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
How Can We Prevent the ICU Team in Transferring our Dad to the Ward Too Soon?
You can check out last week’s question by clicking on the link here.
In this episode of “YOUR QUESTIONS ANSWERED” I want to answer a question from one of my clients Anna as part of my 1:1 consulting and advocacy service! Anna is suspicious about the ICU team’s decision for her dad’s transfer to Neuro Rehab Ward. She is asking why it’s sudden and were all the risks taken into consideration?
My Dad Is In ICU And Still Vulnerable But Why Is The ICU Team Rushing My Dad to be Transferred to the Ward?
Hi Anna,
First off, let’s look at the positives.
Your Dad has improved tremendously and has made a remarkable recovery to this point. He clearly defied the odds and that should be celebrated.
You should definitely be suspicious of their motivations and as you know by now without your advocacy they probably would have let your Dad die many weeks ago! By now, you know their agenda and you also know what helped your Dad to this point!
RECOMMENDED:
Part of it was to never give up and staying positive, whilst also focusing on your Dad’s strength and not his weaknesses! It was also good information that your Dad’s personally suggested that slow and steady wins the race, which is definitely the case in ICU. Recovery is a marathon and not a sprint!
I have just looked through my records and in terms of timelines it looks like your Dad has been in Intensive Care since around mid-April this year. Therefore his stay would be around the three month mark now.
That’s long, but it’s nothing that they haven’t seen before, especially since you’ve mentioned they have had a patient on a ventilator for about 12 months!
You should trust your instincts that they want to send out your Dad before another setback happens! Your gut and instincts is what helped your Dad to this point and you knew that something was off when they first tried to stop and withdraw treatment!
Having said all of that, the risk for infection in ICU is so much higher, therefore sending him out makes sense to minimize the risk for infections. At some point they had to remove the tracheostomy, I was glad to hear that they took it slowly and inserted the
mini-tracheostomy first to see how he goes and it looks like they felt confident to remove it completely.
In some hospitals Patients can leave ICU with tracheostomy once they are off ventilation but it sounds like the neuro-rehab ward doesn’t have the skills to look after tracheostomy.
How much sooner are they sending him out compared to what was talked about initially? Can you give some time frames?
Once the tracheostomy has been removed and no other organs are failing and there is no other life support, I can’t see why he can’t go to a ward. For example, immobility and weakness are usually not indicators to keep a patient in ICU.
What will happen on the ward however is simply that he will go from 1:1 nursing care to 1:4 or 1:6 or even 1:8, potentially 1:10 overnight. It’s best to find out.
The contrast in care will be stark once he’s on the ward. Nevertheless, will he have to make that step.
You are saying “We are all concerned that Dad is a high-risk transfer. We didn’t get the impression there was a rush before. What are your thoughts?”
Your Dad probably is a high risk transfer especially with his significant pre-medical history, however try and look at the positives of it all that he’s finally able to leave ICU, what an achievement!
The rapidity and push for it could simply be that your Dad is finally ready, but obviously the push could also be that they don’t want to spend any more of their expensive ICU resources for him!
The total cost for your Dad’s ICU stay up to now would probably be around £3,000- £4,000 per day. Therefore the total cost to this point would have been between £270,000- £360,000, potentially even more. Therefore hospital administration would be putting pressure on the ICU, no doubt!
By the same token, if he’s off the tracheostomy he will need to leave ICU. Are there risks associated with it? Absolutely. Can they be managed on a ward? Potentially if they have the right skills and some experienced nursing staff.
Furthermore, some ICU’s have an ICU outreach or ICU liaison service. What that means is that they look after patients on the ward two to three times per day because they are at high risk of ICU readmission. Ask the ICU if they have such a service and what’s their plan to follow up on the ward in order to manage and reduce the risk of readmission?
Now, generally speaking, most hospitals have “met call” criteria. What that means is that they call a “met-call” if certain criteria are met. What does this look like in practice? It means that if vital signs are deteriorating such as heart rate, blood pressure, temperature, breathing rate that ICU will assess him. Please see the attachment and have a look at page 6. The sections highlighted in yellow is the dangerous territory when Met-calls are being
called.
Now, when Patients first leave ICU some of the met-call criteria might be adjusted and documented. That means that for example for your Dad that ICU might tolerate a lower threshold for blood pressure, heart rate, breathing rate etc… because they don’t want your Dad back in ICU.
Therefore your first step is to ask for the “met-call” criteria and if they altered the standard met-call criteria when your Dad leaves ICU.
Next is the DNR status. As long as this hasn’t been discussed with you or your Dad, you must assume that your Dad is for full resuscitation. Make sure you set the rules!
Also, if met-call or DNR is a point of discussion, it sounds like your Dad is at a point where he can be asked about what he wants? That should be your default position.
If your Dad can’t be involved because you think he’s not quite ready then it’s you and your family. Make sure you tell them you have discussed with him. Make sure they don’t discuss with your Dad in your absence!
What’s in your Dad’s “best interest” is up to him and not up to the ICU, period! Again, if you feel like he’s not quite ready to enter those discussions make sure you and your family speak with one voice to advocate for your Dad that he was to go back to ICU in case of deterioration!
If they deny that ask for the policies around their decision making process!
RECOMMENDED:
You also ask:
“Do I point out that their prognosis on many aspects of his care has been wrong before?”
Yes, yes, yes!!!
I hope this helps! Stay positive and assume your Dad won’t need to go back to ICU but have the worst case scenario covered!
Warm Regards,
Patrik
Hi Patrik,
Thanks so much for your email, as ever!
Today my brother told me they have removed the inner tube, so my Dad is without the tracheostomy now.
At the ward round today the two consultants talked about discharging Dad to the neuro rehab ward. This is much sooner than was originally talked about. I travelled home this morning and so wish I had been there.
Of course this is a big step forward and positive. To be candid though, I’m suspicious of their motivation and the rapidity of it all, Patrik. The unit is quiet, and has been for a week, so there is no demand on beds and staffing.
My instincts are telling me that they are looking to discharge Dad before the potential of another setback. They had one patient on a ventilator for a year, I know that. I think they want to avoid that kind of (potential) scenario again.
I’ve bought another email package as I really need your help on negotiating this!
We are all concerned that Dad is a high-risk transfer. We didn’t get the impression there was a rush before. What are your thoughts?
Can I request that they keep Dad in ICU until I can come down for a formal meeting with them at the weekend to discuss everything ok detail? Is that reasonable?
In terms of what they told us about non-readmission to ICU and not intubating Dad again etc., what do I need to say to them? How can I show them I have the knowledge that this is not ethical or clinically acceptable?
We think they will put forward the arguments, as they have done before, that it’s not in dad’s best interests, that his body wouldn’t be up to it. How do I respond to that? What key things do we need to say to challenge it? Do I need to say all of this and get their acknowledgement before Dad is transferred out of ICU?
Do I point out that their prognosis on many aspects of his care has been wrong before?
Thanks so much!
Re pod cast: I’ve asked my mother in law do look at her diary to see when she could look after my daughters and I can get back to you with dates and times!
RECOMMENDED:
Best wishes as ever
Anna
RECOMMENDED:
Hi Anna,
It sounds like your Dad has taken more steps forward.
At some point they have to remove the tracheostomy. They have inserted what’s called a “mini-tracheostomy”, therefore taking measured and controlled steps to keep it safe. They would be able to reinsert the bigger tracheostomy easily if needed.
Sometimes tracheostomies are removed without putting in the “mini-tracheostomy”, therefore I feel they are doing the right thing.
In terms of the DNR status, yes it is absolutely necessary to get clarity around it and it is absolutely necessary for you to know that your Dad would go back into ICU if he was to deteriorate!
RECOMMENDED:
Now, for the records, I have just opened up a membership for families in Intensive Care in the last week. There you can get access to me online and get your questions answered privately like here for only $97 per month ($790 annually). I answer questions daily. Furthermore, you have access to all of my EBooks and the Videos that come with it.
https://intensivecarehotline.com/intensivecaresupport-org-membership/
As far as the interview goes, please let me know when you’re available and I should be able to work around your schedule. Currently I’m 9 hours ahead of you.
Warm Regards
Patrik
The 1:1 consulting session will continue in next week’s episode.
