Saturday, July 18, 2009

Advance Directives

From the initial radio call to my initial view of this patient to this CT Scan above, this was a bleed from the get-go. I was about to intubate when the family showed. It was hard for them to follow this patient's advance directive but they did. By resisting the temptation to have us 'do everything' they spared him two to thirty days on the ventilator, a 'bolt' in the brain (a catheter inserted to decompress the blood), and death by progression of the bleed, ARDS, or a host of other life-enders that come when your brain is full of blood and your breathing is directed by a machine.

This patient was a textbook case, he fell unconscious, and by the time we saw him had spiked his blood pressure up into the mid 200's systolic... the body's attempt to perfuse the brain against pressure, and then his pressure dropped, his respiratory rate dropped, his heart rate dropped, and he died.

We are good at 'doing everything' but don't often have the opportunity to 'do nothing'. We did, of course, keep him comfortable as best we could with a few different medicines, but finding the line was difficult.


  1. How old was the patient? Was this from trauma or a spontaneous IC bleed? How long was he down before he got treatment? A catheter wouldn't have helped?

    Not questioning your judgement, just trying to understand the situation.

  2. very old patient. spontaneous. down for over 45 minutes. catheter, per NS, might have worked to keep them alive for a bit longer but neurologic recovery almost zero.

  3. I wish more folks would have a DNR or other form of advanced directive. It is quite ugly being in a room with a bunch of loved ones half of whom are saying do what ever it takes and the other half telling us to let him go.

    Great post

  4. 911Doc, say no more. That was a totally righteous call. Compassionate family and doctor.

  5. i didn't do anything other than encourage the family that they were right to follow previously determined wishes. i wish more folks had them of course and i like to kick death in the teeth when i can, but very little of what i do matters too much. the family here were fantastic, compassionate, and allowed their loved one to die without suffering. i AM NOT in favor of euthenasia or rationing of care, i am in favor of advance directives.

  6. 911DOC ~ Agreed! My only question is, are advance directives enforceable? If this man's family had wanted to, could they have overridden his directive?

    What about if, say, someone documents that he wants to be resuscitated or kept on life support, but the family doesn't want this or the person has no close family members ... how would that play out?

    In the absence of a directive, who makes the call? The Terry Schiavo case still really bothers me! But I wonder, if she had written instructions in place that said she wanted ongoing care, would that have been enough to prevent the decision that was made?

    I'm just curious as to whether directives are legal obligations or not.

  7. Peggy U 2 great questions that are both easy and hard to the answer is, in the ED..
    It Depends..

    "My only question is, are advance directives enforceable? If this man's family had wanted to, could they have overridden his directive?"

    If the pt has severe pre-morbid conditions, say on dialysis or metastatic cancer in a semi-vegetative state, then most doctors would adhere to the pts desires and do nothing except provide comfort..

    On the other hand, if he were a healthy, say 40ish, partaker in tri-athalons type person, then I'd say there is very little chance that, if the family wanted "everything done", that any of us would not go balls to the wall to avoid the sure to come lawsuit..Even tho the outcome would still be the same, we would spend an enormous amount of $$ trying to keep the patient alive and the family happy..

    "What about if, say, someone documents that he wants to be resuscitated or kept on life support, but the family doesn't want this or the person has no close family members ... how would that play out?"

    If the proof was in writing, in a reasonable form, with an explanation of the revocation, then we would probably all honor it. Even if the family didn't want it, we couldn't really be faulted for doing everything we could to keep the pt alive. I really haven't heard of anyone being sued for "wrongful life" yet.

    In the abscence of a written directive, we would make the call most of the time..
    I don't remember the circumstances of Ms Schiavo illness, but she was so young that we probably would have "done everything" for little while until we could be certain she had an appropriately executed advance directive and then I, at least, would have had no problems turning the power off on her ventilator..OF

  8. Thanks!

    As to the Schiavo situation, she was not on a ventilator, but in a long term care facility where she had been for a few years. She was in a "persistent vegitative state", however, and there was a feeding tube in place.

    Her husband claimed she had a verbal directive, and did not wish to be artificially sustained. Her parents, siblings, and friends said they were not aware of such a directive and doubted that is what she would have wanted. Furthermore, they insisted she was somewhat responsive and aware of her surroundings. They requested that her care be turned over to them. The husband insisted that the feeding tube be removed. The decision ultimately tipped in his favor, and Terry Schiavo died of dehydration roughly two weeks later. It struck me as a barbaric way to let someone go.

    The circumstances surrounding the event that led to Terry Schiavo's disability were not clear. The parents claimed that she was injured as a result of spousal abuse; the husband claimed she collapsed because of an electrolyte imbalance brought on as a result of extreme dieting and bulimia. As I recall reading, neither claim was well substantiated.

  9. I can't spell "vegetative". I have vowel problems. ;)

  10. My father's CT looked almost exactly like that. The EMS tubed him for the chopper ride after my step mother called them. He was on the vent when I arrived about 14 hours later, with his signed Living Will in hand. He was decorticate on one side and flaccid on the other. I didn't even need the CT to make the diagnosis, a bedside neuro exam was enough.

    The Intensivist and I extubated him the next morning. His wife said, "If you do that, he'll die!" The other intensivist and I said almost simultaneously, "He'll die regardless."

    He survived another 24 hours and died peacefully in a private room surrounded by family and friends.

  11. CJ, you were family doing the right thing. But at least the Intensivist was willing to back you up. If you were not family, I doubt the call would been made with the wife screaming "he'll die!"

    PU, a BIG difference in the Shiavo case was the possibility of criminal charges against the spouse who wanted to withdraw life support.
    And how many years did that take to get resolved?

  12. Oldfart: Aw, gee thanks for using the initials ;) This is why people keep their maiden names!

    I don't know how many years it took. They may still be fighting it out, outside of the media limelight.

  13. Old Fart thanks. He had suffered enough. I hope someone will do it for me when the time comes.