"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.