To tube or not to tube

[Doczilla]

41 YO F presents to the ED in status epilepticus due to profound hypoglycemia. She has a history of type I diabetes as well as multiple sclerosis. She functions independently at home, but has maxed out therapy for the MS, which has been progressive.

The patient was last seen normal by her husband about 3 hours ago when he went out to run an errand. When he returned, he found her unconscious. Accucheck read "low", so he gave her 2mg of glucagon IM and called paramedics. Blood sugar read 113, though we think this may have been a spurious reading by the meter. Nothing suspicious was found such as a suicide note or empty pill bottles.

She is on an insulin pump, which appears to be functioning well and is not empty. She gets 2mg ativan IV and D50, which stop the seizures. She never regains consciousness in the ER. In fact, she requires multiple doses of D50 and a D10 drip to maintain her blood sugar.

Here's the kicker: she has a DNR order, which the husband produces from 2007 (DNR orders in Ohio do not expire). He, and her father (both at the bedside), state that the patient had explicitly stated that she would not want mechanical ventilation, CPR, or defibrillation at any time, and was quite adamant about it. The DNR form does not specify what treatments can and cannot be performed, simply to not resuscitate in case of arrest. No mention on the standardized form about intubation or any other measures.

I'll tell you later about what happened with her.

I got into a discussion with a couple of the nurses about what to do with her. I did not think that intubation was appropriate, as we had an (albeit old) DNR form and two close family members that said she would not want it. The nurses said that she is young, still very functional and relatively healthy, so why would we not intubate or resuscitate her if needed? I cited two chronic, progressive, debilitating diseases, although I concede she is not bed bound or demented. They brought up the fact that the husband may be stretching the truth for his own purpose, i.e., to rid himself of her. They brought up the possibility that he may have given her an intentional OD of insulin, though at the present time there is no evidence of foul play. She is currently maximized on therapy for the MS, and in fact exceeding typical doses of her medication (not illicitly, but with doctor's order) to try to slow the progression.

So, if it is medically appropriate (i.e., for airway protection, need for ventilation) do you intubate her?

I am not concerned with discussing details of her treatment right now, only the ethical question of intubating or defibrillating her if it becomes necessary.

'zilla

[DwayneEMTP]

I have to go with no Doc. She has the DNR, has stated to two close family members specifically not to be intubated. It sounds like a woman who is done fighting, and I believe that she has the right to make that decision, and is blessed to have family members that are willing to fight for her right to do so.

I would likely get jammed up on this no matter what service I worked for, but I will not knowingly disregard a persons end of life wishes. Especially this woman, who has fought so hard for so long with these diseases. I'm going to (Maybe) wake her up and tell here that not only has her life been raped by disease but I chose to rape her once more by removing any power she had left by ignoring her wishes. Aint going to happen.

Not only do I think it should be honored now, despite what the nurses feel her quality of life is, but she had these wishes four years in her disease's past! Certainly she's much more tired, and much less happy now than she was then, at least from a health point of view.

I'm guessing you'll tell us the ultimate outcome at some time?

I really, really love the moral/ethical debates. I don't think that we have them nearly enough here...

Dwayne

Note: How did you determine that the seizure was cause by the hypoglycemia and not the MS? Unless that's best left for another time. I know you want to keep this moral/ethical instead of pathophysiological, so if there is not a simple answer, please disregard this question.

[medicgirl05]

I recently had a very similar call.

In Texas DNR orders do not expire. Also, we discussed what treatment DNR orders cover. We came to the conclusion that intubation is mechanical ventilation and unless otherwise specified a patient with a DNR does not get tubed.

However, if there was any doubt in my mind as to wether it was the correct thing to do I would tube the patient as a tube can be pulled later.

That's just my opinion though. Im curious to read other responses...

[chbare]

Damn Doc, I really appreciate the doc's continued involvement on the city. At this point, I'm going to have to go with no intubation as well.

Take care,

chbare.

[mobey]

Another vote for witholding intubation.

If she has not updated her DNR, I assume her feelings have not changed on the subject.

I do understand where the nurses are coming from, allowing death is not really what we are programmed for, but we are not in the buisness of ignoring human rights either.

[paramedicmike]

I'll also say no intubation.

The only point of contention with the nurse's argument regarding the husband wanting to be rid of her is that her father was also on board with no intubation.

So who called for the ethics committee consult?

And I'm looking forward to hearing the outcome.

[Aussieaid]

Here's the kicker: she has a DNR order, which the husband produces from 2007 (DNR orders in Ohio do not expire). He, and her father (both at the bedside), state that the patient had explicitly stated that she would not want mechanical ventilation, CPR, or defibrillation at any time, and was quite adamant about it. The DNR form does not specify what treatments can and cannot be performed, simply to not resuscitate in case of arrest. No mention on the standardized form about intubation or any other measures.

To me this implies that she has obviously had extensive discussions about her wishes with her family. Perhaps they were just not aware that you needed further instructions related to what advanced life support options you do or don't want such as intubation.

I would concur with not intubating. I understand the nurses concerns for potential malice on the part of the husband (less likely that both husband and her father would be in collusion) but it doesn't really compare to the rights of the patient to not suffer unnecessarily or have her family suffer with her potentially in a vegetative state. Unfortunately even though she could potentially live many more years without disabling symptoms the fact that she is currently not waking up shows a poor prognosis.

The defibrillation part should be covered in the DNR so I would not go there at all.

Interested to hear the outcome (and more on the pathophysiology of her presentation!)

[Eydawn]

Definitely one to turf to the ethics committee for final say-so, but I'm going to say no intubation. She has a valid DNR order (which should really get updated every year or so to avoid any confusion), and spouse (legal control, yes?) says to uphold it, as does her father (next in line as next of kin).

Sad situation, definitely one that makes you think...

'zilla, when can we have the pathophys and other details? ;-)

Wendy

CO EMT-B

Student Nurse (am I a dork for updating my sig like this?)

[island emt]

If there are no indications of foul play and the DNR is valid then you honor the wishes of the PT.

Both husband and Her Father concur , so i doubt it's something they have schemed up to get rid of her.

A patient's wishes trump all other medico-legal issues in my mindset.

I dealt with this issue the other day.

An elderly gentleman in failing health had filled out a DNR/POLST order and had called me to let me know of his exact wishes.

As his health continued to decline , several family members became involved, and wanted to start making his healthcare decisions for him.

I produced a copy of his orders and explained to them that these were his wishes when he was of sound mind and we would be following them.

Well they wanted to override the POLST/DNR so I asked them to contact his physician. Low & behold the DR advised he had helped the PT to come to terms with his diseases and that the orders were truly the PT's wishes. The family members were not happy but at least they allowed him to have his final days his way.

[NYCEMS9115]

I've been in Pre-Hospital Care for 15+ years; 12 years as a Paramedic. In the Last Quarter of the Nursing Program. I've learned Human Autonomy. I've heard about it in Continuing Edu Lectures. I read it in Medical Articles. I believe in it. Do onto others as you would want then to do onto you. We've heard all the cliches. So why has these Protocols hinder the autonomy of others. Why in NYS can I only accept the DNR in the Pre-Hospital setting. Why are the Heathcare Proxies, DNI, Power of Attorney, Living Wills, & other recognize Advanced Directives ignored by EMS in NYS? Now we have another form NYS DOH EMS has accepted, MOLST. Its nice but a lot of others in the Heathcare field are "Huh?" about it. Are we trying to individualized this? Are we going to have patients fill out another form, sign it, notorized, MD review and signed. Another form. C'mon; they already have the DNR, Living Will, Power of Attorney, and Living Will. What more does one need? Dying is already expensive but we've made the process more difficult than ever. All the best...