Continuing the theme from the last post…

Mr G, 63 yr old, has a long history of ischemic heart disease.  Unfortunately, due to Mr G’s coronary artery anatomy, neither coronary artery stenting or bypass surgery offered potential benefit, so medical management was his only treatment option.   As expected with this condition, he has been hospitalized several times over the past few years and although Mr G has ‘recovered’ each time, his overall health continues to decline.

A month ago, his cardiac function as measured by ejection fraction was at best 15% (normal ~60%).

Ten days ago, he was admitted to the ICU in shock secondary to sepsis caused by acute cholecystitis.  Mr G was so sick, that cholecystectomy, the operation necessary to remove his infected gallbladder, was impossible- he likely would have died during the procedure.  So, a more limited procedure, placement of a drainage tube in his gallbladder was done, to try to control the infection.

Mr G remains in the ICU.  He continues on iv antibiotics and requires two pressors to help him maintain a barely adequate blood pressure.  In addition, because his heart is so weak, his liver is not working normally and Mr G intermittently requires help with his breathing- so he has been on and off BiPAP for respiratory assistance.

Despite all of these treatments, he has not shown any signs of improvement.

For the past few days, the ICU team has had multiple conversations regarding ‘code status’ with Mr G and his wife.  To the team’s frustration, Mr G continues to want ‘everything’.   And now, one more set of organs- his kidneys- are failing. Because Mr G will never be able to tolerate dialysis, the ICU team really feels like it’s time to stop these aggressive interventions and shift to comfort focused care.  So, the palliative medicine consult was placed- ‘to help the patient/family understand’.

Before visiting a patient, I use my review of their records to help paint a picture of the person.  After reviewing Mr G’s records, I envisioned a very frail, barely conscious, critically ill man.  Imagine my surprise when instead I found a hearty appearing (although quite yellow- from his liver dysfunction) Mr G, reclining quite comfortably in bed on supplemental oxygen by nasal prongs, reading the Sunday NY Times.  His wife was there at his bedside, casually working on the crossword puzzle.

Not a typical site in the ICU.

Yes he was still requiring 2 pressors- at almost max doses, with systolic BP barely in the 80’s, yet, he was awake, alert, in great humor.   Mr G’s main concern what wondering when they would let him get out of bed to start physical therapy.

Mr G and his wife had a good understanding of his overall disease and current condition.  Because he has been living so long with severe cardiac disease he’s been told he’s ‘dying’ on several occasions.  And each time, he’s managed come off the aggressive ICU treatments, get well enough to leave the hospital and although admittedly with functional decline, he’s kept on going “like the energizer bunny”.

Mr G explained that prior to this hospitalization, he was essentially home bound, but thanks to technology, he remained in regular contact with family and friends.  Despite his limitations, Mr G feels there is high quality to his life.  And his family and wide network of friends are very supportive.

Mr G doesn’t understand why the fuss?  And even though he’s never had the added problem of kidney dysfunction, he doesn’t feel he’s ready to give up.  “I’m not ready to die yet.”

I don’t think the ICU team really gets that by asking Mr G to decide to transition to comfort care, in essence they are asking him to die.  And in his current state, he’s not ready to do that just yet.

Would you?

When the patient/family are not ready to make any changes to their overall treatments despite the providers feeling there’s little hope for a good outcome, my advice is to back off, at least for a bit.  Give them some time or wait until a new event occurs which further reinforces your belief that continued aggressive treatments are not effective before bringing up this subject again.

In Mr G’s case, before consulting us, the ICU staff brought up ‘code status’ almost daily and this was causing undue friction and unnecessary tension.  In fact, his family started to wonder if the providers were truly doing all they could for him-  distrust that is damaging, and the last thing you want to develop between providers and patient/family.

So, give them time.

And try to remember that what is unacceptable for one patient, is totally acceptable for another.  For some people, a life as limited as Mr G’s would be too burdensome, but it wasn’t for him.  So even though you as the provider may foresee a poor outcome, what’s ‘poor’ for you, may actually be acceptable to the patient.  It may allow the patient time to reconcile with a family member, to experience a special event (I’ve helped arrange several in-hospital wedding ceremonies), or just have a little more time to be alive.

I visited daily with Mr G and his wife- and except for checking to ensure any symptoms were controlled, we discussed anything except his medical issues.  And after a few days, as his renal function continued to decline, I could see Mr G was now starting to feel the ill effects.  His body became more swollen, and he was more tired.  Because his breathing was more labored, he required high flow oxygen or BiPAP around the clock- neither of which is particularly comfortable.

And when I asked him how he was doing, both he and his wife were now quiet.  And the room was filled with a sense of profound sadness.

They knew.  This hospitalization was going to end differently.  Mr G was not going to improve.  And as we talked, he made the decision to shift to comfort focused care.  Mr G was transferred out of the ICU to a more peaceful setting, and he died hours later with his family at his side.