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 last week was

I have lost my 62 year old husband last year in Intensive Care after cardiac arrest! The Intensive Care team withdrew treatment against my will! Could he have been saved?

You can check out the answer to last week’s question by clicking on the link here.

In this week’s episode of “YOUR QUESTIONS ANSWERED”  I want to answer another question from one of our readers and the question this week is

My mother went into cardiac arrest after a heart attack! She’s been in ICU for 1 week, has brain damage and is not “waking up”, what should we do?

This question from Malik formed part of an email counselling and consulting session with me.

Malik writes

Hi Patrik,

my 79 year old mother had a heart attack 7 days ago. She went into hospital and there went into cardiac arrest. It took 18 mins for the doctors and the nurses to bring her back and resuscitate her.

She has been in the ICU for 1 week now and they say she can't breathe without the ventilator because she has heavy damage in her brain. This brain damage has been confirmed after an MRI of the brain and an EEG testing.

Heavy brain damage means that she is not responding to anything, her pupils are dilated and they are not responding to light, she can't breathe without the ventilator, her heart rate and all the other vital signs are normal but the doctors say there is no hope after seeing the MRI report!

They have taken off all the sedation now and she’s not responding.

Because of that they don’t want to do a tracheostomy and they are now referring to a “one way extubation”…

The Intensive Care team has been a bit vague about what this all means and we are very confused as to where my Mum is really at.

We understand that the brain damage is significant but we are unsure if we are making all the right decisions.

Can you please explain what they mean and what do you suggest we should be doing?

Many thanks,

Malik

Hi Malik,

thank you for making contact and thank you for your question!

Thank you also for signing up for my 1:1 email counselling and consulting service!

First of all, I'm very sorry to hear what you and your family are going through!

This is a difficult time in your life and my thoughts are with you and your family!

From a bigger picture perspective, your mother had a heart attack and then went into cardiac arrest.

She had to be resuscitated and it took 18 minutes for your mother to be revived and get her heart to beat again.

During this time, there is a very high chance that the brain sustained irreversible brain damage due to the lack of  cardiac output(= the heart pumping) and the lack of oxygenated blood being delivered to the brain.

Whenever critically ill Patients go into a cardiac arrest, it’s a race against the clock because anything above three minutes with no meaningful cardiac output and no blood pumping around the body, the biggest risk is that vital organs such as the brain, the kidneys, the liver and the lungs are not getting adequate supply with oxygenated blood and therefore are getting irreversibly damaged.

What often does happen in cardiac arrest and during cardiopulmonary resuscitation is that cardiac output(= the heart pumping) will be restored in a time frame that is more than three minutes and therefore the risk for significant damage in the major organs such as the brain, the kidneys, the liver and the lungs can’t be eliminated.

Related article/video:

• What is the prognosis after my critically ill loved one’s brain has not had sufficient oxygen supply(hypoxic brain injury)?

Prior to the cardiac arrest, please keep in mind that your mother also sustained a heart attack. Given that she went into cardiac arrest relatively quickly after the heart attack, there is a big chance that the heart attack caused so much damage that a cardiac arrest was inevitable.

Therefore the odds were stacked against your mother from the start.

18 minutes “down-time” or 18 minutes of cardiopulmonary resuscitation and then having brain damage that has been evidenced by the MRI of the brain and the EEG sounds to me like the Intensive Care team has done all of their due diligence to give you the right diagnosis and prognosis.

Given that an EEG has also been done, it’s also a good sign that they’ve looked at this situation from more than one ankle.

An EEG requires the involvement of a Neurologist and therefore outside input. That’s a good sign from my perspective that they are willing to consult other doctors as well.

Given that your mother is not on any sedation anymore she should also “wake up” after the induced coma. Now that the sedation is no longer there, the coma is not induced any longer it’s more like a natural coma because of the irreversible brain damage.

Given that’s the case, the chances are that the irreversible brain damage is causing your mother not being reactive to anything, including stimuli.

Furthermore, the non-reactive pupils are a pretty good sign that irreversible brain damage has been sustained as well.

From that perspective it does make sense that the Intensive Care team is not suggesting a tracheostomy and rather let nature take its course.

Furthermore, even though you haven’t mentioned it, your mother is most likely on Inotropes such as Adrenaline, Noradrenaline, Dobutamine and/or Milrinone. Those Inotropes are drugs of choice for life sustaining treatment after cardiac arrest and/or heart attack.

Therefore when the Intensive Care team is referring to “withdraw life support” they are not only referring to a “one-way extubation”(=removal of the breathing tube), but they are also referring to the withdrawal of the Inotropes.

Inotropes generally speaking increase blood pressure and strengthen the contractility of the heart muscles.

It therefore also suggests to me that you, your family and your mother are facing a “real” end of life situation.

Related article/video:

• The difference between “real” and “perceived” end of life situations when your loved one is critically ill in Intensive Care!

Therefore it’s now important for you to make sure that you and your family can prepare for your mother approaching her end of life in Intensive Care!

It’s very important that you and your family can make informed decisions, get peace of mind, power and influence during this “once in a lifetime” situation that you don’t really want to get wrong!

What do I mean by that?

By that I mean that you and your family don’t want to be “rushed” into the withdrawal of life support and the “withdrawal of treatment”!

Related:

• THE 5 THINGS YOU NEED TO KNOW IF THE MEDICAL TEAM IN INTENSIVE CARE WANTS TO “LIMIT TREATMENT”, WANTS TO “WITHDRAW TREATMENT” OR “WITHDRAW LIFE SUPPORT” OR WANTS TO ISSUE A “DNR” (DO NOT RESUSCITATE) OR AN “NFR” (NOT FOR RESUSCITATION) ORDER FOR YOUR CRITICALLY ILL LOVED ONE!

On the one hand it’s very important that your mother is comfortable, pain free and is not suffering. You haven’t mentioned that so I assume that’s not the case, which is good because now it’s easier for you to determine the next steps.

A “one way extubation” means that the removal of the breathing tube(=extubation) is only done once and therefore chances are that your mother may pass away relatively quickly after the removal of the breathing tube(=extubation). Passing away after the removal of life support and the removal of the breathing tube can happen within minutes, hours and sometimes even days, even in the most critically ill Patients who are approaching their end of life.

Given that your mother had a cardiac arrest after a heart attack and sustained irreversible brain damage, chances are high that she’s going to pass away quickly after the removal of life support. Again, in your mother’s situation the removal of life support means removal of the breathing tube(=extubation) and the ventilator, as well as the removal of the Inotropes.

That’s why it’s so important to make sure that your mother is comfortable when taken off life support so that she’s not suffering.

Related article/video:

• HOW LONG DOES IT TAKE TO DIE AFTER REMOVING THE BREATHING MACHINE OR LIFE SUPPORT?

You can prepare for that to happen in the next few days, but you and your family need to be ready for that and you want to make sure that you and the rest of your family had enough time to say goodbye to your mother.

There is a high chance that the Intensive Care team wants to remove the breathing tube quickly and let nature take it’s course, because they are in need of the bed and the other resources(staff and equipment) that go with it.

Please don’t let anybody pressure you to take the breathing tube out when it’s convenient for them but do so in a time frame that you and your family feel comfortable with.

I have seen a many bad end of life situations where the Intensive Care team pressures families in Intensive Care to remove life support as quickly as possible because it’s convenient for the Intensive Care team often because they have such high pressure on their “in-demand” ICU beds.

Therefore you and your family need to make sure that your and your Mother’s spiritual, religious, cultural or any other needs that are important to you and your family are fulfilled.

If an end of life situation in Intensive Care is rushed or hastened it can leave many families bitter and resentful and that’s why it’s so important that you and your family have a say about how and when you want to proceed with the removal of life support.

What often happens is that the Intensive Care team is calling for a “formal family meeting” where the Intensive Care team is using their “perceived power” and their “perceived authority” to get what they want.

Therefore you and your family need to be prepared for any formal meetings that you are going to have with the Intensive Care team.

Related:

• FOLLOW THIS ULTIMATE 6 STEP GUIDE FOR FAMILY MEETINGS WITH THE INTENSIVE CARE TEAM, THAT GETS YOU TO HAVE PEACE OF MIND, CONTROL, POWER AND INFLUENCE FAST, IF YOUR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE!

On the one hand, you don’t want to let your mother suffer unnecessarily and you don’t want to prolong life unnecessarily when nature is about to take it’s course, however you and your family also want to have enough time to come to terms with the inevitable.

Therefore, after you and your family had enough time to come to terms with this situation, after all of your cultural, spiritual, religious or any other needs have been fulfilled and also making sure your mother isn’t suffering in the process. If she’s suffering the Intensive Care team can give sedative drugs and pain killers again, but if she’s not suffering, you and the Intensive Care team can go-ahead and remove life support.

It’s so important that death in Intensive Care and the decision making around it is in a cooperative and amicable environment as you and your family don’t want to feel like you have made the wrong decisions.

I'm very glad Malik that you've come to me in a timely manner. Many people come to me when it's too late, when their loved one has passed away already.

Whilst I can't save your mother, I can show you what's important and I can show you what you need to do in order to make informed decisions, get peace of mind, control, power and influence, no matter the outcome!

I hope this helps Malik. Please let me know if there‘s anything else I can help you with.

​​​​​​​

Wishing you and your family all the very best!

Your friend​​​​​​​

Patrik

Related:

• THE 5 THINGS YOU NEED TO KNOW IF THE MEDICAL TEAM IN INTENSIVE CARE WANTS TO “LIMIT TREATMENT”, WANTS TO “WITHDRAW TREATMENT” OR “WITHDRAW LIFE SUPPORT” OR WANTS TO ISSUE A “DNR” (DO NOT RESUSCITATE) OR AN “NFR” (NOT FOR RESUSCITATION) ORDER FOR YOUR CRITICALLY ILL LOVED ONE!