welcome to another MedCram video we're
gonna talk about palliative care in the
intensive care unit and what we call a
terminal extubation or terminal weaning
and as we talked about in the first
video these are the type of patients in
situations where we have done full force
full code everything that we got all the
stops pulled out and these are on
patients who are really sick and have
responded halfway in terms of we're
supporting the pillar of the heart
pillar that's fallen down we've
supported the pillar of the lungs for
instance which has fallen down and also
let's say the the patients on dialysis
because the kidney pillar has fallen
down and let's say that the patient is
on antibiotics because the immune system
pillar has fallen down and so what we're
doing in these situations is the
patient's very sick and we're holding up
the positions of these pillars to keep
this patient viable in the ICU the
problem is is that we hold up these
areas there's risks with that right so
the longer we have vasopressors on the
more life that the patient is going to
get tissue breakdown and necrosis in the
extremities the longer that the patient
is on a ventilator that increases the
risk of ventilator associated pneumonia
the longer the patient is on
hemodialysis that can cause infections
in the dialysis catheters and the longer
the patient is on antibiotics that can
cause other issues as well and side
effects thrombocytopenia elevated lfts
etc so we're holding up the patient here
but the pillars which we ultimately need
to have come up are not coming up they
should be coming out but they're not
coming up we're stuck holding up the
roof and sometimes what can happen you
know some people have different values
than others the family would say look he
would not want to be on this ventilator
for more than a week or two and it's
already been three weeks so we just
can't stand the way he's suffering
anymore he would not want to be in this
situation what do we do
and so what we do in that situation is
we have to pull back the supports of
these positions that are holding up the
roof with the understanding that what's
gonna happen is this roof is gonna fall
and the patients get a pass away in the
intensive care unit but the way we want
to do that is in the most gentle and the
most dignified way that we possibly can
and the one I want to focus on
specifically is this lung pillar because
pulling out an endotracheal tube out of
somebody could cause them shortness of
breath and discomfort things that we
exactly don't want to do in the
intensive care unit so if we're in that
situation what I tell patients is that
look we've been here in the intensive
care unit we've been trying to do
everything that we can to make him
better from a bodily standpoint and we
haven't been able to do it so instead of
trying to make the patient better from a
bodily pathophysiological standpoint and
at the same time trying to treat his
pain in a way that doesn't interfere
with our blood pressure and things of
that nature now what we're going to do
is we're gonna switch to making him
perfectly comfortable and not worry
about those secondary side-effects of
morphine or dilaudid or benzodiazepines
and that's called palliative care so we
always want to make sure that patients
are comfortable but the problem is is
sometimes the medications that we use to
make patients comfortable have negative
side effects for instance they could
drop the blood pressure when we get to
this situation where we cannot make the
patient better and we've come to that
decision then we can concentrate fully
on making the patient comfortable as
possible and now what we're doing is
we're going to treat to the fullest
extent that the patient is comfortable
and not be worried about a drop in blood
pressure and not be worried about a drop
in consciousness and things of that
nature so what are the things that we're
looking at we want to treat pain and the
way we can look at pain is we can look
at heart rate because sometimes the
patient can't talk to us so we can look
at heart rate we can look at facial
expressions so a furrowed brow or a look
of pain we can look at the respiratory
rate all sorts of things that we can
look at to see for pain so what we'll do
is we'll treat the patient we can take
off things that are not
comfortable but are not necessarily
supportive we can make sure that the
patient is pain-free so that would mean
starting a morphine drip or a versed
drip a fentanyl drip what-have-you and
then what we start to do is we look at
the ventilator and we start to pull back
the support so if the patient is on AC
mode ventilation will start to back off
well maybe put the patient on simv mode
ventilation and will start to back off
on the rates we may back off on the
pressure support and we do it in a
stepwise fashion and every point along
the way we're always checking heart rate
facial expressions respiratory rate and
if we start to see that those are going
in a direction of pain so if the heart
rates going up if there's facial
expression of pain if there's
respiratory rate that's going up we stop
at that point we don't go any further
and we make sure that we were increasing
the pain medication to make sure that
those heart rate facial expression
respiratory rate go back to normal once
they go back to normal we continue to
pull back the support from the
ventilator until finally in a stepwise
fashion the ventilator is completely off
and then we can pull the tube out and I
always tell family look the purpose here
is not to have your loved one pass away
in the intensive care unit the purpose
of this is to make sure that the patient
is comfortable and I can tell you
sometimes in my experience I've seen
patients pass away even before we've
taken the endotracheal tube out and
sometimes we've seen situations where
the endotracheal tube comes out the
patient does well and actually lives for
a number of days or weeks afterwards but
the point of this is not to have the
patient pass away the point of this is
to make sure that the patient is
comfortable and if the patient is able
to support themselves after we pull off
the support from the ventilator or the
bays opressors or the dialysis or
whatever it is if the patient is able to
support themselves so be it
the point is the patient's going to be
comfortable the patient doesn't want to
have any more of these invasive measures
and the patient should be in control and
and the part of all of this that's sort
of granting all of this is the ethical
principle of
autonomy so autonomy is big especially
in Western culture autonomy means that
patients themselves are able to
determine for themselves what medical
treatment they should have and what
medical treatment they don't want to
have so it's okay for them to refuse
medical treatment even if it means that
they're going to have a shortened life
expectancy
this has to be mitigated with your
understanding course of whether or not
the patient is in their right mind point
is is that what we believe in in Western
culture is that patients should have the
ability to determine for themselves what
treatments they have and what treatments
they don't realizing that these
treatments sometimes have a lot of side
effects they're painful they're
uncomfortable so this is a discussion
that I think has to be open-minded in
the final analysis of all of this when
we wrap all of this up the point is this
is that the medical doctor the medical
professional the healthcare professional
needs to come to the family with
realistic expectations about how things
are going and the family needs to bring
in the patient themselves if they can
need to bring information to the
healthcare decision makers about what
the values are of the patient what they
would have wanted given those set of
prognosis and then together both family
and the professional need to come up
with a decision about what the direction
is for the patient sometimes I have
noticed that health care professionals
don't bring up these alternatives and so
they don't feel that the family doesn't
feel that this is a alternative that
they can actually go down so it's
important as a healthcare professional
to bring up these different options in a
dignified way so that patients and
families can make their decisions so I
hope this was helpful in terms of
understanding what DNR means what DNI
means CPR palliative care what it is
that we do in the intensive care unit
and I hope that this will further your
medical experience in the intensive care
unit and your dealings with patients
about this very difficult discussion
thanks for joining us
