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Is it ever ok to be paternalistic (play God?)


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So, actual case recently so details will be a bit vague.

Gentlemen in his 90s. never seen before at our facility. Known stage 4 lung CA, HTN, DM, angina. Recently decided he disagreed with his oncologist's assessment that there was no further options to extend his life. Had a DNR, which he revoked, making himself a full code. Gets very short of breath and calls 911. Medics know him and state he told them he wants all the stops pulled out to save his life.  Lives alone, has no family. does not sound like covid. Can not speak. can only shake head yes or no. Medics did not attempt intubation. No IV access. 

Presentation: arrives in severe resp distress on NRB mask at 15 L/min. Sao2 75%. pale/cool/diaphoretic

Pulse 30(sinus brady with PVCs). RR 36, labored with minimal tidal volume. temp 32 degrees(we got this later from the temp foley). BP 86/40.

Initial interventions: IO placed (crappy IV access with multiple ems attempts and a few by my RNs), trial of bipap with sao2 to 80% on 100% o2. atropine 0.5 mg IV x 3 with HR increase to 54. BP remains in the toilet. Considered pacing, but decided this was an inotropy issue, not a chronotropy issue Fluid boluses given to total 3L over next hr or so. push pressors epi doses x 3 at 25 mcg each with pulse to 64. BP remains abysmal. told patient that he would need to be intubated if he wanted us to continue, but that there was no shame in saying please stop, I'm done. Shakes his head yes, he wants to be intubated. huge snaggleteeth, difficult intubation, malampatti 3, but done with positioning, suction, and 1 attempt with glidescope after preoxygenation on flush with nrb mask to 94%. sao2 to 100%. tube in good position by xray. cxr as ugly as you might expect with adv lung ca. End tidal co2 20(later optimized to 35), OG tube placed, foley placed(this is when we get the temp: bare hugger applied with eventual normalization of temp), additional line placed by u/s in AC by an excellent nurse who showed up from the floor to assist. bloods drawn and sent. norepi started and maxed out. epi drip added and maxed out. pulse now 55-65 with bp 90-120 systolic. quick u/s shows really floppy looking hypokinetic   LV. The only facility that knows this guy is on divert....

significant labs: wbc 28,000, h/h 10/30, lactate 1.7, ua with micro wbc TNTC on cath specimen(rocephin given, should probably have been cefepime/vanco). TSH 38(yes, 38). mag 1.6(and repleted). PH after intubation on blood gas 7.28. blood sugar 350. renal and liver function ok. Considering multiple etiologies to include myxedema state(with bradycardia, hypothermia, and hypotension), covid or influenza(both neg as was rsv), pneumonia, PE, PTX, ACS, CHF, DKA, etc. Never stable enough to run through the scanner. 7 hrs of critical care time spent optimizing drips and vent settings and calling every hospital within 65 miles. all closed to icu traffic. . any attempt to turn oxygen below 100% results in desat. got norepi down to 10 mcg, but could not budge epi without hypotension and bradycardia. considered additional pressors(specifically dopamine), but felt to be truly futile(and anesthesia agreed when I asked them) . finally found icu and intensivist willing to accept 90 min away. guy wants medevac. I put my foot down and said no. weather ugly, but flyable, but I am not ok with risking a flight crew for a guy who will probably be dead within a few hrs regardless of speed of transfer. No one present(including my PA student, myself, the nurses, and the crna who later arrived after an hr or so as he heard through the grapevine that we were dealing with a cluster) felt even remotely ok about this case.

So this begs the question(and it is a serious question): when can you stop a resuscitation against the will of a competent patient when you KNOW your efforts to be futile? This all happened on night shift so no ethics committees, etc available. If he had arrested at any point I would have felt ok with calling the code very quickly, but that never happened.  I never called our hospitalist as I knew the patient was too sick to stay at our facility and he would have nothing to add(he is 20 years younger than I am) and it was o'dark 30 and I wanted to let the poor guy sleep. he does 7 on/7 off. . . He saw me the next morning and said "heard about your moral injury last night. that sucks. ".

Discuss.

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In reviewing the most pro-life of the various Christian ethical stances, the Roman Catholic (sorry I quote them all the time, but protestants are a hodgepodge mishmash with no unified voice) take on bioethics makes a distinction between ordinary care and extraordinary care that I believe applies in this case.  Ordinary care, in this case, probably includes what you did do, but at the very least involves a minimum standard of human decency: you kept him warm, comfortable, nourished (to the extent it made sense) and above all kept him from dying alone.  Extraordinary care always includes CPR and emergency surgery, and in this case I have no doubt you correctly classified the helicopter as an extraordinary intervention.

It makes no sense to start CPR on him.  I remember reading the last hospital notes of the first family medicine patient I KNOW I lost--36 YOF, malignant melanoma that I'd biopsied and had correctly and timely referred... it just skipped a sentinel lymph node and mets'ed all over the lungs a year later. I'd probably lost others, but this one I knew from diagnosis through death--and it included a note about the discussion of "no code" status with this patient and her husband, noting that lung cancer was not a reversible process, and so they had consented to no CPR.

Everything prehospital in me screams that we need to do that CPR on the young woman: We can get 50, 60 QALYs back for her, can't we?  But no.  Cancer doesn't remit just because we do high-quality compressions, nor any of the much more elaborate interventions you did for your patient.

In your gentleman, I wouldn't have started CPR at all.

What could you have done differently? You may not have an ethics committee up at zero-dark-thirty, but it would have been nice to have a chaplain come talk to him.  If I'd been your on-call chaplain, I would have introduced myself and started off with something like "I'm so very sorry to hear that you are dying.  How can I help you die well?" and wait and listen.

In the end, I'm presuming he died either during the ground transfer or sometime afterwards.  You gave him time to organize his thoughts around dying; who knows what he actually used it for?

One of the key things about a DNR is that it never says "do not treat", "do not comfort", or "do not care for".  It only precludes extraordinary, and perhaps some ordinary, interventions.

Hopefully, medicare will pay enough for the futile care that your rural access hospital will not lose significant money on the events.  You, your nurses, your PA student... all now have more experience dealing with the elderly, ill, decompensating patient.  You never know where that practice will pay dividends down the line, where the lessons learned in the futile care will save a life somewhere else.

Sorry that's not more organized; those are my initial thoughts on the care rendered. I'm nothing remotely like an intensivist and have nothing to contribute to or critique regarding your practice of medicine.

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Thanks, Rev. Honestly never thought about the chaplain because he was intubated and paralyzed early in the course of his hospital stay. I think he is still "alive" if that counts being intubated on a paralytic and 2 pressors.

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One old school question from years past, isuprel due to poor LVF?  Life includes death.  Most do not accept this fact as part of life in my experience.  Physical death is separation of spirit from the body.  Spirit lives on while the body decays.  Life decisions dictate the end result in my belief at that point.  I can’t imagine anything further that you could’ve done.  The patient has clearly expressed their desire prior to intubation, however I would’ve been quick to call it if he had arrested.  It’s difficult to reverse death, regardless of its source.  

The most rewarding experience of my 36 year career was being dumped on by a UTSW IM resident at the Dallas VAMC who without discussing with me beforehand had me scheduled to discuss with a lung CA pt. his desire to proceed with a risky bx. that could’ve been fatal in its own right as opposed to terminating further care.  At the end of the discussion, and review of the films on my computer screen, we formed a prayer circle with he and his family and left it in God’s hands.  I left shortly thereafter.  There were other similar instances during my six months there but the takeaway, just as with a statement not infrequently made by my former pastor, is that we are there to deliver the message to the best of our ability and at that point it becomes the individual’s ultimate decision as to how they wish to proceed.  Your patient made his decision, you respected it to the best of your ability, he made it to the tertiary facility alive, so I don’t see how you could’ve done anything differently.

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I've been in similar situations fairly regularly this last year man, I get it. I will honor the patient's and family's wishes in the acute setting to the point of arrest, at which point any reversible causes are quickly addressed and the code called. CPR ain't designed to fix CA, or sepsis, or most of the things that end up killing 90yos.

The lactate of 1.7 makes absolutely no sense to me. Whatever the underlying etiology, be it septic shock leading to myocardial dysfunction (most likely in my mind) or myxedema (did you happen to get a reflex FT4? Sick euthyroid will commonly give those TSH's of 30/40/50) or whatever...that prolonged period of hypoxia and malperfusion should've led to a bump.

Guessing if the trop had done anything you would've mentioned it.

Strange case. And frustrating, have almost the exact same guy in one of my outliers, family won't pull the trigger, refusing to make any decisions. So we did a two provider futility decision, gentleman is now DNR at least.

Need a beer sometime let me know man.

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I was under the impression that TSH values in the 40-50 range weren’t typically indicative of/associated with myxedema.  My daughter’s was over 100 as a child when it was discovered (always took a sweater whenever we went out to eat, even in 100+ N. Texas summers).  No peripheral edema or facial puffiness.  With diminished LVF in this patient the key would be to check for pitting versus non-pitting LE edema.  Oops, that requires a PE (had to bring up another thread).  Now, where’s that tape measure that I always used to carry with me in the ED to measure LE’s...

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Short version: stop when the patient's heart stops.

You and your team did an extremely skillful job respecting the patient's wishes, even though it's almost certain that the patient will die within hours/days.  Having a thoughtful discussion with the patient isn't possible because: 1) it's EM and we inherit everyone else's messes and the oncologist likely had that discussion, 2) the patient was intubated and even before then probably didn't have the mentation to fully participate.

I'm afraid we have to respect the patient's wishes.  We can consoles ourselves in these situations that we learn alot about critical care and ethics.  You taught that PA student an incredible career long lesson.

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You did well

respect patient wishes 

don’t further endanger life/limb (no helicopter in bad weather)

keep pushing and trying when guy is alive 

on coding not sure what would have been best.  If he was not a DNR probably consider a few rounds of cpr and EPI then call quickly.  I think you have a minimal duty to act at that time but I am no attorney.  And with horrible lung CA and all the hx likely fine either way.  

their is a reason they call it the practice of medicine. 

thank you for sharing what is obviously a tough ethical case. 

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It's interesting to see how the U.S. approach to healthcare has evolved outside of the remainder of our allies.  CPR in other countires isn't a guaranteed thing, you essentially need to qualify for it.

Worked with an attending a few years ago who approached it along the following lines:

"Performing CPR is a medical procedure which has benefit for some people, and none for others.  CPR is not going to benefit you so I am not offering this procedure."

Some folks didn't agree with his approach but I was pretty well on board in certain situations. 

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10 hours ago, ohiovolffemtp said:

 

I'm afraid we have to respect the patient's wishes.  We can consoles ourselves in these situations that we learn alot about critical care and ethics.  You taught that PA student an incredible career long lesson.

Indeed- She had never been in that situation before, had never seen an intubation, an IO, or pressors used. The ethical issues were huge, but she also learned a lot about medicine that night as we tweaked the BiPap and later the vent, the meds, gave atropine and push-preessor epi, corrected the acidosis and hypothermia. She had never used a BVM before. Lots of good student stuff here all around. 

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3 hours ago, ventana said:

 

thank you for sharing what is obviously a tough ethical case. 

Thank you for this. My chief called me the next day because he heard we had all had a rough time on this one. It is a small town. The patient is a friend of his. he was happy with how it was handled, so I feel a bit better about that. 

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31 minutes ago, GetMeOuttaThisMess said:

Wonder what, if any, role the hypothermia had in his initial survival?

Good question. I was thinking of the hypothermia as a symptom, not an incidental environmental factor. His bradycardia certainly seemed to improve as he warmed up, despite constant pressor infusions at that point. 

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That's tough but you did excellent treating the patient as they presented and fulfill their desire to be full-code even though futile honestly. As the ER Provider, the goal is to stabilize whatever that comes in and you did just that. Now let inpatient services deal with the rest regarding the ethical portion of it. I personally wouldn't feel okay working with a provider who refuses to initiate life saving treatment because of a patient's prognosis and acting against the patient's behalf (paternalistic approach). I would feel totally okay with a provider who initiates life saving treatment and then terminate such treatment once proven ineffective.  

Experienced something similar a few months back. 50 YOF with stg 4 lung CA with a prognosis of <1 year to live. ER Doc who signed up for the code with ACLS in progress in field recognized her and said prior to the patient's arrival that she knows her hx and she was a full code from the nursing home. We did ACLS for a good 5 minutes (1 epi and 1 round of CPR) before she called it. She rendered care. I would want nothing to do with that scenario if I over heard the doc saying we're pronouncing her DOA without rendering in-hospital care.

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Skipping past the medical issues, that I believed you handled well, I don’t decide for patients when they want to go. If they want, everything done, then I do everything. The opposite is true for me as well. If a mentally sound patient wants to go, even though I think they have a decent chance of survival, I respect that to. If it were legal, I would even assist a dignified death. In this case, I may have been brutally honest. “Sir, I understand your survival instinct and fear of the unknown surrounding death, but you ARE going to die and very soon. If you want to be flogged with every treatment that I can provide, I will do it with all the greatest skill I can muster, but it will be ultimately futile. Or, I could make allow you to pass in a peaceful, comfortable, dignified manner.” His choice.


BUT, this doesn’t mean I never play god. I 100% agree with your decision. Same way I make a decision in a mass casualty who gets out 4 units of uncrossed blood. In the navy, I was trained pretty extensively on triaging care in large scale simulations both behind and beyond “the wire.” Just like the best care under fire is returning fire (you can’t help anyone ever again if you die), I do not triage this man’s futile care over the life of the helicopter crew.

lastly, my obligation stops shortly after his heart does and would call it quickly.

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