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Live your life, don't prolong your death!
By Pippy Pipster
If anyone has read my other intel, 'Changing Careers', you know that I have worked as an ICU nurse for 21 years. Within the ICU environment we dealt with a lot of death and dying. Most often when people passed through our doors, they were able leave healthier than when they entered, but on some occasions, they would have no hope of survival and would succumb to their illness. This is a natural event that we all inevitably will face. In the hospital environment, there is what is known as a 'code status' assigned to every patient. A code status is given to a patient and defines what will happen to that patient in the event of a life threatening emergency. In other words, if your heart stops, what action do the nurses and physicians take? The code status of "no code" would dictate that the nursing and medical community perform no medical or nursing interventions, in the event of a life threatening situation. This determination, of 'no code' or 'code' is made by a group of people, including the patient, their family or next-of-kin, nurses and physicians. In that way, we as medical and nursing staff can be assured that the decision was made in the best interests of the patient, both legally and ethically. Sadly, the less common scenario that takes place in hospitals is that patients, with no hope, as determined by this group, are allowed to die in a humane, or at least as humane as possible, way. This is not considered euthanasia; it is considered a natural and inevitable event for a critically ill patient that experiences a life threatening event. So, what do you do if you have not yet had this discussion with the family, next of kin or patient? Well, of course we would have no option but to perform 'heroic measures' on the patient. The ethical dilemma for health care providers is that, statically, after a patient in hospital experiences a cardiac arrest, they have approximately a 15-20% chance of living long enough to leave hospital. In addition to this, their rate of survival decreases significantly with every co-morbidity that exists, i.e. diabetes, cardiac history, etc., etc. You can see that the rate of survival after such an event really is very low even if you arrest in a fully equipped hospital environment with many very well educated professionals. The really disturbing fact post cardiac arrest, besides your extremely low chance of ever leaving hospital, is that to achieve that goal of 'survival' we have to do such invasive and painful interventions to a patient. A 75 year old gentleman that had just been out for a stroll on the beach with family developed chest pain, no history of cardiac disease, no co-morbidities. Upon arrival of the EMT, the patient who was sitting on the beach, experiences a critical event; ventricular fibrillation. This means the bottom, largest chambers of the heart are beating so quickly and erratically that there is no blood being pumped to the vital organs, i.e. the patient is in a cardiac arrest; the heart has effectively stopped. The EMTs successfully, after two attempts, revive the patient. His heart is shocked back to a regular rhythm but the rate is very slow; 35 beats per minute. The patient is now having severe chest pain and pulling at the artificial resuscitation mask on his face. The EMTs remove the mask and apply an oxygen mask. Family is frantic and at his side. It becomes very obvious that this gentleman is having such pain and recent ventricular fibrillation because is that he is experiencing a heart attack. The EMTs scoop him up and they are off to hospital. Upon arrival at the hospital, the EMTs give report of the cardiac arrest, ongoing chest pain, vital signs, history that they were able to obtain from the elderly wife, and any other relevant data that they have collected. The patient over the course of the 'golden hour' experiences another cardiac event; asystole, which we all know as 'flat lining'. The heart has again stopped. This is a really bad sign, even more so than the ventricular fibrillation on the beach. The patient during this cardiac arrest is intubated, where a tube is insert into his mouth to pass into his airway, in order to deliver oxygen to him in the absence of his own respirations. That tube is connected to a ventilator which is assisting his breathing. A large bore IV is inserted into his neck, internal jugular vein, to float a temporary transvenous pacemaker. This 'floated in' pacemaker is connected to a battery pack that illicit an electrical impulse through the catheter down to the heart, giving a mild shock to the heart, for each and every heart beat, in order for the shock to bring on a heart contraction, in other words, we are now making his heart beat as well. He has two large bore IVs inserted in his forearms, one on each side, that are delivering anti-arrhythmic drugs, sedation and coronary artery dilators. In addition, he has inotropic drugs infusing to attempt to keep his extremely low blood pressure high enough to maintain life. In his bladder the staff has inserted a catheter to drain his urine, as he in unconscious from the events and the sedation. His arms are restrained bilaterally to protect him from inadvertently extubating himself, in which case he would have a chance of hypoxia and perhaps death. He has approximately 8 inch square areas, one to the left of his sterum and one mid-axilla, at about nipple level that staff has shaved and placed large adhesive pads for the external pacemaker that was used prior to the transvenous insertion. He has a tube inserted into his left nare passing into his stomach to deflate the air that was pushed in during resuscitation and to empty any contents and decrease the chance of aspiration. Later on this same tube will be used to feed him, if his condition allows his stomach to absorb the concoction that we will infuse. Ok, so he survived this part. He is now admitted to ICU where we strip any of his clothes that remain on, covering only his genitals, in order to get a comprehensive 'head to toe assessment'. The family who have been placed in the waiting room are later approached and asked about their feeling about 'heroic measures', in the event that the patient arrests again. They are given all the the medical information including the the fact that the patient is now in cardiogenic shock and that the rate of mortality with just this one consideration, without the history of two cardiac arrests and a heart attack, is somewhere around 80%. Armed with all of this information we approach the 78 year old wife about her 75 year old husband. They have been married for 56 years. Even with all of this information, she decides that she cannot make a decision to 'do nothing'. We explain that she is not making the decision to 'unplug' her husband but to just not do anything further. In other words, we are now keeping his heart beating with a pacemaker, keeping his blood pressure barely acceptable with inotropic drugs, breathing for him, feeding him, and he is totally paralyzed secondary to medication we are giving him to decrease the work load of the body. Her decision is made and it is firm and it is legally binding! We will intervene when this patient inevitably arrests again. Not a nice feeling for people that are here to help people through the life cycle not prolong their deaths. So, we ventilate his poor gentleman and preform all functions for him, as he is in a drug induced coma. We do this for an additionally 7 days, as his dear little wife watches on praying for a complete recovery. While the recovery never came, the inevitable death did. We made sure he was as comfortable as possible by the means of additional medications and made sure his dear little attentive wife felt as assured as possible in his comfortable passing. By the time of his death, she had been at he bedside everyday, mostly all day and at his side every night, mostly all night. To me this served a purpose, not sure what it was but I know that it was not all in vane. His prolonged death did allow his family to arrive home from all around the world and allowed his wife to whisper in his ear sweet thoughts and read to him, hold his hand and quite frankly exhaust herself. I am also sure that this was not fair to our patient what any person would wish on any member of their family or loved ones. I think before it is too late, all of us should state our intentions of 'code status' and our wishes to our loved ones. We should let other know what we plan to do in case they become seriously ill and what to do in case you yourself become seriously ill. It is not to be put off, not by me, because I or none of my loved ones will ever experience a death that we put so many through, knowing full well that they will not survive and that we are only prolonging their death. |
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May, 2012
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