a chance of recovery.

Option two is going straight to a tracheostomy. This is a more committed pathway that suggests the ICU team believes your mother will need longer term ventilation. A tracheostomy can be more comfortable than a breathing tube through the mouth, allows for better oral care, allows for stopping sedation pretty much immediately, allows for stopping opiates pretty much immediately, and makes weaning from the ventilator much easier in the short and long-term.

Option three, extubate and do not intubate, DNR (Do Not Resuscitate), or comfort care. This is essentially palliative or end of life pathway where the focus shifts from life sustaining treatment to comfort care. Now, especially for number one and for number two, but also for number three, there’s another option that the hospital hasn’t told you about, which is Intensive Care at Home, and I will come to that in a minute.

The critical questions you need answered right now. Angela, here’s what concerns me about your situation the most. You are being asked to make a life and death decision, but I need to know, do you have access to all of your mother’s medical records? This is absolutely critical and lifesaving because you cannot make an informed decision without knowing what was the exact cause of the cardiac arrest. How long was your mother down before resuscitation started? How long was the actual resuscitation? What do the brain scans, CT or MRI scans show about the extent of the brain injury? What are her neurological examination findings? Has she had an EEG (Electroencephalograph) to assess brain activity? What’s her prognosis based on prognostication scoring systems? What were her underlying health conditions before the cardiac arrest? What’s her current organ function, kidneys, liver, heart?

Have a look at all medical records, including doctor’s reports, nurses’ reports, ventilation charts, arterial blood gases, other laboratory and pathology results, fluid balance charts and the list goes on. You can leave no stone unturned here.

What I strongly recommend, Angela, is before you make any decision tomorrow, I strongly suggest you do the following.

1.  Get immediate expert advice.

You need to book a consulting call with myself or someone from my intensivecarehotline.com team. And this is why it’s so important. We can review all of your mother’s medical records with you. We can help you understand what the ICU team is really seeing clinically, but not necessarily telling you. We participate in a consulting call with you and the ICU team to ask the right questions. We advocate for your mother and make sure you’re getting complete information. We help you understand whether the prognosis is truly as limited as they might be suggesting.

2.  Do not rush this decision.

You mentioned the doctor wants an answer tomorrow. Angela, unless there’s a genuine medical emergency, you have the right to take more time. A day or two of additional information gathering could mean the difference between life and death for your mother. Ask the ICU team, what is the medical urgency for making this decision tomorrow? Can we have 48 to 72 hours to consult with outside experts? What additional testing can we do to better understand her prognosis? and

3.  Question the timeline for the tracheostomy.

The doctor mentioned considering a tracheostomy in two to three days if option one fails. That’s a very short timeline. Typically, we’d want to see how your mother does for at least seven to 14 days after a hypoxic brain injury before making permanent decisions about tracheostomy or withdrawal of treatment. The brain needs time to recover and early assessments can be unreliable.

Understand the do not reintubate option. If the ICU team is pushing option three, extubate and do not reintubate, you need to understand why. Are they saying your mother has no chance of meaningful recovery, and at the end of the day you need to decide what’s meaningful for you. If they say that, on what evidence is it based? Have they done a full prognostication assessment, or are they being influenced by resource limitations, limitations such as beds, staff, money, or are they having any other biased assumptions?

This is where having an advocate from intensivecarehotline.com on a consulting call with the ICU team becomes absolutely invaluable. We ask the hard questions for you and make sure you’re getting honest, complete answers.

Also, what’s important, the hypoxic brain injury timeline. After cardiac arrest and hypoxic brain injury, the standard of care is to wait at least 72 hours and often longer after sedation is stopped before making prognostic assessments. If your mother is still sedated, it’s too early to know her true neurological status. You need to ask when was sedation last stopped? How long has she been off sedation? What’s her neurological examination when she’s not sedated? Has she had any purposeful movements or signs of awareness?

And Angela, there is something else you need to know about. There’s the long-term option for Intensive Care at Home. If your mom does need a tracheostomy and long-term ventilation, you have options beyond keeping her in ICU or sending her to a nursing home, which wouldn’t take her anyway on a ventilator with a tracheostomy. The option is Intensive Care at Home and you can find more information at intensivecareathome.com because we offer a solution here that will keep your mother out of ICU predictably and permanently if she needs long-term mechanical ventilation, tracheostomy care, or even if she needs BIPAP or CPAP ventilation, and all of that requires evidence-based 24-hour Intensive Care at Home nursing with intensive care nurses. And yes, even end of life care if that becomes the only option. It’s a much better quality of life option than institutionalized care and it’s something you should know about before making irreversible and potentially deadly decisions.

And Angela, you asked if you should choose option one and do it tomorrow.

Here’s my advice. Do not make this decision tomorrow alone without number one, getting all of your mother’s medical records, every test result, every scan, every progress note, every ventilation chart. Leave no stone unturned by booking an emergency consulting call with myself. Call us at the number on intensivecarehotline.com or send us an email immediately to support at intensivecarehotline.com and having me or one of my team members participate in a consulting call with you and the ICU team. We can ask the questions you don’t know to ask and advocate for your mother. Understand the full prognosis, not just the ICU team’s opinion, but based on objective data and evidence, and knowing what more time really means, is it days, weeks or months?

The fact that you want to buy your mom some more time tells me you’re not ready to give up and you shouldn’t have to make this decision under pressure without proper support. Take action now, Angela, and contact us right now. Don’t make a life and death decision without having all the facts and having expert advocates in your corner. You can do this, Angela. Your mother is lucky to have a daughter like yourself who’s fighting for her and asking all the right questions.

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 because of our insights. You can verify that on our testimonial section at intensivecarehotline.com. You can verify it on our intensivecarehotline.com podcast section where we have done client interviews because our advice is absolutely life changing.

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

That’s why I do one on one consulting and advocacy over the phone, Zoom, 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 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 in case 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, 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 have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded. All of that will help you to improve your life instantly, 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.