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 from one of my clients Richard and the question from Richard in last week’s episode was
My mother in the ICU is unable to come off the ventilator. Is giving sedation and
doing a tracheostomy going to help her?
You can check out last week’s question by clicking on the link here.
In this week’s part 4 episode of “YOUR QUESTIONS ANSWERED“, I want to answer the next questions from one my clients RICHARD as part of my 1:1 consulting and advocacy
service!
Richard’s mother suffered from a fractured bone due to a fall. His mother was then transferred to ICU due to cardiac arrest and had a tracheostomy during her stay in the ICU
The ICU team is giving my mom too many sedatives. Are they slowly killing her or are they helping her to wean off the ventilator?
“You can also check out
previous 1:1 consulting and advocacy sessions with me and Richard here.”
PART 1
PART 2
PART 3
Hi
Richard,
Here are more thoughts and questions about the situation
- What was her neurological condition before she deteriorated in the last few days? Why was she not asked or informed about the commencement of the Morphine infusion?
- Ventilation > if your mother weighs 118Kg her ventilation volume per breath should be ~7-10 mls/kg. That should be a minimum of 826
mls per breath. In the pictures you have sent, her volume has been 350-450 mls/breath. With my other comments about increasing pressure support and her breaths/minute, in order to get CO2 down, the volume per breath has to be appropriate to the body weight.
Morphine and Midazolam are used to “palliate” or “euthanize” a Patient. The minute they stop ventilation your mother will die. Midazolam and Morphine are used in an induced
coma. Considering your notes in your email, they haven’t been open and transparent.
Kind Regards
Patrik
Find more information and recommended details about induced coma:
Hi Patrik
Thanks for the chat and re-sending the e-mail for recap
with helpful advice and thoughts.
Could you just send me a quick short simple e-mail (when convenient), in your own words, something along lines… on xx/03/18 (28/03/18 I think), I spoke with Dr. Smolensk and he informed me…. Sedation implemented/administered to manage/improve ventilation etc. for patient, Gabrielle Fox.
Just been reading up on Alfie Evans. Thanks for highlighting his case. I can relate to some aspects. I will be thinking of him and his family and will say a prayer.
Some thoughts: –
Without knowing
the details of the case, but as you indicated, the option of Italy/Germany being denied seems both sad and restrictive to me.
For family to have to deal with high pressure legal court case and at same time ICU and imminent possibility of death of child – this must be almost unbelievably tough and stressful.
I found some of the media and public feedback comments very interesting in terms
thinking, opinion and knowledge (selective and/or limited as it may be) re this situation.
Perhaps someone can write an informative news/educational article along the lines of what you described in Germany to show what is possible and for this to get public mainstream coverage and debate – maybe one day!
Thank you
Richard
Related article:
Hi Richard
Here is also my summary after talking to the ICU doctor
Thank you for your reports.
ABG’s (Arterial Blood Gas) deteriorating could be sign of infection, we can discuss later.
I’ve seen your latest images.
They have now changed the ventilation settings and she’s not breathing spontaneously any longer. The machine is doing most of the work.
Probably a side effect of the Morphine. CO2 still high. They could
bring it down by increasing her breaths per minute and by potentially ceasing Morphine. It looks like she’s on 4 of Morphine but the image with the infusion is not quite clear. The infusion with 2 was Insulin yesterday unless they have ceased it, it might still be Insulin.
Doctor talking rubbish if he says ventilation shouldn’t be withdrawn whilst he’s increasing Morphine. The Morphine will eventually kill her if they don’t stop it, especially
if kidneys are starting to fail.
They are basically trying to euthanize her by telling you they continue medical treatment but put her to sleep on the other end with
Morphine.
I questioned him why they wanted to withdraw treatment and he said that there are no plans to withdraw treatment and that sedation was only started to improve ventilation due to her infection.
According to him this was a temporary measure and he would expect improvement going forward.
My gut was telling me at the time he wasn’t truthful.
Starting sedation in form of Morphine and Midazolam is usually either used to
a) Sedation and optimise ventilation
b) In end of life situations to “euthanize” a Patient
Given that the next day your Mum “crashed” I believe they were preparing for end of life the day prior.
The truth will be in the medical records. We can look at them for you or with you and we can get the answers you are looking for so you can get closure.
I would be delighted to help you with a review of the medical records once you have access to them.
We can talk about this in more details when we get on the phone a bit later today.
Will be busy but ready and available when you need me.
Kind Regards
Patrik
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Richard: Hello?
Patrik: Hi Richard, it’s Patrik here, can you hear me?
Richard: I can indeed, yes.
Patrik: Right.
Richard: Just give me a second. Okay. I’m here with Heather and I’ve just stepped out of the ward.
Patrik: Right. So I’ve had a fairly lengthy chat with him. Sorry, do you want to put
this on loud speaker so Heather can hear as well?
Richard: Turning it up and turning it down, if it makes sense. I think we’re on the same page. All set up. Thank you.
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Patrik: Okay. I’ve had a fairly lengthy chat with him. What can I say? I think he’s making excuses because … So they were clearly of the view that, and he mentioned that a couple of times, is it now 30, 35 days that your mum’s been in ICU is that
correct?
Richard: That’s 31, I think.
Patrik: 31. Yeah. So he’s mentioned the 30-day mark a couple of times, where I said to him, “Look, so the 30-day mark is your cut-off. If somebody hasn’t improved, then you’re moving them into a different category of patient.” Now he sorts of denied that, saying, “Look, it’s not a matter of time, it’s a
matter of whether patients are improving, and it’s a matter of patients’ comorbidities whether we would then advance a treatment or not.”
So, what he’s saying, and you would have seen earlier, me on WhatsApp, saying morphine and midazolam is a drug
where patients get in end of life situations to hasten death. Now he’s clearly denying that morphine and midazolam are given to hasten death. He actually has an explanation for me why she’s getting that. I don’t trust in what he said but it could be an explanation, but I don’t trust him yet because his actions down the line will speak what it’s really being given for. So-
Find more information about end of life
care:
Richard: No, it’s
the ward nurse seeing if we wanted anything.
Heather: No me. She was looking for me.
Richard: Sorry to interrupt you Patrik.
Patrik: Oh no, that’s okay. That was one of my first concerns. I said, “Why are you giving morphine and midazolam all of a sudden? How can
she go from being mobilised two days ago to all of a sudden going on to morphine and midazolam?” And I said to him, “Are you planning for an end of life situation without telling the family?”
Richard: Yes, yes good.
Patrik: Then he says to me, and I do believe he thought hard about it before he was giving me a response to that. My impression is,
yes they are planning for an end of life situation, but as soon as I confronted him with that he changed his response, I believe. So what he said is, “Ah look, you know, she’s not breathing properly, and as you would know, if she’s not breathing properly one way to increase the volume is sedating the patient.” Do you remember I said that in-
Heather: Yes.
Patrik: Right, I said that earlier in the email, where I said, “Look, her volumes are pretty low for her weight.” And he now says they are sedating her to get more volume in her to get the CO2 out-
Richard: You’re breaking up again Patrik. One moment, I’m just going to stand up. Could you repeat that, please? I just lost you for a minute.
Patrik: Yeah. As I said, my concern was that when you told me that she’s now on morphine and midazolam that they’re basically working her up for an end of life situation, right?
Richard: Yes.
Patrik: Then when I confronted him with that, he said, “No, no, the morphine and midazolam are not to
palliate her, they are to increase her volumes.” Right? And that makes sense to me.
Richard: Okay.
Patrik: Well that makes sense to me, right? That you would sedate a patient because they are breathing against the ventilator, and that’s one way to manage ventilation. However, I do believe that when I confronted him with that, he was thinking long and hard before he was giving me that response.
Richard: Right.
Patrik: Right. That was my impression. Then I sort of tried to hone in on, “Well, what’s your plan?” With your Mum. Why are you doing all of this if you’re on one hand you are sitting down with the family and saying, “Look. She’s not going to get any better. She doesn’t have any quality of life, it’s probably best for her if she’s going to die.” And then he confirmed that they are not planning to remove any treatment, but at the same time, they’re
not planning to escalate treatment either.
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Richard: Yeah. Okay, I see where you’re going with this, okay.
Patrik: Is that something they mentioned yesterday? No escalation of treatment?
Richard: No. They said they would continue the same level of medical care
wouldn’t go down or they will be withdrawn.
Heather: And add palliative care on top of that and the medical care wouldn’t go down or be withdrawn.
Richard: So it wouldn’t be withdrawn, but they certainly didn’t say one word about escalation or improving things. They did talk about more aggressive palliative care. But that was a different
subject.
Heather: Yeah.
Patrik: Mm-hmm (affirmative). So, I do believe that irrespective of what he said, I do believe their plan really is to make your mother comfortable and let her die.
Richard: That’s what they said today.
Patrik: Right.
Richard: That’s exactly what they said.
Patrik: However, I did ask, when he said to me that they are sedating her to improve the ventilation side of things, so then I said to him, “Well if that’s the case, that then means once you’ve stabilised her ventilation you should wake her
up again.”
Heather: Yes, so then we can talk to her. And if she chooses herself she wants to go, that’s fine, we understand that, because it would be her choice then properly in front of us and whoever else she wants to say it to.
Richard: She is certainly, what I would call, on minimal alert or zero alert.
Heather: Yeah.
Patrik: Of course she is, and that is because of the morphine and the midazolam now. And that is what I said to him as well. I said to him, “Have you informed her about the decisions that you’ve made?” And he clearly denied that. He said, “Look, we haven’t.” And he was apologising then, saying, “Look, it probably wasn’t the right approach.” I said
“Look. That’s inappropriate, really, I think-
Heather: Yeah I got the feeling if anyone was going to agree with us over that, it would have been him.
Patrik: Right.
Richard: I think he listened to that. I think he was receptive to
that.
Heather: He has been told one thing by the other consultants.
Richard: As far as I could tell he was not the one who actually did that.
Heather: Yeah.
Richard: He
wasn’t the one who spoke to Mum, and without family there asked her these questions. I think, as far as I can tell, the last person was Dr. Miller, and then prior to that it was one or two of the nurses over the previous day. That’s my guess, but it might not be. As far as the anaesthesia person was not the one who the inappropriate handling of the source of the decision making-choice etcetera…
Heather: And he
hadn’t had the call back before he….
Richard: And I don’t think he had been informed of that at all before that meeting. That is the impression I was getting.
Patrik: Right.
Richard: And he didn’t sort of say, “Yes I was doing that.” He couldn’t say much
with everyone there, of course, naturally …
Heather: Yeah, if the family had been there he probably would have told him it was an inappropriate sort of behaviour.
Richard: Yeah. With us watching over him. Yeah.
Patrik: Right. What he certainly did do is, I
wouldn’t say he was blaming … He wasn’t blaming, but what he did say is, “Oh, we’ve had a good chat with all the senior consultants and with all the physicians, blah blah blah.” He was trying to delegate responsibility onto other people. Right? So he didn’t want to take personal responsibility for the decisions that have been made, but what I clearly said to him was, “Look, I’ve seen those situations many times, but what I don’t understand is why you haven’t involved your Mum in this process.” I
said to him, “Have you asked, her what she want?” And he clearly said, “No, we haven’t.”
Right.
Richard: Exactly.
Patrik: So, that-
Recommended:
Richard: In the first place, that’s crazy.
Patrik: That’s right. I said to him, “By not being transparent in your decision
making …” If they had told you yesterday, “Oh we’ve sedated her because we want to improve ventilation.” Well, you probably could have accepted that.
Richard: Well, they didn’t say that to me. They definitely did not say that to me at all. I agree with you. It would have been helpful information to understand that that was their true or false, but that was their presentation.
Heather: Yeah because the way things are going now with that sedation, Richard may have missed, I’m sorry Richard to say this, your last chance to have a communication about consent and whatever with your Mum and her wishes.
Richard: I believe that unless something’s changed that’s almost certain. That’s my feeling at the moment. Looking at where she’s at, looking at the
drugs, looking at medication, look her situation in terms of what I call zero alertness I think whatever window that did happen was very limited, because of what had been going on, but that that’s now gone. I was very clearly, I was wishing to do that, was endeavouring to do it, but Mum wasn’t ready at that point. She was too unwell. In that very moment they gave me, a very short period of time for me to step back. Quite frankly I had a clear though of how things going on, including obviously
navigating that systems. You know already how difficult is that. That’s slowing me down in terms of any true ability to work with my Mum on that. The lack of information being … telling me three days later, made a huge difference, that whole process. And initially, they were completely wrong and false, saying, “We have been telling you this for three days straight.” And that was the ward nurse, the previous one, and I was extremely unhappy about that because it was totally untrue. And yet she
wouldn’t budge an inch on that. So that’s to me them covering their back on that there.
Heather: Yeah. She heard him.
Richard: That’s not the one today, that’s the other one.
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Heather: Yeah.
Richard: It’s difficult.
Patrik: The other thing that I noticed, once I had the information that I needed from him, I was ready to finish the call, and he actually tried to reel me in again.
Where I just thought,
“Okay, you are making explanations for what you’ve done.”
And I was very nice to him, I wasn’t confrontational, but I wasn’t-….
Heather: Assertive. There’s a difference.
Patrik: Yeah. Just having a conversation with him, but at the same time asking all the difficult questions. So
once I had the answers to the difficult questions, then I realised, okay well I’ve got the answers, that’s fine, and then he was the one who tried to keep the communication going, and he was telling me, “Oh I know you guys in Australia you are using advanced care directives and blah blah blah we don’t have them in Ireland.” And then he asked, “Would you keep a patient ventilated for longer than 30 days?” And that again, he kept coming back to those 30 days, where I was just thinking ok
well….
Heather: Did your Mum have an advanced care directive in the UK?
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Richard: No, but having said that, there was a very clear conversation I understand between herself and her actual GP, locally
here, and that was before she was admitted to A and E, before any of the current story, as I got very clear information from the nursing home, I trust them-
Heather: And the GP.
Richard: And I can obviously double check with the GP, but number one, yes, she did wish to be alive, and resuscitation and all the rest. And even if she was in
different circumstances she still wished to be alive. I can confirm that because then when I spoke to her after … when she was in here, when of course she was in better alertness than what they said very clearly to me, which again was another thing I take great exception to, is they say the previous family with Dr. Higgins, which was the day before yesterday, two days ago, that on three different days they’d asked Mum, about this, did she want to live et cetera et cetera, she said, “No, she
didn’t wish to live.” And that’s so out of sync with Mum.
Heather: She could be saying, “No, go away,” then.
Richard: Absolutely. Now it could be of course that she said something different to the nurse than to me, I haven’t had accounts, it could be that there is a miscommunication which again is where-
Heather: But if they had of had her chaplain here or you know.
Richard: At least somebody to monitor what…
Heather: And if they were okay with that…
Richard: And if they saw any sense of manipulation or
misdirection, then clearly they would have had some opportunity to say to the chaplain or to me, or anybody, to say, well actually I think you should have presented it in a different way. Or actually, she wasn’t well enough, there is no independent verification of how exactly was that decision made to withdraw treatment-
Kind Regards
Patrik
