To tube or not to tube

[tniuqs]

With both father and husband in agreement that this was her wishes and unless another family member appears out of the blue to disagree one would be forced to just write orders for C+C use i.e. care and compassion and not withdraw of any life maintaining or present therapy.

NPT and transported to floors no ICU admission, internal medicine consult.

After many years in ICU it has been my observation that we humanoids are mortal beings. There is a clear distinction between supporting of a life and prolonging a death because we can. I always try putting myself in the position of all participating in an event like this (nope it doesn't make it easier) if it were Myself with MS and a brittle diabetic with very little hope other than to slowly deteriorate I believe I would like to see what is on the other side of door #2.

Agreed with the majority, If it were MY CALL to intubate I believe I would choose to side with patients legal wishes with some input from family members (that said there is always one family member that wants to believe in miracles and the individual will walk out the door tomorrow)typically proven wrong.

I sense that Doc has some hesitation with a concern of criminal intent, this should always be in the back of ones mind as one just never knows, the justification of husbands position a bit "clinical" but living with someone that suffers like this one must feel for him also.

In my old unit there was a very clear and predetermined with this type pathology "code DNR therapy" if in the event of arrest .. as in yes or not to "protecting an airway" yes or no to "electricity" yes or no to "arrest drugs" yes or no to CPR and yes or no to "narcotic sedation".

Always a tough call no matter in EMS or ER or ICU, I personally believe that committing to a vent and then after a period of many months bed ridden, to then slowly die from multiple infection's (as typically immune system is overwhelmed and a systemic fungal infection does the job) this is a situation worse than death itself in my view, well .... today.

You really think about these things when you are the ONE that has to physically turn off the ventilator, or written extubate to Room Air "death" order, besides seldom are the MDs writing this order EVER around to witness.

57 is a number that I am not particularly proud of, perhaps a major reason why I returned to EMS.

[Bieber]

Okay, well, this is my understanding: a DNR is not an order to withhold treatment, it's an order to withhold resuscitative efforts. Insofar as that no treatment given is for the purpose of resuscitation, or that once in arrest the patient is not given rescuscitative treatment, I don't think it's legally prohibited by the DNR. Is intubation invasive? Yeah. Does the patient WANT intubation, even if it's not for the purpose of resuscitation? Probably not. From an ethical point of view, no, I don't think intubation is the correct course of action. I would hazard to guess that when the patient signed the DNR, she may have thought that it will prohibit drastic measures from being taken up to and INCLUDING cardiac arrest. However, I can't make guesses as to what the patient would want, so I would have to defer to the pure legal facts: intubation is NOT being used as a resuscitative measure, but as an appropriate medical treatment for a patient that is still very much alive, and therefore in the absence of a DPA or advanced directions, is not prohibited by the DNR.

Now, were it me in the field, I would hold on the intubation till we got to the hospital and let someone with a bigger pocketbook than mine make that call. And that's a luxury I have in the field. I don't know what the exact rules/laws are regarding physicians, but I have seen--at least in my neck of the woods--physicians withhold certain treatments not covered by a DNR per family wishes. Ethically, I think we ought to respect the wishes of our patients who are aware of their fast approaching end, and if it were within my power to realize those wishes, I would rather give them a peaceful death than a terrible life. It's a tough call, and down one route you may never know what the patient's wishes were for certain; but down the other, you could violate their trust in the medical society, in their family, and further abuse an already tormented body.

[fiznat]

What is your legal responsibility in Ohio? Is there a separate DNI form that either accompanies or does not accompany the DNR? What are the state laws regarding power of attorney for unconscious patients? Does the hospital or your group have a policy?

I understand that there are moral and ethical ideas that get mixed in here, but I wonder if might be in the doc's best interest to ignore all that and simply follow the law as written. DNR does not necessarily mean DNI, and unless the family has a explicit right to make decisions on the patient's behalf, it might be best to follow the patient's documented wishes to the letter. Intubate, do not resuscitate.

How much good can the doctor do if he is sued or loses his job because he chose to make an independent, moral assumption about the patient's wishes? How many patients will he be unable to help then? It might not serve the greater good for the doc to risk his job over this single patient, and don't forget, intubation might actually be life saving!

Edited February 5, 2011 by fiznat

[HERBIE1]

I am concerned about something doc said here:

She required multiple doses of D50 and D10 to maintain her glucose level. Why? Malfunctioning pump or could someone have tampered with it? If she has an insulin pump, then should I assume her pancreas is completely nonfunctional or maybe her pancreas suddenly begin producing excess insulin? In other words, why does her glucose level keep dropping? I sense something wrong here- either she is trying to kill herself- maybe an insulin OD, or the husband(or someone else) has done it to her. Either way, I would be concerned that this is a criminal incident.

I'd want some answers ASAP before she coded and I'd have to decide about that DNR. I would definitely want the Risk control/legal/law enforcement folks involved. If this is a criminal manner, what are the obligations in terms of honoring the DNR and finding out if this was a suicide or homicide attempt.

[tniuqs]

I am concerned about something doc said here:

She required multiple doses of D50 and D10 to maintain her glucose level. Why? Malfunctioning pump or could someone have tampered with it? If she has an insulin pump, then should I assume her pancreas is completely nonfunctional or maybe her pancreas suddenly begin producing excess insulin? In other words, why does her glucose level keep dropping?

Yeah good pick up HERBIE .

[DwayneEMTP]

...How much good can the doctor do if he is sued or loses his job because he chose to make an independent, moral assumption about the patient's wishes? How many patients will he be unable to help then? It might not serve the greater good for the doc to risk his job over this single patient, and don't forget, intubation might actually be life saving!

I'm not clear how it was independent, as he consulted the document and the pts family. And I don't get how it was a moral decision as opposed to an ethical one? He's not deciding to allow her to die despite her wishes to live because he believes that she is too damaged to live, right? He's simply saying that though being a doctor is pretty big shit to most folks, me included, perhaps it's still not big enough to override the pts wishes.

Though Herbie does make an interesting point.

For those of us in the do not intubate crowd...does your opinion change if it turns out that this is a suicide attempt?

How about if it's actually a murder attempt and she's been left with additional deficits?

How does your opinion differ if it's neither of those but simply a malfunction in her pump?

Dwayne

[HERBIE1]

I'm not clear how it was independent, as he consulted the document and the pts family. And I don't get how it was a moral decision as opposed to an ethical one? He's not deciding to allow her to die despite her wishes to live because he believes that she is too damaged to live, right? He's simply saying that though being a doctor is pretty big shit to most folks, me included, perhaps it's still not big enough to override the pts wishes.

Though Herbie does make an interesting point.

For those of us in the do not intubate crowd...does your opinion change if it turns out that this is a suicide attempt?

How about if it's actually a murder attempt and she's been left with additional deficits?

How does your opinion differ if it's neither of those but simply a malfunction in her pump?

Dwayne

Looking at this from my scope of practice, and the same circumstances- prehospitally- if this person arrested and the DNR said no mechanical ventilation, then I would use the BVM, CPR, and contact medical control, citing the DNR. I would cite any concerns or suspicions about a possible suicide attempt and/or foul play, and let medical control sort it out. Based on similar ambiguous cases(questionable DNR's), our medical control usually advises to continue BLS resuscitation enroute to the ER. It's a lot easier to discontinue efforts vs waiting for clarification and then starting.

I honestly do not know if there are any medical/legal wrinkles with such a death, with a DNR, under suspicious circumstances. I suspect that the DNR may trump everything- regardless of HOW the person ended up pulseless and apneic. I wonder if we have any lawyers here that could answer that.

[Timmy]

I agree, things don’t feel right here, everything seems to be a bit airy fairy with no direct pathway of action.

I don’t know what you DNR orders look like in America but certainly here things are a little different. At the top of the form we have the not for resuscitation orders, this specifies that in the event of cardiac arrest (were your heart has stoped beating, you have stoped breathing and are clinically dead) the attending medical team are to withhold CPR, ETT, Defib and other life saving measures, so you tick the boxes as to what you want withheld. So when this patient goes into cardiac arrest, I can look down at the tick boxes and see that they want i.e. only want CPR but no other treatment or they want no treatment at all.

In the middle of the form we have a limitations of medical treatment order, this specifies that in an event were the patient becomes acutely ill or unresponsive the following medical interventions are to be withheld. Again tick boxes: to withhold intubation and ventilation, IV antibiotics, to withhold all medical treatment and to follow a palliative care pathway and there’s a few other interventions which I can’t remember.

At the bottom of the page is were all the parties involved sign there life away. It’s pretty easy to follow, all you have to do is look at the tick boxes to know what interventions the patient wishes you to take.

It sounds as though your DNR is only valid for a cardiac arrest, which the patient is not suffering from which makes the order not valid. With the possibility of foul play in question I’d say tube the patient until a legal directive can be made and the decision to withhold life saving treatment is all above board and legal. This patient might have a directive, medical power of attorney or any number of things that the people present, telling you to cease treatment are not actually included within. These family member could be hovering around waiting for her to die to inherent her millions of dollars…

I don’t support keeping people alive to prolong there zero quality of life, I respect there wishes and palliative care pathways but in this situation were the DNR only specifies what to do if the patients suffers from Cardiac Arrest you need to keep her alive until a better, more legal directive has been reached or the patient goes into cardiac arrest. I follow the CARE theory, Cover Ass, Retain Employment.

[fiznat]

It sounds as though your DNR is only valid for a cardiac arrest, which the patient is not suffering from which makes the order not valid.

Yes, this is the point I was trying to make. The patient could have filled out a DNI form, or a comprehensive list of advanced directives, but she chose not to. The only documentation of the patient's wishes we have is Do Not Resuscitate. Unless the family has a legitimate legal right to make decisions on the patient's behalf, what they would prefer, or what they think the patient might prefer, is of no consequence.

[chbare]

I'm not clear how it was independent, as he consulted the document and the pts family. And I don't get how it was a moral decision as opposed to an ethical one? He's not deciding to allow her to die despite her wishes to live because he believes that she is too damaged to live, right? He's simply saying that though being a doctor is pretty big shit to most folks, me included, perhaps it's still not big enough to override the pts wishes.

Though Herbie does make an interesting point.

For those of us in the do not intubate crowd...does your opinion change if it turns out that this is a suicide attempt?

No.

How about if it's actually a murder attempt and she's been left with additional deficits?

No.

How does your opinion differ if it's neither of those but simply a malfunction in her pump?

No change.

Dwayne

Take care,

chbare.