Assalammualaikum.
Some time ago, we had a female patient in her 40s, came in with respiratory distress into ED.
She was just discharged from the medical ward for some pneumonia and with advanced chronic kidney disease.
She was already advised for dialysis, but her husband and she were not happy with the diagnosis, they took an AOR discharge and defaulted follow up.
She came back in a bad shape; creatinine >4000 and urea >60 and a face and body full of uraemic rashes - wet and angry lesions.
She was intubated in ED, suffered a cardiac arrest and arrhythmia - CPR and defibrillated and brought into ICU.
We treated her for hospital-acquired pneumonia and an array of complications of kidney failure.
Strong antibiotics pumped into her with many other life-sustaining drugs to keep her heart pumping well.
Few days later, her blood parameters improved but her general condition didn't - she wasn't waking up and her breathing effort was minimal.
I met the husband and explained about the current condition and introduced him to tracheostomy - while exploring her social support.
Two days later we managed to extubate her and put her on NIV machine - a machine to help with breathing but without the tube in the patient's mouth.
However, she became weaker and weaker as the hours pass.
We had to re-intubate her after a few hours. She managed to speak to her husband on that day.
We told the husband she might deteriorate further.
A few days later, she still wasn't making a good recovery. She was still very fragile and perhaps demotivated.
She cries and appears gloomy.
She understands us, but she was so weak she can only lift her fingers and perhaps some nodding or shooking.
We implored again the husband's thoughts on tracheostomy, and he adamantly refused it.
He refused tracheostomy, he doesn't want to discuss it.
But he also refuses to withdrawal of care, he wants the wife to be kept ventilated but refuses both tracheostomy and CPR.
It was perhaps a good decision, if we perform a tracheostomy on her, the woman will now be very dependant on the husband.
Not only she needs a carer for her tracheostomy (I wrote about tracheostomy before here), but she also needs dialysis 3x a week.
The whole family needs to be really dedicated and invest time and effort and energy and emotion.
Perchance, this is the best choice for her.
But we were bitter with the husband's verdict.
We felt like the husband gave up.
He refuses active intervention, he wants to wait until the patient recovers, but that is a far cry from reality.
That is a hope that might never come true.
I remember my colleagues thinking "Men, they will bail out if they can. Who want to take care of a sick and dependent wife?"
We wondered will the decision be different if we have asked the mother instead?
Will a mother give up?
But deep down I know, or perhaps I hoped - this man just did not want his wife to suffer longer.
That he loves her, and enough means enough.
Perhaps it was just his way of expressing his decision that made us disturbed - he was almost rude, he questioned and blamed our decisions, he questioned all the interventions done to his wife during all her previous admissions (which we the ICU team can't really justify as we do not know the situation then).
And his wife was young! 40s!
Her daughter is still in primary school - and she is going to lose her mum.
It was very frustrating to let a young woman die. We know if there is no active intervention, she won't make it.
Why did she default all her treatments?
Why did she take an AOR discharge then?
Why did the husband and her waited until she was very severely ill before bringing her back to the hospital?
Why even bring her to the hospital if they trust traditional medicine more than the doctors?
All these questions kept playing in my mind - unanswered.
At last, we managed to extubate her but she was so weak she can't even cough out her own sputum herself.
The nurses did vigorous chest physio and suctioned her sputum frequently.
And after a day, we discharged her to the general ward.
And she succumbed to her illness.
I see this kind of patient very often.
Every time, it breaks my heart to make that kind of decision.
-Because life is a test-
-AkMaR-
http://nur-akmar.blogspot.com
Some time ago, we had a female patient in her 40s, came in with respiratory distress into ED.
She was just discharged from the medical ward for some pneumonia and with advanced chronic kidney disease.
She was already advised for dialysis, but her husband and she were not happy with the diagnosis, they took an AOR discharge and defaulted follow up.
She came back in a bad shape; creatinine >4000 and urea >60 and a face and body full of uraemic rashes - wet and angry lesions.
She was intubated in ED, suffered a cardiac arrest and arrhythmia - CPR and defibrillated and brought into ICU.
We treated her for hospital-acquired pneumonia and an array of complications of kidney failure.
Strong antibiotics pumped into her with many other life-sustaining drugs to keep her heart pumping well.
Few days later, her blood parameters improved but her general condition didn't - she wasn't waking up and her breathing effort was minimal.
I met the husband and explained about the current condition and introduced him to tracheostomy - while exploring her social support.
Two days later we managed to extubate her and put her on NIV machine - a machine to help with breathing but without the tube in the patient's mouth.
However, she became weaker and weaker as the hours pass.
We had to re-intubate her after a few hours. She managed to speak to her husband on that day.
We told the husband she might deteriorate further.
A few days later, she still wasn't making a good recovery. She was still very fragile and perhaps demotivated.
She cries and appears gloomy.
She understands us, but she was so weak she can only lift her fingers and perhaps some nodding or shooking.
We implored again the husband's thoughts on tracheostomy, and he adamantly refused it.
He refused tracheostomy, he doesn't want to discuss it.
But he also refuses to withdrawal of care, he wants the wife to be kept ventilated but refuses both tracheostomy and CPR.
It was perhaps a good decision, if we perform a tracheostomy on her, the woman will now be very dependant on the husband.
Not only she needs a carer for her tracheostomy (I wrote about tracheostomy before here), but she also needs dialysis 3x a week.
The whole family needs to be really dedicated and invest time and effort and energy and emotion.
Perchance, this is the best choice for her.
But we were bitter with the husband's verdict.
We felt like the husband gave up.
He refuses active intervention, he wants to wait until the patient recovers, but that is a far cry from reality.
That is a hope that might never come true.
I remember my colleagues thinking "Men, they will bail out if they can. Who want to take care of a sick and dependent wife?"
We wondered will the decision be different if we have asked the mother instead?
Will a mother give up?
But deep down I know, or perhaps I hoped - this man just did not want his wife to suffer longer.
That he loves her, and enough means enough.
Perhaps it was just his way of expressing his decision that made us disturbed - he was almost rude, he questioned and blamed our decisions, he questioned all the interventions done to his wife during all her previous admissions (which we the ICU team can't really justify as we do not know the situation then).
And his wife was young! 40s!
Her daughter is still in primary school - and she is going to lose her mum.
It was very frustrating to let a young woman die. We know if there is no active intervention, she won't make it.
Why did she take an AOR discharge then?
Why did the husband and her waited until she was very severely ill before bringing her back to the hospital?
Why even bring her to the hospital if they trust traditional medicine more than the doctors?
All these questions kept playing in my mind - unanswered.
At last, we managed to extubate her but she was so weak she can't even cough out her own sputum herself.
The nurses did vigorous chest physio and suctioned her sputum frequently.
And after a day, we discharged her to the general ward.
And she succumbed to her illness.
I see this kind of patient very often.
Every time, it breaks my heart to make that kind of decision.
-Because life is a test-
-AkMaR-
http://nur-akmar.blogspot.com
Hi Dr, I like the way you write it's nice to read, keep writing :) from your IMU junior.
ReplyDeleteHi. Thank you for the kind words :)
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