Friday, July 4, 2008

Mrs. Hardy cont.

Mrs. Hardy is now on a Levophed drip to keep her blood pressure up. It is running at a dose of 5 micrograms a minute. This is not a particularly high dose – which would be a sign that death is near, but neither is it a low dose of 1-2 “mics” which indicate that she might be okay without it shortly. Mrs. Hardy’s body is responding to the Levo – her systolic blood pressures are in the 120’s whereas they would probably be in the 70’s without it. As she gets closer to the end she will need higher and higher doses to maintain her blood pressure. Other pressors can be added as well. Since most pressors work by causing peripheral blood vessels to constrict, thereby preserving core circulation, high doses will cut off blood flow to the arms and legs almost entirely. The pulse-ox sensor (for measuring blood oxygen levels) will no longer read on the patient’s finger and will need to be moved to the earlobe and then finally to the forehead. If Mrs. Hardy had a “no pressors” stipulation, she would probably have died already. With unrestricted use of pressors, she may live another three weeks or so. This time will, without a doubt, be spent in coma. Of all the different types of interventions, people in general have the most difficulty understanding the evils of pressors. It is easy for families to say “no shocks, no chest compressions,” but what is wrong with a little medicine to keep the blood pressure up? Mrs. Hardy is anyhow still a full code. It will be a few more glorious weeks.

Mrs. Hardy now has three types of virulent bacteria and two types of fungus in her blood as well as in her wound, lungs and bladder. Essentially, her body has already started to rot systemically. She is also rapidly developing contractures. Her right hand is bent at a right angle at the wrist and at the fingers so that her finger tips are almost touching her forearm. Her elbows and knees are also folding up. She still “opens her eyes to command,” which means if you say, “Mrs. Hardy! Open your eyes!” she does so. She is otherwise unresponsive.

This week is the first week of the year for the doctors. The interns are now fresh out of medical school and the residents are fresh out of their internships. I listen to rounds to see how Mrs. Hardy’s case will be presented to them. It is acknowledged that her case is hopeless and that it would now be a good time to discuss limits on care with her family. It is not mentioned that the same has really been true for the last three months. None of the efforts of the palliative care team are mentioned. Mrs. Hardy’s desires regarding her own care are not discussed. There will be a family meeting in the afternoon. The SICU attending (head physician), Dr. Lew, expresses that he is personally uncomfortable with the principle of withdrawing care, but feels that not escalating care would be appropriate at this time. The plastic surgery team has been Mrs. Hardy’s primary service, and they will also need to be present at the family meeting. Dr. Lew questions the plastics resident, who has come by for rounds, to see if everyone is on the same page for the meeting. They are not. The resident announces that her attending has taken a “special interest” in Mrs. Hardy. They want to give the antifungal medications a week to work and they want to try a third skin graft. The second skin graft turned to mush in two days and Mrs. Hardy’s abdominal cavity is full of slime. There is no chance that a third one will be successful. The skin for the graft would be harvested from another part of Mrs. Hardy’s body, which would leave another painful wound. Why put her through another operation? The resident is questioned and responds philosophically. She speaks about offering all possible treatments and not abandoning hope. I find myself wondering what the real reason is – are they looking to send out more bills? Do they want a safe practice case for the beginning of the year? I do not understand it, and I am not alone, but then that is nothing new either.

From the beginning, there has been a quiet consensus among the nurses that Mrs. Hardy should be allowed to die without all of this torture. We now speak about it openly. It is really time to let her go now. We share what we know about what is going on. The family is the main obstacle at this point. While it is true that they have received conflicting reports from the doctors, the feeling is that they have been told directly enough and often enough about what is happening that they ought to understand their mother is dying. Even the plastic surgery attending is said to have told them months ago that there was no chance of her getting enough nutrition to enable her to heal. Mrs. Hardy’s children have not come to see her for three weeks (she was talking back then). They are still waiting for her to get better and come home.

Susan, the palliative care nurse, arrives on the unit mid morning to prepare for the family meeting. “You’ve got to set them straight, Susan.” I say, lightly. I spoke too softly and she does not hear me properly, “What did you say? I’ve got to castrate them?” I laugh, “That’s not what I said, but I like that better.” Susan plans to be as direct as possible with the family. She says that the oldest son gets it, but that the younger son and daughter (youngest) do not. After the meeting she feels she has reached the daughter, but the younger son remains adamant. He claims that before all of this started Mrs. Hardy said she would want everything possible done. What are her wishes? She has said different things at different times. To the nurses she has spoken often of her desire to end her suffering, but she has not spoken to her family in this way (some would say because of being intimidated). She has also been more inconsistent with the doctors. The differences may be attributed to the amount of time we spend with her as nurses. We are also the ones who inflict the most pain on her during her care. We are the ones who turn her and clean her. For now, Mrs. Hardy remains a full code.

Later in the day, the plastic surgery resident returns to talk with the new ICU fellow about a skin graft (fellows are senior to the residents and junior to the attendings). He reiterates his misgivings about performing this procedure at this stage of illness. The plastics resident repeats the philosophical line she has received from her attending. The fellow shrugs. He disapproves, but it is not his call. He does put the procedure off though. Mrs. Hardy is on Levo, which denies peripheral circulation – the graft would not have a chance. “When she has been off pressors for a couple of days, you can take her.” Well spoken.


Makarios said...

Incredible! A three-way cockup, and no mistake.

Is the plastics attending aware that what he is proposing is unethical at best and, at worst, assaultive and illegal?

Speaking of which, has anyone called for an ethics consult on this whole train wreck?

And as for the family essentially directing the care team to "do everything" and then vanishing from the scene for three weeks. . .well, have you ever heard of the "daughter from California syndrome?"

Another post that should be shown to family members who admantly insist on the provision of inappropriate treatment.

Leo Levy said...

I chose to write about Mrs. Hardy because her case is actually typical of what I see on a daily basis. Psychiatristy, palliative care, ICU and surgical teams are all well aware of the situation. I doubt an ethics panel would find a problem (see "first death" post for my last experience with ethics panels). The plastics attending does seem to be pushing the envolope a little, but with the family behind him I do not think there is much to say about it. It also seems very unlikely that Mrs. Hardy will every be well enough again for them to attempt the procedure.

Devadeva Mirel said...

stories like this make me think that people should just let nature take her course. but then again, sometimes a little medical intervention is warranted. these families, however, do not know when to draw the line...or pull the plug. i feel so bad for mrs. hardy. sounds really really painful!