Thursday, May 22, 2008

Letting Go

There's no protocol in the United States for the process of making a patient DNR. I don't mean the simple act of writing "DNR-CC" (Do Not Resuscitate, Comfort Care) in the chart after a long discussion with family members. What happens next? Do you open up the "death playbook" and run the offense with morphine and benzodiazepines? It doesn't exist. Palliative intervention varies from hospital to hospital, from doctor to doctor. It's something you make up as you go along.

As a surgeon, I get involved in futile cases more often than I would like. As the population ages, we find more and more 80-90 year olds in ICU's who develop acute abdominal emergencies, such as ischemic bowel, toxic megacolon, neoplastic colon obstructions, and perforated ulcers. Often, they show up without family or contact information. Dementia and/or toxic encephalopathy precludes an honest discussion of how aggressive the level of care will be. The patient will die without an operation. However, the concomitant coronary artery disease, COPD, and heart failure make any surgical intervention fraught with hazard. What do you do?

Sometimes surgery is life saving. That can't be denied. I've seen it with my own eyes; elderly patients smiling as they are wheeled out to the rehab facility, a week after being on death's door. There are few things as gratifying in a general surgeon's practice. Another year on earth. More time to be spent with loved ones. Some aren't ready to be done with this thing called life.

But there are others who don't do well no matter what you do. You can do the perfect operation in an expeditious manner and it's all for naught. They won't wean from the vent. They go into heart failure. Multiple organ failure develops. An inevitable, ineluctable downward decline hurtles them toward oblivion despite your best efforts. The futility of the situation eventually becomes obvious to all and the time comes for "the talk" with the family members.

I've had two patients in the last month who presented in extremis with peritnotis and/or ischemic bowel. One was an open and close case; entire length of small bowel gangrenous. The other was an incarcerated hernia with dead sigmoid colon that had perforated into the peritoneal cavity. Both patients were octogenarians. Both had lived full, enriched lives according to the respective families. It was time to say goodbye.

But how is this done? We agree to withdraw supportive care. Antibiotics are stopped. Vasopressors are halted. Directives are given not to run a code when the patient starts to deteriorate. There are no chest compressions. No epinephrine. The primary objective is palliation. Make the patient comfortable. In this synthetic environment, where some semblance of life is propped up with machines and tubes and drugs, it isn't ethical to merely "turn everything off". They've decompensated beyond the stage of self-sustaining life. Unplugging everything and stopping all the drips is about as cruel a thing as I can imagine. I never terminally extubate a patient. There's nothing more gruesome than watching a patient suffocate after terminal extubation. A wise old nurse made me experience it when I was a resident. No reason to pull that tube out. The dead bowel or the fecal peritonitis is going to stop the heart soon enough. No reason to expedite the death with unnecessary agony.

Here's my ICU orders for these cases:
-Do not extubate
-Morphine 4 mg IV q 15 minutes
-Propofol drip titrated to complete sedation/unconsciousness
-Turn down the sound on all monitors.

People don't die on cue. Sometimes it happens right away, as soon as the levophed is unhooked. But not always. I've seen patients linger for hours, heart rates in the 30's, blood pressure barely registering. The families are in the room, keeping vigil, together for the last moments of the loved one's life. The patient is peaceful looking, sedated, unrushed on his journey toward death. We cannot control the inevitable end, but we can control how gently we allow these poor souls to land.


Anonymous said...

A thought-provoking post. I'm not sure we need more protocols (already over-run with those), but your orders certainly sound kinder than what I've seen so far. At my institution, "withdrawal of care" usually means exactly that. "Comfort measures" should be something better than that.

rlbates said...

I agree with Alice. I like your orders.

Hey, You said...

Why "do not extubate"? I mean, isn't that uncomfortable to have a tube down your throat? So is not being able to breathe, but couldn't you use CPAP+O2 as a possible substitute? Just curious.

The Happy Hospitalist said...

we actually have an end of life order set.

All I need to do is sign it and everything happens just like it should.

Jeffrey Parks MD FACS said...

For surgical patients in extremis, I find that extubating leads to increased suffering from air hunger. These patients often have ARDS from the svere metabolic insult and CPAP masks don't provide much comfort.

Love to see a copy of that order sheet.

The Happy Hospitalist said...

BS (I like that). Go to my website. This one's for you.

Jeffrey Parks MD FACS said...

I like the order set... am going to try to get something similar implemented at my facilities...

Hey, You said...

Dr. Buckeye,

Thank you for the explanation. You sound like a very compassionate doctor.

Christian Sinclair said...

Here is an article titled Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American Academy of Critical Care Medicine (Subscription or OVID required)

Here is a point that highlights both of our main points:

"Considerable variation in practice attends to the decision of whether to extubate patients when withdrawing mechanical ventilation or whether to leave the endotracheal tube in place while the ventilator is weaned (54). Since survivors of critical illness frequently recall endotracheal tubes and suctioning as significant sources of discomfort, an argument can be made to remove artificial airways (55). Neither ethical principles nor current empirical evidence can support a dogmatic view on this question; clinicians should solicit input from team members and the family to make the decision in individual cases."

After doing a literature search, I realized how little there is on this fairly common practice. Thanks again for bringing this up.

Christian Sinclair said...


I posted a short rebuttal post to some of your points. I think we both agree on trying to avoid agony, pain, and suffering. We may have different ways of approaching it, and I wanted to present the view from a palliative medicine doctor.

I am glad that you have addressed palliative care issues on your blog, so please consider my post as addressing the same concerns. It is meant to be constructive. I hope to see you posting about palliative care more. One of the reasons I posted a different view on the same topic is to encourage more dialog about such a difficult issue.

Jeffrey Parks MD FACS said...

Your post well well written and insightful. I guess I would say that there are different palliative solutions for different scenarios. The post operative patient usually suffers from incisional pain that makes breathing difficult. Add on top of that ARDS or congestive failure and you intially end up with a patient who is gasping for oxygen as you try to titrate sedation levels with the tube out.

Another thing: I practice in a hospital without residents and without a formal palliative care team. There isn't someone to sit with the patient at bedside and make all the crucial adjustments necessary for true palliation. Leaving the tube in and keeping the patient snowed with propofol and morphine is a less labor intensive, and still quite humane, way of easing the patient on to death.

melvin said...

Buckeye surgeon ruminations by a non academic general surgeon from the heart of the rust belt. The primary objective is palliation.

Rositta said...

I googled air hunger and you popped up. My husband is at his mother's bedside in a Greek hospital. He has thyroid cancer that has spread to the lungs. She is 83 and the doctors in their "wisdom" operated to debulk last week and intubated. Now they refuse to honor the family's wish and extubate. They say it's against the law in Greece. They want to operate again to increase the airway. What the heck is the point I wonder. Would they do that here in North America I wonder...ciao

Dr.Abhijit Dam said...

I too am against extubation. This often leads the relatives to think that death is probably being hastened and it definitely sends out "bad signals" in a 'virgin'community like that in India where the concept of palliative care is still in its infancy. I deal with a lot of patients with massive intra-cerebral haemorrhage & if their ICH scores are deteriorating after 24 hours, I prefer to switch off the ventilator & connect them to a T-piece with a O2 flow of around 2 l/min..that way everyones happy! The discomfort of the tube can be minimised by narcotics & endo-tracheal instillation of lignocaine. In fact, I am currently pursuing this as my current area of research.

Anonymous said...

While for some patients this may be appropriate, I've seldom seen a case where atropine sublingual or scopalamine patch, pain meds and sedatives would not work to stop any potential discomfort. Some patients may not need to be sedated. extubation allows some to talk one last time. Even if unresponsive, consider that many families appreciate seeing their loved one "sleeping" without machines in a quiet inpatient hospice bed instead of a nerve-wracking, expensive ICU vigil. It's something to think about...thanks for the patient-centered thinking on this page.