A 72 year old woman (55kg), Mrs X, with a history of severe emphysema and chronic bronchitis is intubated in the Emergency Department (ED) because of drowsiness associated with hypercarbia after her initial arterial blood gas analysis revealed:
You are called to the ED to assess and admit this woman to ICU. The history from her daughter reveals that Mrs X lives independently but is limited by severe breathlessness with exercise. After 3 weeks of difficult ICU management Mrs X is discharged to the ward.
(e) What are the principles of managing her should she deteriorate and require readmission to ICU?
That night she develops sputum retention and becomes drowsy. Her daughter demands ICU admission.
(f) What will you do?
After 3 weeks in ICU this 72 year old lady with severe CAL is entitled to the opportunity of a frank discussion about advance care planning. The aim of this question was to explore discharge planning to prepare Mrs X and family for eventualities. Much will depend on what has been learnt about her disease and whether the admission was the result of inexorable deterioration of her lung disease or precipitated by a reversible event. A group conference should be organised before discharge.
The general plan being:
- prepare for the discussion by providing a suitable environment, gaining the medical facts, getting a medical consensus on a contingency plan
- establish what the family and patient know
- determine how much information they want. How open and frank a discussion.
- explain the medical information and a proposed medical plan
- assess the response of the patient/family and respond to their emotion, questions and disagreements
- establish general, accepted goals for long term care
- finalise a plan
Details will include Mrs X’s desire for intubation if necessary in the future, the use of non-invasive ventilation etc
That night she develops sputum retention and becomes drowsy. Her daughter demands ICU admission
(f) What will you do?
The response will depend on the results of the conference, and the plan reached. If her daughter demands ICU admission for Mrs X it is best to
- assess the medical appropriateness of admission at this time
- assess alternative or more appropriate avenues of management
- discuss with admitting consultant to agree on a plan
- communicate with Mrs X’s daughter and arrive at a mutually agreeable plan bearing in mind that the stated wishes of Mrs X are paramount
A review of events of the day should be undertaken to ascertain if there is a cause for this deterioration eg sedation, narcotic administration, sepsis, pneumothorax.
If readmission appears to be appropriate then there is no problem.
If it is not, because of terminal irreversible condition or it is against the clear wishes of Mrs X, the feelings and motivation of the daughter will need to be addressed and answered.
In the discussion with the family,
Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine." Journal of critical care 34 (2016): 125-130.
Palda, Valerie A., et al. "“Futile” care: Do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses." Journal of critical care 20.3 (2005): 207-213.
Sibbald, Robert, James Downar, and Laura Hawryluck. "Perceptions of “futile care” among caregivers in intensive care units." Canadian Medical Association Journal 177.10 (2007): 1201-1208.
Danbury, C. M., and C. S. Waldmann. "Ethics and law in the intensive care unit." Best Practice & Research Clinical Anaesthesiology 20.4 (2006): 589-603.
Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine." Journal of critical care 34 (2016): 125-130.
Schneiderman, Lawrence J. "Defining medical futility and improving medical care." Journal of bioethical inquiry 8.2 (2011): 123.
Ardagh, Michael. "Futility has no utility in resuscitation medicine." Journal of medical ethics 26.5 (2000): 396-399.
Schneiderman, Lawrence J., Kathy Faber-Langendoen, and Nancy S. Jecker. "Beyond futility to an ethic of care." The American journal of medicine 96.2 (1994): 110-114.
Waisel, David B., and Robert D. Truog. "The cardiopulmonary resuscitation-not-indicated order: futility revisited." Annals of internal medicine 122.4 (1995): 304-308.