Tuesday, June 5, 2012


     As a pulmonary -lung specialist , I see patients in ICU who are very sick. We also come across patients that are on life support and the time comes when further medical treatment may be futile. So I tend to talk to the families about the futile care and withdrawal of the life support. Sometimes it is clear cut and easy , and other times it is very difficult. When there is diagnosis of cancer or patient is unconscious then it is easy , but when the patient is awake and can communicate , then it is very hard on me as well as families. This one belongs to the latter type.
      I was called in on a consult for a patient , who was admitted to the hospital with pneumonia . He was 55 years old White male , who had history of high blood pressure. Four months ago he had severe headache and was admitted with stroke and altered mental status . Further work up showed that he had bleeding in the brain . So the neurologist and the neurosurgeon operated upon him and drained the blood . He did survive, but the bleeding left him with severely impaired status . They could not wean him off the respirator and as he could not eat , he had to have feeding tube . (PEG ), He was otherwise stable , so was transferred to nursing home , on the respirator . In the respirator he developed pneumonia and so was transferred to the hospital in ICU and I was consulted .
      I saw him in the ICU. There was not much to examine . He was 55 years old , who was significantly impaired due to the stroke . The respirator was doing the job of supporting the breathing. The x-ray did show the pneumonia . He was started on the antibiotic. He could not move both legs and right arm . He could  move left arm , though not well coordinated. He could not open both eyes, only one eye , he could open . He was on respirator with the tracheotomy and was being fed via gastric feeding tube .
      Next day when I entered the ICU , I heard the banging noise coming from his room . As I entered the room I saw him banging his left arm on the side rail. I rushed in and held his hand . He could understand everything , though could not speak. I asked him, 'are you mad ? ' He answered , yes ,So I asked him 'is it because  the nurse could did not come quickly?'  He answered , no . I looked in his eyes , I knew the answer . I said to him , 'You are mad because you are here in this situation , bedridden, on the breathing machine, can't do anything, can't talk , eat . 'He  in his own way answered ,Yes.  I told him that we stop this , but I also told him  that if I would stop the breathing machine , he may die . He was willing to do it . I was not sure how I could go about it . But he was determined . I called his family . I also called the hospital 'risk management ' The patient was quite oriented ,So ideally if he did not want to continue life support , he could make that decision .But sometimes we can have medico legal problems or the families may not be agreeable or happy with the decision .
       I called his 2 sons . Both of them agreed to do whatever the father wants. I asked him to come in the town and sign papers. He agreed to come on the Friday. The other son was far away and told me that he would sign papers and fax them .
       The Friday came . I talked to the patient and the son . They both agreed and the son signed the papers . I signed the papers. and we did the withdrawal of the ventilator. He continued to breath on own and did not die . So we decided to transfer him back to the nursing home .
      He was transferred with one eye open , one hand barely moving  , with trachostomy , not able to speak or eat and with feeding tube . The only difference was that he was off the breathing machine.

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