"He would never
have wanted this." Through the tears, my patient's family were clear their
father would never want a breathing machine to sustain his life, if even
temporarily.
The endotracheal tube
was secured 25 cm at the teeth. It had been that way for about 2 hours,
but I'm certain it seemed like an eternity to the two daughters of Mr. S. when
they walked into the ICU room that morning at about 7:30am. Although Mr S. had
previously been well sedated, he quickly started coughing upon his daughters
entering the room. Their tears echoed his disdain for the situation.
As a former high school
teacher and coach, Mr S had lived a full life. The ripple effects of this were
evident in the love his daughters were showing for him. He had undoubtedly
touched the lives of many through his teaching, in and out of the class year.
As the years went on, however; so did his mind. Although his body was
relatively young at 92, his mind was not. Alzheimer's, a difficult disease and
form of dementia, had sent in some years ago. The disease progressed, as it
normally does and activities of daily living became more difficult. About 2
weeks ago, he got out of bed quickly to use the restroom, had a mistep, heard a
pop, and fell to the ground. After family had brought him to the emergency
room, it was discovered that the pop was in fact a broken bone in his left hip.
Several days later, the
patient was having difficulty with pain and confusion. After undergoing a
surgical repair for a broken hip, his post operative course was proving to be
more complicated than the procedure itself. Days after the operation, his groggy
mental status and severe pain led to difficulties eating and swallowing. This
common set up for aspiration leads to more problems. Unfortunately, he
developed respiratory failure in the middle of the night, and was transferred
to the ICU. In an emergent response, the patient was intubated so that a
mechanical ventilator could assist his breathing.
Although family had been
contacted in the middle of the night prior to their father going on the
breathing machine, nothing prepared them for the reality of the situation when
they walked into the room the next day. Hours later, the patient passed
comfortably after family members elected a comfort care approach.
Unfortunately, this is
not an uncommon situation in today's healthcare system. Healthcare providers
performed quality care. The family was present, caring, and supportive of their
loved one. The patient, perhaps the most vulnerable, presented for help in a
time of need. So how did Mr. S. find himself in a situation he would never have
wanted?
Mr. S. had never filled
out an Advanced Directive.
