Advance Decisions in Critical Care

 

An 85 year old man with good pre-morbid function was admitted to the ICU following emergency laparotomy for a ischaemic perforation of small bowel. He had undergone a small bowel resection and primary anastomosis. Preoperatively, the patient had been delirious and unable to consent for surgery, assent was granted by his wife.

Postoperatively, the patient required mechanical ventilation, vasopressor support and renal replacement on admission. He stabilised by day 5, but remained mechanically ventilated. On day 5 of admission, during a discussion between the surgeon and the patient’s wife, the wife admitted regret that she had not had “better” discussions with the surgeons pre-operatively and raised doubts as to whether the patient would have wanted such treatment. Following those discussions between the wife and surgical team, limitations on care were placed; renal replacement therapies would not be restarted and vasopressor support would not be escalated beyond the existing level. A DNR order was implemented. On day 10, during discussion with the duty ICU consultant, it emerged that the patient had a written advance decision refusing “aggressive medical treatment”.

 

The patient continued to improve but could not be weaned from ventilation. A percutaneous tracheostomy was sited on day 10. On day 15 he was liberated from mechanical ventilation and able to use a speaking valve. He had regained mental capacity sufficient to discuss his care and wished to continue given the progress he had made. It was agreed that he would not be mechanically ventilated in the event of deterioration and the existing DNR order was confirmed. Subsequently, it became apparent that the small bowel anastomosis was leaking; it was agreed that treatment would be non-operative.

In total the patient was treated on ICU for 20 days before he was placed on an end of life pathway and died.

 

What are the implications of Advance Decisions on Intensive Care?Read More »

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Declining Admission to Intensive Care

An 86 year-old man was referred to ICU because of oliguria, acidaemia and decreased conscious level. He had originally been referred by the general practitioner to the acute general medicine team with unexplained weight loss, malaise and reduced mobility, 19 days previously. He had a longstanding history of bronchiectasis and COPD. He had been able to mobilise independently around his house and garden until suffering a pneumonia several months before this admission, and since required a four-times-daily care package.

During the current admission the patient had been treated for a further pneumonia on the basis of new chest x-ray changes, breathlessness and raised inflammatory markers. He had also undergone a CT chest/abdomen/pelvis for the unexplained weight loss. This was consistent with chronic COPD and bronchiectasis but no other positive findings. A week prior to ICU referral he was found to have acute kidney injury (creatinine 280 µmol/mL, baseline 90 µmol/mL) which had failed to improve. In the 24 hours prior to referral had become progressively drowsy and oliguric.

The patient appeared frail, cachectic and oedematous. He groaned in response to voice and could not follow commands. He had Kussmaul breathing at a rate of about 18 breaths per minute with SaO2 of 91% on 35% oxygen via facemask. Arterial blood gas showed pH 7.09, pCO2 7.1 kPa, pO2 9.1 kPa, base excess -9.3 mEq/L, lactate 1.3 mmol/L, glucose 8.7 mmol/L, creatinine 294 µmol/mL. His chest x-ray showed persistent bilateral patchy consolidation. He had a blood pressure of 98/55 mmHg with a pulse of 110 beats/min and cool peripheries. ECG showed sinus tachycardia. He was afebrile. Abdomen was soft and a urinary catheter had drained only 25 mL in the last 4 hours. Other than reduced responsiveness, neurological survey was non-diagnostic.

Evaluation of this patient revealed an elderly man who was severely unwell with acute kidney injury, probable sepsis, and a poor response to treatment to date. This was on the background of chronic suppurative lung disease, and diminished health for several weeks. No specific treatment limitations were in place. His next-of-kin was unaware of any prior expressed wishes and was under the impression that the patient would prefer active treatment. The referring team were of the opinion that intensive care should be considered.

Although no unifying diagnosis for this gentleman’s kidney injury had been identified, a single, rapidly-reversible condition was not apparent. The principal indication for intensive care was for renal replacement therapy for an unknown duration. In view of the status of his neurological, respiratory and cardiovascular systems, it was deemed that airway protection, invasive respiratory support and vasopressor treatment would almost certainly be required. His overall health status made the prospect of survival from a prolonged period of multi-organ support on intensive care highly unlikely. After discussion with the intensive care consultant and the referring consultant it was decided to withhold admission to the intensive care unit. Appropriate family discussions were held. The patient was actively managed on the ward for a further 12 hours, after which fluid management, antimicrobials and further investigation were ceased. He died the following day.

What uncertainties do we face when declining admission to intensive care?Read More »

Advance Directives

An elderly man presented to hospital with an acute abdomen. He was fit and well, with a background of well-controlled hypertension and chronic back pain. He had previously had admissions with a recurrent gastric volvulus, each time it had resolved spontaneously.

A CT scan was performed and revealed a gastric volvulus which was decompressed endoscopically. He was transferred to the high dependency ward post-procedure for observation as it was deemed high risk for recurrence and therefore likely that he would need surgery to correct it. Overnight he required increasing amounts of fluid and analgesia and suddenly deteriorated with a tachycardia, rising lactate and peritonitic abdomen. He was taken for an emergency laparotomy and had a gastrectomy. A feeding jejunostomy was inserted during the procedure.

The post-operative course involved a period of septic shock and multi-organ failure. He remained intubated, on a noradrenaline infusion and was receiving CVVH for renal failure. On the third post-operative day, despite a 24 hour sedation hold, he was showing no sign of any neurological recovery and was not eye-opening or obeying commands. It was at this point that his wife presented the team with an advance directive.

The advance directive was presented at a point in the care whereby the patient was already receiving high levels of support for his cardiovascular system (noradrenaline 0.3mcg/kg/min), respiratory system, renal system (CVVH) and gastrointestinal system (jejunostomy feed). It was discussed and a plan was made to, for the current time, continue management, but it was explained that the outlook was bleak.

His renal function worsened over the next few days (urea 27, creatinine 400) and despite a long sedation hold, he was still unable to obey commands. However,care was continued as both the cardiovascular and respiratory support was decreasing, with the noradrenaline having been weaned by day 6. He was extubated by day, but remained mildly confused and agitated. The following day, he became more tachycardic, tachypneoic and hypotensive. He deteriorated significantly to the extent where he became peri-arrest and was re-intubated. A CT confirmed an intra-abdominal/mediastinal catastrophe.

He once again developed severe septic shock with multi-organ dysfunction. His antiobiotics were restarted (meropenum) and an anti-fungal (fluconazole) introduced. NJ feed was commenced. He improved to the point of extubation on day 11, but again deteriorated. At this point, a decision involving his wife was made to palliate him. He died later that day

What are the implications of advance directives on the ICU?Read More »

Attempted Suicide and Treatment Withdrawal

A elderly man  was found unconscious at home having taken an overdose of prescription medication. This event may have been precipitated by a recent bereavement and worsening of his preexisting depression for which he had recently been reviewed by psychiatric services and commenced on an SNRI. He left a note at the scene of the suicide attempt, clearly stating that he intended to take his own life and did not wish to be resuscitated in the event of being found alive. He was discovered in his home by a relative who had been growing increasingly concerned as to his welfare, having not spoken to him for several days. On arrival in ED his Glasgow coma score (GCS) was 3/15. He was known to be taking venlafaxine for depression and amitriptyline for chronic back pain, and empty packets of each drug were found at his home.

He was intubated and transferred to the intensive care unit. Supportive care was provided including vasopressors (noradrenaline) for hypotension, electrolyte correction and ventilatory support. Plain chest radiograph showed a probable aspiration pneumonitis affecting the right upper and middle lobe. He was hypoxic with a high Fi 02 requirement and needed high levels of PEEP to maintain adequate oxygenation. His conscious level fluctuated over several days and he became increasingly agitated and exhibited signs of distress. At this stage it was not clear if he was orientated in time, place or person. He underwent percutaneous tracheostomy to facilitate weaning and reduce sedation requirements.

We were then able to wean him from sedation by day 11 of his admission. The patient’s ventilatory requirements were still high requiring mean airway pressures of 30 cmH2O, PEEP of 10 cmH2O, and an inspired oxygen concentration of 60%. At this stage he indicated to the ITU team that he did not wish treatment to be continued. We found him to be fully orientated in terms of time and place and he was aware of the preceding events and his intentional overdose. It was clearly explained to him that if treatment were discontinued he would die. He indicated to us that he had no intention of changing his mind.

We referred him to the liaison psychiatrist for the hospital who independently assessed and found him to be competent and able to fully understand the implications of such a decision, i.e. his likely death from respiratory failure. The psychiatrist also found him to be depressed but noted that this did not interfere with his competence and ability to give or withhold his consent. With his consent, his family were informed of this development. They had been agonizing for some time over whether they had made the right decision to call emergency services when they first found him. They attempted to dissuade him but his resolve was unshakeable. Invasive ventilation was withdrawn on the morning of his 15th day of ITU as per his wishes. Diamorphine was administered to reduce symptoms of respiratory distress. He died of hypoxia later that day. Cause of death was recorded as aspiration pneumonia.

Describe the ethical and legal framework utilised in the management of this patient.Read More »

Organ Donation

Improving Rates of Organ Donation

A 75 year old man with stage 3 chronic kidney disease and ischaemic heart disease was resuscitated from a witnessed out of hospital VF arrest. CT head on admission showed a large intracranial haemorrhage with midline shift and effacement of ventricles. Neurosurgical intervention was thought to be futile. There were some family members abroad, who wanted to be present when treatment was withdrawn so care was continued for 24 hours awaiting their arrival. On the day that treatment was planned to be withdrawn, the possibility of organ donation was raised by a team member. The specialist nurse for organ donation (SNOD) was contacted, but was delayed by several hours. The local ICU consultant made the initial approach to the family when they were all present which was promising. A subsequent conversation took place when the SNOD arrived. Consent for organ donation was eventually refused. The family felt that further delay to treatment withdrawal was inappropriate.

How can we improve rates of consent for organ donation on the ICU?Read More »