Podcast: Play in new window | Download

Subscribe: Apple Podcasts | RSS

Quick Tip for Families in Intensive Care: What Questions Should You Ask the ICU Team When Advocating for a Tracheostomy for Your Loved One?

“What questions should you ask the ICU team when advocating for a tracheostomy for your loved one with a breathing tube?” That’s what I want to talk to you about today because this is a question we get quite frequently from families in intensive care.

My name is Patrik Hutzel from intensivecarehotline.com, where we help families of critically ill patients in intensive care to make informed decisions, have peace of mind, control, power, and influence, even if you’re not a doctor or a nurse in intensive care, so that your loved one gets best care and treatment always.

So, let’s get right into it. If your loved one has been in ICU for more than 7 to 10 days and is still on a ventilator with a breathing tube or an endotracheal tube, you’re probably being told that your options are limited. You might be hearing things like number 1, “They’re not waking up.” Number 2, “They’ll never come off the ventilator.” Number 3, “There’s no ‘quality of life’” or even worse, “We should consider comfort care or withdrawal of treatment,” which is basically a death sentence.

But that’s not the full picture, and that’s why I’m here to give you real advocacy tools, the kind of questions you need to ask now to stop the ICU from giving up too soon and to give your loved one the time and treatment they need. So let’s get into it.

So, number 1, why is my loved one still on the breathing tube? Start here. You need to find out the real reasons why they haven’t been extubated. Extubation is the removal of the breathing tube. Is it a respiratory issue? Is it a neurological delay? I.e. Is your loved one not waking up despite being off all sedatives and opiates? Therefore, is sedation still running? Are opiates still running? Are they potentially not strong enough to get extubated just as yet? The ICU team must tell you clearly why your loved one can’t come off the ventilator.

Here is a bonus question for you in this situation. Has the ICU team done everything beyond the shadow of a doubt to get your loved one off the ventilator and the breathing tube and avoid the tracheostomy or comfort care? It’s a very important question. I have made a video about this, “How to wean a critically ill patient of the ventilator and the breathing tube?” I will insert a link to that video right here.

Number 2, what’s your plan if my loved one can’t be extubated in the next few days? This is a crucial question. If the ICU team doesn’t have a plan, you need to create one with them, and that plan should include tracheostomy if your loved one is medically stable, avoiding a “one-way extubation” if there’s a risk of failure, and stopping sedation to assess neurological function properly.

The other thing that we’ve learned after having worked in intensive care and critical care for over 25 years in three different countries, where I also worked as a nurse manager for over 5 years, ICU teams are not even telling you half of what’s going on. If you don’t ask the right questions, you will be fighting an uphill battle. I can’t tell you how many times I’ve seen over the years where ICU teams trying to “sell” families on an end of life situation, and they’re not even talking about the tracheostomy. They’re making it look like there’s no other options.

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. That’s exactly what you’re up against if you don’t get the right advice and the right advocacy.

Next, is my loved one ready for a tracheostomy? If they’re not progressing, a tracheostomy may be the best chance for them to, number one, come off sedation, come off opiates, wake up properly, start physical therapy, and breathe more comfortably. If the team says no, ask why not. What’s stopping them? Is it medical or is it potentially hospital policy?

The other thing that you need to ask is for ventilator settings. Sometimes, your loved one might be off sedation already, but they may not wake up, and they are in high ventilator settings. So then, a tracheostomy may not be safe to do. For example, if oxygen levels, FiO2 (Fraction of inspired oxygen) on the ventilator are above 40%, if PEEP (Positive end-expiratory pressure) is above 8 or 10, it’s very risky doing a tracheostomy. Or if your loved one is on medications such as nitric oxide, it’s very risky, if not impossible to do a tracheostomy. Ventilation settings need to be reduced. Support needs to be reduced.

Again, the devil is in the detail, which is why you need an expert such as myself by your side to handhold you through this once in a lifetime situation that you simply cannot afford to get wrong.

Next, what are the benefits of a tracheostomy in this situation? So, let me explain. Once again, does it reduce sedation needs? Commonly used sedatives in ICU are midazolam/Versed, propofol, and Precedex, most commonly. Sometimes, another sedative such as ketamine is used as well.

Next, does it reduce opiates? Commonly used opiates in ICU are morphine, fentanyl, sometimes oxycodone, hydromorph as well. Because one of the main goals for doing a tracheostomy is simply for your loved one to wake up and not use any sedatives and opiates because they have terrible side effects, including limiting the respiratory drive, and the goal for your loved one should be to wean off the ventilator.

Next, does a tracheostomy help with weaning off the ventilator? Does it allow for more patient comfort and mobility? Make them justify the decision either way, this is your loved one’s life on the line.

Next, what are the risks of keeping the breathing tube in longer? They need to tell you about damage to vocal cords or the trachea, increased risk of ventilator associated pneumonia (VAP), discomfort, and inability to wean. Also, another risk is, again, the usage of sedatives and opiates. The ongoing use of sedatives and opiates have terrible side effects. Your loved one gets deconditioned day by day if they’re not waking up, if they’re not doing physical therapy, they can’t be moved towards rehabilitation, physical therapy, etc. A tracheostomy is often less invasive long-term than keeping someone on a breathing tube indefinitely. You can’t keep someone on a breathing tube indefinitely.

Next, are you recommending a tracheostomy or just pushing for withdrawal of treatment? This is where you separate ICU treatment from ICU agenda. Too often, once Day 10 or Day 14 hits, ICU starts pushing families towards end of life care, especially if they think the patient won’t recover quickly, and the most important word here is quickly.

Patients often do recover, and they’re often not recovering in timelines that are convenient to ICU teams because it’s money, it’s bed blocks. ICU beds are in high demand.  Therefore, you must ask. Is a tracheostomy being considered seriously by the ICU team? Are you recommending it medically or discouraging it because of policy, staffing levels, state management levels, or financial management?

Next, what happens after a tracheostomy? Ask for the full plan. If you’re in the United States, you need to ask if they will go to an LTAC (long-term acute care), a step down unit, or potentially home with a ventilator. Home with a ventilator is possible with a service like Intensive Care at Home. I encourage you to check out intensivecareathome.com for more information.

Next, what are the chances of getting them off the ventilator after the tracheostomy? Will they be able to eat, talk, and do rehabilitation? Also, what are chances that your loved one can get off the ventilator, but potentially needs to keep the tracheostomy in until it can be further evaluated? Because there are plenty of patients out there that end up with a tracheostomy and a ventilator in ICU. They can be weaned off the ventilator, but then need to continue having the tracheostomy. You must know what comes next so you can prepare and make the best decisions.

Next, can you stop sedation and opiates so we can see if they’ll wake up? This is critical. Sedation and opiates often mask your loved one’s ability to breathe, respond, and recover. ICU teams will say things like, “They’re not waking up” or “They’ve been sedated for 2 weeks.” Of course, they’re not waking up. Ask, when will you stop sedation and opiates? When will you do a neurological assessment of sedation? Will you do a CT scan of the brain or an MRI scan of the brain if sedation and opiates have been off for many days, but your loved one isn’t waking up? Will they get a neurological consult? Only then can you truly know if a tracheostomy will help move things forward.

Next, is your decision based on patients’ needs or hospital limitations? Let’s be real. ICUs often operate under pressure and constraints: limited beds, limited staff, policy timelines, and limited finances. But those should never ever override your loved one’s right to live and have a fair chance at recovery. If you’re being told that your loved one is not going to recover, but they haven’t even had a chance for a tracheostomy, it’s time to push back, and push back you must.

ICU teams have their own agenda. Like I said, I’ve worked in intensive care and critical care for over 25 years in three different countries, where I worked as a nurse manager for over 5 years in intensive care. I know exactly how intensive care units operate and what’s important to them. What’s important to them is sometimes not important to you.

Next, can we revisit this every 24 to 48 hours? Let’s face it, things change quickly in ICU. If the answer today is no tracheostomy, it might be yes in 24 or 48 hours. Ask the team for daily updates, keep the pressure on. More importantly, you need to get access to the medical records as quickly as possible so that you can get an independent assessment from us, so we can guide you and handhold you step by step. If you don’t have access to the medical records, you’re basically flying blind. Do you think you can afford flying blind in life or death situations in ICU? I’m sure you have the answer yourself to this question.

Also, keep in mind that an advocate like myself, if you and I were to get on the phone on a phone call with one of the ICU doctors, you will see the dynamics change very quickly. I will ask all the questions that you haven’t even considered asking based on ventilator settings, blood gas analysis, blood results, and medications your loved one is on.

You don’t know what you don’t know. You need to talk to someone that can give you independent advice that understands intensive care inside out, which is what I do. I’ve been consulting and advocating for families in intensive care here at intensivecarehotline.com since 2013, and we have saved many lives.

In summary, a tracheostomy can be a turning point in your loved one’s recovery. But if you don’t ask the right questions, you may never be given that option. Or worse, you might be pressured into giving up too soon, and you might be falsely led into a withdrawal of treatment, which is a death sentence for your loved one.

So, if you need help advocating for a tracheostomy, we can help because we’ve helped hundreds of families in intensive care get tracheostomies done and save their loved ones’ lives when ICUs were giving up. Time equals life. Don’t let your loved one be written off because the ICU is running out of patience and perceived options.

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.

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, share the video with your friends and families, and comment below what you want to see next, what questions and insights you have from this video.

I also do a weekly YouTube live where I answer your questions live on the show. You will get notification for the YouTube live if you are a subscriber to my YouTube channel or 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 for now.