Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where
we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question in this series of questions from our client Robert and the question last week was PART 5 of
My 68 year old mother is in ICU with gastric perforation and she’s not “waking up” after the surgery! Will she need a
tracheostomy? (PART 5)
You can check out last week’s episode by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to answer
another the next question from our client Robert, which are excerpts from email counselling and consulting sessions with me and the question this week is
My 68 year old mother is in ICU with gastric perforation and she’s not “waking up” after the surgery! Will she need a tracheostomy?
(PART 6)
Robert continues with his mother’s situation below
Hi Patrik,
Here is another question: Right now, I don’t believe they are giving her any pain meds at all (to help increase the odds of “waking up”). Is there any risk that she goes into shock or something like that?
Should she be on some pain meds?
A few days ago, they were going her a “light” pain med that doesn’t cause sleepiness. But they stopped that too.
We don’t think my mom is in pain – she actually looks quite peaceful and comfortable.
The doctors are planning to perform the tracheostomy and PEG tomorrow.
Will keep you posted — and I’m sure I’ll have a few more questions.
Thanks,
Robert
Recommended:
Hi Robert,
I would imagine that not giving pain meds is due to them wanting
to “wake up” your mother.
Normally in ICU the doctors and the nurses will assess your mother’s pain status while she’s unable to communicate properly through Non-verbal pain assessment tools as well as asking simple “Yes” and “No” questions. If she’s not ready to answer “Yes” and “No” through nodding or shaking her head they will simply assess her non-verbal responses.
Also, they will have a
good idea in how she’s going with pain, depending on how well she can breathe on the ventilator.
For example a sign that she has minimal or no pain is that she’s breathing with a normal respiratory rate (=breaths per
minute), as well as breathing with good Tidal volumes (=Volume in mls per breath) and Minute Volumes (=breathing volume in mls per minute) which are adequate for the size of her lungs.
It would also show up in her arterial blood gases where
a low CO2 (=Carbon dioxide) would show up for hyperventilation as a sign of pain. If she’s not in pain and breathing fine, she will have normal Arterial blood gases (ABG’s).
Therefore, taking her off the pain meds such as Fentanyl or Morphine makes sense
from my perspective, especially since those pain meds are long acting and also addictive. After nearly one month of being in and out of an induced coma, as well as being on and off ventilation, the sooner they
can rid the Morphine/Fentanyl the better. I’m sure they would be giving some light pain meds such as Panadol/Paracetamol and/or small doses of Morphine in Tablet or Sachet form.
I do believe that if they can stop pain meds it’s a good sign as long as she can tolerate it of course.
But also important in all of this, what do you and your family think? Do you think your mother is in
pain?
As long as she’s not in pain, there is no risk of shock and I would imagine that an experienced ICU nurse or experienced ICU doctor can recognize a Patient who has pain with some non-verbal pain assessment tools.
If pain goes unmanaged it can certainly cause harm, but I do have trust and faith that the staff can recognize it with their assessment tools.
I hope that makes sense.
Any questions please let me know.
Warm Regards
Patrik
Hi Patrik,
One decision the family needs to make is on what level of “intervention” we would like
the medical staff to do (not directly related to today’s tracheostomy, but just in general):
- Dialysis
- Chest compressions
(much beyond general CPR, which they always do).
We’ve heard that chest compressions are a final, desperate measure and all sorts of other things are going wrong at that point. And that it’s an aggressive/violent activity sometimes.
What’s your take? What do most families do?
Many thanks
Robert
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Hi
Robert,
as I briefly outlined in one of my previous emails, “Yes” to Dialysis and “Yes” to Cardiac compressions.
Most families in Intensive Care opt for full
treatment. Treatment limitations are usually something that the Intensive Care team is driving for a number of reasons. In rare cases, families opt for treatment limitations and sometimes when treatment is
being “futile” (=of no benefit to a Patient), a mutually agreed treatment limitation plan can be agreed upon.
Related article/video:
From my perspective and
from all the information that I have, I see every treatment your mother has been given and may need in the future as of benefit for her. You and your family can always re-visit this if the situation changes and the Intensive Care team are usually the first one to make you aware of it and I believe they have already mentioned this.
For now, with your mother’s heart beating strong, it also makes it less likely for her needing dialysis. Dialysis
is needed for kidney failure and kidneys can fail in ongoing severe sepsis and during prolonged low blood pressure (=hypotension). People with Diabetes also have a higher risk of needing Dialysis for Kidney failure.
The Sepsis she seems to fight Ok for now and therefore hopefully she won’t need dialysis for kidney failure.
With the heart beating so strong thus far (unless there is a heart condition that I don’t
know of) I would strongly advocate Cardiac Compressions (CPR= Cardiopulmonary resuscitation) especially in light of the fact that the ICU team has mentioned “withdrawing treatment” at some stage already.
By you stating that you want full treatment including cardiac compressions, you are keeping all of
your options open thus far and you are showing the team that “withdrawing treatment” at this point is not an option for you and your family.
And as you have correctly pointed out, you can always change your
position down the line.
One of the recurring themes in Intensive Care as well as for our client base is that if anything, Intensive Care teams can be very quick at wanting to withdraw or limit treatment. This from my perspective happens way too often and also prematurely. A lot of our work is coming from helping families when the Intensive Care team is trying to push
towards a withdrawal of treatment, often without family consent.
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This often early push towards withdrawing treatment from Intensive Care teams happens for a number of reasons, including financial budgets, lack of ICU beds, staffing issues, medical research interests and the list goes on.
We can help families very quickly to position their loved one’s diagnosis, prognosis as well as care and treatment that helps families to get the outcomes that they want.
Also, in light of the fact that your mother currently is only on one major life support mechanism (=mechanical ventilation) I think she’s in a fairly good position to get through this challenge and leave Intensive Care
alive.
Recommended:
You are correct to point out that Cardiac Compressions are a final desperate attempt to save a life, however if there is any environment where people are well trained and have all the equipment and resources to deal with such a situation it would be an Intensive Care environment.
Yes, survival rates are
not great after Cardiac compressions, however people still do survive. I also feel like 69 years of age is not very old. People above the age of 80 get resuscitated in Intensive Care all the time and some of them do survive.
Another component would be if you and your family have discussed this issue with your mother in the past? What do you think she would want?
I do strongly feel that
opting for full treatment and also for full resuscitation in case of a cardiac arrest you and your family are very safe to keep this option for now. I believe it’s very important from a bigger picture point of view that the Intensive Care team knows that you want
to stay in control of your mother’s destiny as much as you can.
I hope that helps Rob.
Let me know if you need further clarification of this topic.
Did the tracheostomy/PEG go well?
