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 our readers and the question was
My Mom is in the ICU for Septic Shock. Why Does the ICU Team Wants Her To Be Discharged?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Laura as part of my 1:1 consulting and advocacy
service! Laura’s mother is in the ICU for Septic Shock and is asking if the hospital has a policy on withdrawal of treatment for toxic patients.
My Mom is in the ICU for Septic Shock. Is My Mom at the Last Stage of Treatment?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Laura here.”
PART 1
PART 2
PART 3
PART 4
PART 5
PART 6
PART 7
Laura: I know.
Patrik: But that’s not … We can’t rule that out now with everything that’s-
Laura: Right, right.
Patrik: Right. I feel like going to another hospital could be the answer, however given that they have to restart the Levophed at significant rates, by this really high rate, another hospital might say, “Look if she’s on that much support, they need to sort out the primary issue first.” Another hospital would have to almost agree to take her and look at the primary issue and the primary issue is the stent.
Because another hospital in this situation would most likely say, “Well she’s too critical unless we look at the primary issue, we wouldn’t take her.” And they might say, “We can’t look at the primary issue because she’s too unwell.”
Laura: Yes. That’s right. That’s where we’re at this point.
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Patrik: That’s exactly right. That’s where we’re at. What does Medicare say?
Laura: I got my messages mixed up and they were going to open a case for early termination appeal and investigation but now I’m assuming that that was probably not the right road to go down.
Patrik: Say that-
Laura: They opened a case for early discharge but then when I talked to the nurse, she said, “Well it’s not a discharge. It’s just a termination of treatment.”
Patrik: And did you-
Laura: Apples and oranges, I guess.
Patrik: Yes. Did you mention the termination of treatment with Medicare? Did they have a point of view on that as well?
Laura: That’s a good question. I need to get out that treatment facility and see if that is a part of it and maybe it is extending to that as well. Let’s see.
Okay, it says here … It says reporting any concerns you have about the quality of care you received to the Quality Improvement Organisation. I did call them, and I made those complaints.
Patrik: Right.
Laura: It says here Medicare discharge is right … Let’s see. Appeal the discharge. That’s mainly what it is.
Patrik: Yeah, okay. Good. I have some other thoughts, Laura, and in order to cover the worst-case scenario, I have some other thoughts. Okay? Did you have an opportunity to give them the state laws of Minneapolis? Did you have the opportunity to print that out or email it to them? Did you have that opportunity at all?
Laura: No, I haven’t given them or emailed to them, but I’ve told them verbally about it that I know my rights, that the surrogate has rights to choose on behalf of the patient when the lack the aptitude. But the head doctor and the ICU doctor shook their head. He’s in charge. He’s confident that they’re not going to treat her and that’s it and no more discussion.
Patrik: Okay, but he’s basing that on him feeling confident. He’s not basing it on any law or any policy.
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Laura: Well, maybe he’s covered under this policy that they gave me.
Patrik: How long is this policy? You’ve got the policy? Can you email that to me or text it to me?
Laura: Yeah.
Patrik: That would be helpful.
Laura: Yeah. Let me see if … Yeah.
Patrik: Please do that.
Laura: You didn’t receive an attachment? You didn’t receive one?
Patrik: Just give me one sec. No, I have not received anything in terms of attachments.
Laura: Okay, let me do this. I’m going to take a picture of it-
Patrik: Yes, that would be great.
Laura: And I’m going to send it to you on an email. Let me do that real quick.
Patrik: That would be great.
Laura: I’ll try to get it in the …
Patrik: Thank you. Why don’t we-
Laura: It’s kind of small. It’s kind of hard to see.
Patrik: Right, okay. That’s all right. Then, I’ll come to covering the worst-case scenario because we really need to look at that and I’ll tell you how we would go about that. We did this successfully the other day with another client. In order to cover the worst-case scenario, you may have to go to the Supreme Court and that could be as simple as making a phone call. We did that successfully with another client on a Sunday the other day.
Similar situation. The ICU was threatening to remove life support, whatever time it was, Monday 5:00, whatever the case may be. The family was told that on a Sunday and we couldn’t get hold of a lawyer on a Sunday. It was very difficult to get hold of a lawyer. Then, we rang the Supreme Court ourselves on a Sunday. Bear in mind everything’s closed but there was an afterhours number and low and behold somebody picked up and within a couple of hours the Supreme Court put in an
injunction.
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That was without the involvement of a lawyer. That was just purely by stating facts and referring back to the law. All the court is interested in is in the law. The court is not really interested in hospital policies. Yes, that might be down the track, but I do believe with the documents from the excerpt that I sent you about the law, that should be enough to potentially go back to the Supreme Court in Minneapolis and say, “Look this is what’s happening, and we
need an injunction.”
Laura: Yeah okay-
Patrik: Because no matter how confident this doctor feels, at the end of the day this is life or death. All you want is for your mom to have treatment continued. That’s all you want. If they can’t save her life because they’re doing everything they can, so be it. But if they’re not doing everything they can, that’s a concern and I keep going to potentially using strong language. Okay, now I’ve got your attachment here. Just give me one sec
please. I’ll just open this up.
Laura: I sent two or three of those.
Patrik: Yeah, that’s all right.
Laura: Maybe one is easier to see than the other.
Patrik: Yeah, no. I can see it. Are both the same?
Laura: I think they’re all the same. It’s just the first page where it’s talking about when you have a care decision conflict resolution.
Patrik: Yeah.
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Laura: They’re saying that by life support, as a Catholic doctor they cannot continue the support because it’s too tiring. It’s not humane or something to that…
Patrik: Yeah, something to that effect. Laura, can you give me five minutes? I’ll have a quick read and I’ll call you right back. Is that all right?
Laura: Sounds good. Yes.
Patrik: I’ll just quick here have a good read and I’ll call you right back. Okay?
Laura: Sounds good. Thank you.
Patrik: bye.
Laura: Bye-bye.
Laura: Hi, Patrik, I’m here.
Patrik: That’s okay. Thank you for waiting. I’ve had a read through this so this is okay. I would have chosen, you look at number one, define care issue at conflict and then I would have chosen down that list. They said, “Surrogate or caregivers being unwilling to stop an existing treatment”.
Laura: Mm-hmm (affirmative).
Patrik: If you look at this, it’s OK. “Surrogate or caregivers being unwilling to stop an existing treatment”. Then it outlines the steps and the steps are, “Involve supervisor to determine best way to assist in resolving care decisions”. It talks about potentially getting an ethics committee in and have a care meeting. Now, since we spoke on Friday, have there been any meetings?
Laura: Well, there was supposed to be a meeting today. However, excuse me for a second. Let me talk to Patrik. There was supposed to be a meeting today that I was going and that gave me the three options, that they would then transfer to another hospital, that they would okay that if I got an admitting doctor. Or if I get an ICU or a home hospice, I believe, was the other one, if I remember correctly. I’m kind of getting fuzzy in my brain,
but something happened just now, I need to tell you about, while you took a few minutes to read.
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I called them, the health supervisor, and I said, “Well, what’s going on with this case?” She said, “Well, you’re okay for today and probably tomorrow because it’s going to take a time to look into this issue that you’re raising”. She said, “You need to talk with the team in the ICU. They’ll keep you apprised as …” I guess they’re doing a little investigation into this conflict, see? So, it’s buying us a little more time. I got the word today from Mona, I’ve got
to write down her name. She said that we have at least 24 hours, if not more. She goes, “Maybe even until after Christmas”. But she said, “You’ve got to keep in touch with the team on the floor at the ICU where she’s at”.
Patrik: Yeah. I’ll tell you what. I suggest the following. Yes, they’ve bought you 24 hours, that’s fine, but it’s still only another 24 hours. Let’s just run this through in our heads. If you were to have a meeting with them today, it would probably still be the three points they wanted to discuss, which is number one, termination of life support. Number two, going to another hospital. Or number three, removing life support and taking your mom home.
Laura: Mm-hmm (affirmative)
Patrik: Right?
Laura: Yes.
Patrik: Then with that in mind, if I was you, I would argue with them, “Okay, well, here are your three options. My fourth option is to continue treatment”, okay? And then ask for a meeting and then in that meeting, bring in the policy that they’ve given you, but also the state law.
Laura: Okay.
Patrik: What you could also do in the meantime, and from experience I would recommend that, if I was you, I would ring the Supreme Court, tell them your situation and see what they say. Because the reality is it’ll be much harder to get hold of the Supreme Court tomorrow than it is today.
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Laura: Yes, right. Okay.
Patrik: That’s what I would do because by the looks of things, you will need an injunction to buy you time and you may get that injunction by talking to them, but you couldn’t rely on that at this stage.
Laura: I see. Okay.
Patrik: Right? That’s how I feel about this. You mentioned something on Friday. Your brother is helping you with this, is that right? Your brother and your nephew?
Laura: Yes, my brother is, and my 17-year-old daughter is close with her grandmother as well, so the three of us, mainly. We have some friends too and relatives.
Patrik: Sure, sure. You are mainly doing the talking with them. It’s not your brother. You are doing the talking with them mainly?
Laura: Correct, yes.
Patrik: Sure. Look, I feel like I’ve seen all sorts of things and, unfortunately, if they want to withdraw life support tomorrow, whether it’s Christmas day or not, they potentially might. And even
though they’re Catholic and whatnot, you think that on such a day they would honour their faith, religion or whatever you want to call it. It looks like it may not happen. I do believe you need to call the Supreme Court and tell them about your situation and … I believe if the holidays were over, it might be easier to get a bed in another hospital for your mom. I do believe that at the moment with the holidays, nobody’s interested in any added complexity.
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The unfortunate reality is that some hospitals do ignore whatever you throw at them in terms of state law, in terms of end of life care
policies and whatnot. They tend to ignore that and that’s why I do believe in order to prevent that worst-case scenario, you need to go the Supreme Court and just give them a call and get a feel for where they stand. Clinically, there is a chance that if the Levophed keeps going up and if the Vasopressin keeps going up, there
is a chance that they may not be able to save your mom’s life regardless, but we don’t know that. We can’t look into the future.
Laura: Right.
Patrik: Right? Obviously, the biggest turning point for me, even from your emails yesterday is that she’s back of Levophed. That’s a big …. it’s changing everything. By the same token, she’s here and they will need to continue that. Also, again, from an ethical point of view, you and your mom don’t want to give up. If she was to pass away on maximum life support, well that’s probably what she wanted and that’s probably what you want and
they’re not honouring that.
Laura: Yeah. Right. That’s true.
Patrik: I would definitely do that. I would contact the Supreme Court if I was you as a next step to have that potentially up your sleeve because that might be your last resort going forward. If nothing else is going to … if you can’t come to an agreement with them. I’ll tell you what I also believe. You may only need another two or three days because the reality is your mom will either pull through, and if she pulls through, then I do
believe chances for getting a bed in another hospital will increase because she’s shown some resilience, she’s shown that she can pull through and then chances might increase to get her somewhere else.
In the meantime, and the other thing that I would do is I would ask for a second opinion.
Laura: Say that one more time?
Patrik: I would ask for a second opinion.
Laura: Okay.
Patrik: Because, again, it’s all about buying time.
Laura: That’s right.
Patrik: It’s all about buying time and if a second opinion will buy you time, then I would do that.
Laura: Okay. So, I must find a doctor that will give me a second opinion.
Patrik: Yes. However, here the opportunity is also important. Again, with the holiday coming up, you could say, “Hey, I need time to organise that doctor”, and given that it’s now one day before Christmas day, you could say, “I need time”. Right?
Laura: Yeah, that makes-
Patrik: Make use of that holiday period, make use for your own good and say, “Look, I understand what needs to happen, but I need time and given that it’s holiday time, I probably need a couple of days”, and in the meantime you refer back to the conflict and you refer back to the policy. You refer to the state law. I would not mention to them that you are going to contact the Supreme Court. I would do that, but I wouldn’t mention it to them
until you get an answer from the Supreme Court in terms of where they stand.
Laura: Okay. All right.
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Patrik: Does that sound like an action? I’ll quickly summarise it one more time. Get a second opinion. Ask them to continue treatment until you found a doctor for a second opinion. Refer to the conflict and ask for a meeting for conflict resolution. Okay? Keep referring to the state law, keep referring to the policy that they’ve given you and go to the Supreme Court. Ask the Supreme Court.
Have you talked about them potentially murdering your mom? Have you used those words?
Laura: I talked to the Medicare lady and those were the words I used to her when I thought they were discharging us early. I did make some complaints about the treatment of the admitting doctor and the doctor in the ICU to the … What’s the name of the person who helps… supervisor? I made some complaints there, but I might need to up that complaint for everyone.
Patrik: I think you need to because it’s coming to a point where you don’t know what they’re going to do. Anything is possible and you sort of must prevent the worst-case scenario and one way is to starting using stronger language. How do you feel at the moment? You keep talking about the nurses. It’s probably a stupid question. Is it very tense, the situation? Or do you feel like-
The 1:1 consulting session will continue in next week’s episode.
Kind Regards
Patrik
