Thursday, June 04, 2009
When Futility Wins
We got a notification at 9am on Thursday morning that a Jane Doe, approximately 60 years old, found down at the scene with 90% TBSA burns was being transferred. We set up the room, the ventilator, the pumps, etc, and then we waited. Four hours passed before we heard anything else. We assumed that the patient didn't make it, as it was reported that the other person in the fire was pronounced dead on the scene. However, at 1pm, EMS called and said they would be there in 15 minutes. We gowned up and organized ourselves.
As the trauma elevators opened, the smell of charred flesh filled the corridor. We listened intently as the paramedics gave us report. Turns out the patient had been identified by neighbors and was not 60 years old, but rather in her late 20's. The dead person at the scene was her mother. To make matters worse, the patient had Cerebral Palsy (CP) , an uncontrolled seizure disorder, and the cognitive function of a middle schooler. Her mother was her primary caretaker. It's always hard to deal with breaking the news of loved one's death, but when there is a cognitive delay and/or deficit it's even harder. Thankfully, as crass it it sounds, this patient was unconscious and we didn't need to tell her yet.
Upon arrival her vital signs were stable, but she quickly decompensated. We placed an arterial line to monitor her blood pressure, a central line with cordis for venous access, and a SWAN to monitor her hemodyamic stability. Her blood pressures plummeted, despite liters of fluid. Her oxygenation dropped due to an inhalation injury. She was cold, 34.0 Celsius, despite fluid warmers, a heat shield, and a bair hugger. Her coags were out of control, INR = 2.6, and we were pretty sure she was in DIC. We lost pulses in her bilateral upper extremities and performed escharotomies at the bedside. She became anuric (stopped making urine), her bladder pressure soared to 35, and we opened up her belly at the bedside.
The first 24 hours were tenuous. Administer blood products- give fluids- check labs, check ABG's-adjust the ventilator. We were fighting a loosing battle. We were able to contact the family, maternal aunt, uncle, cousins, etc. They sat vigil at the bedside, but knew were this was going. They made the patient DNR. Many people not in the health care field are scared of DNR's. They think that's the equivalent of "puling the plug" or removing life support, but they are wrong. DNR- on a already intubated patient, simply means that if the heart should stop, no CPR would be given.
By Saturday afternoon, the patients' prognosis was dismal at best. Given her % burn, her lung injury, her preexisting conditions, and hemodynamic status her survival rate was less than one percent. The family listened as the doctors and nurses talked. When I came on shift that night, the aunt pulled me aside and said, "It's not good, is it? I just want her to be comfortable. She wouldn't want to live like this..."
I hate these moments. I looked at her and said, "She's sick, very sick. Even if she were to survive the next day or so, she'll never be the same. She has no skin and will likely develop an infection. We don't know how much damage her brain suffered when she was unconscious at the scene. She is currently maxed out on medications to sustain her blood pressure. We have no other options."
And then she made the toughest decision of her life. She decided that she wanted to withdraw care. However, it was not quite that simple. She wasn't the patient's health care proxy, so we needed to have two attending physicians write notes of medical futility and get approval from the administrator on call. There was nothing we could do but wait. Until that paper was approved, signed, and placed in the chart, we had to keep treating her. Around 5:30 am as the sun was rising and the sunlight was streaming into her room, her heart rate slowly began to drop; her blood pressure soon followed. When she didn't respond to any medication, a few of us nurses went in and sat with the patient at her bedside. She had no family there, but we talked to her offering words of comfort. We told her it was okay to go, that her mom was waiting for her. We talked, and talked, and talked. I swear she heard us. At 6:05 am she passed away.
As hard as it is to see someone so young die, it's even harder to think about ethics behind medical futility .