By: David Bonham, M.D.

Dr. BonhamI was on call for my group of ICU doctors Wednesday night when I was called by a nurse and told that a new patient was just being transferred to the ICU in severe respiratory distress. The patient was an elderly gentleman suffering a neurological condition that caused progressive swallowing difficulty - to the point that he had to be fed by a gastrostomy feeding tube for several years. In spite of this he had been recurrently aspirating, developing pneumonias and other breathing difficulties. He was so frail now that he needed care in a nursing home. He and his wife had previously agreed on a “do not resuscitate” decision.  When he was brought to the emergency room earlier that evening, however, he said “Well, try and bring me back once.” Accordingly he was made full code status. He was comfortable on oxygen for a while but suddenly began to struggle for breath.

I immediately saw him in the ICU and it was apparent that he was in need of prompt life support treatments if he were to survive. I called the patient’s wife who had gone home just before his sudden deterioration. After I told her that he required intubation to survive, she said, “Please try to keep him going without that until my family and I can get there.” As she and her three children rushed to return to the hospital, I put a temporary bipap breathing mask on her husband to try and buy some time.

When the patient’s wife arrived with two of the children, they were distressed by his worsened state but not surprised, as his condition had been deteriorating for some time. They clearly had had previous discussions about the patient’s desires regarding end of life treatments. We discussed our potential options including intubation, mechanical ventilation and other medical treatments that might delay his imminent death but would not reverse the overall deterioration of his health. We also discussed “comfort measures” which would focus on relieving pain and suffering, but not subject him to the uncomfortable bipap treatment or to aggressive intubation and other “heroic” interventions. 

While we were talking, his oldest daughter arrived and was clearly shocked by her father’s condition. She rushed to him and asked, “What’s going on?” Tearfully, her mother explained that her father was dying.  She couldn’t accept this and urgently asked, “Is this permanent?”  Uncertain what her frantic question meant, I explained as gently as I could that her father’s neurologic problem was causing recurrent aspiration and debilitation and was never going to get better. We had arrived at a crisis point, as he was unable to breath adequately. This explanation did nothing to lessen her distress.

Then the patient’s wife approached me at the foot of her husband’s bed, tugged on my sleeve, and said, “Let’s just do it”.  I asked her to clarify exactly what she meant, and she said, “We should do the ‘comfort measures’ and not put him on a respirator. That would just cause him more suffering.”

I suggested to the family that they take some time together in the hospital room to talk about the situation, and that I would return after they had come to a decision.  The youngest daughter came up to me as I left the room and urgently said, “Please don’t go far.” I said that I would return soon and updated the nursing staff about the situation. I then attended to some other patients in the ICUs and rejoined them after fifteen minutes.  

The family then was ready to proceed with “comfort measures”.  We all talked about the choices a little more, including the oldest child who was still very upset but did believe that her father would not want to be kept alive on a breathing machine. We then removed the tight bipap mask and provided additional treatments to relieve shortness of breath and pain. The hospital team, including the nurses and chaplain and myself, continued to support them all as best we could.

I left to see other patients, feeling very fortunate that I had been able to spend some hours helping this patient and his family.  I later learned that he had died a few hours later and seemed to be comfortable during his last hours. 

Sometimes I think we do the most good as ICU doctors when we help patients and their families to accept imminent death, relieving pain and suffering as best we can. It is seldom possible to bring everyone involved to perfect consensus, but keeping the focus on loving care and comfort can be the result of our providing information and guidance as well as the sharing of their feelings and fears.  Advance care planning can greatly enhance the ease with which this final stage unwinds.

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