Futile care

Specialties MICU

Published

How many times have you had patients like this?

80+ yr old patient coded on the floors, unknown downtime, lungs are trashed, in ARDS, on 100% O2, PCV, PEEP 12, rate of 24; kidneys are shot, on CVVH, heart only works because he's on dopamine, epi, levo, vasopressin and isoproteronol drips. I have no idea what the doc's tell the family but the family "wants everything possible to be done".

Of course, we all know the eventual outcome . . . a week, two weeks, a month later . . . the patient codes and we can't bring him back.

Of course, we have to care for all patients . . . but, I don't get a lot of satisfaction taking care of these patients . . . some of my cynical colleagues call them "test dummies" for the interns and residents. Your thoughts?

In the absence of good physician to family communication I feel perfectly free to help the family understand myself. I will explain the chances of their loved one, our available palliative care unit, what happens when we code grandpa, I will share my past experiences with similar patients. If all this fails I try to get the ethics committee involved. I have also refused to code patients several times.

I don't disagree that often times, the families aren't ready to let go and we end up basically torturing their loved ones until they die. I also agree that it is completely appropriate to present the facts to the family, the expected course based on our prior experiences, and discuss comfort/palliative care/hospice with them. However, it sounds like you are very aggressive in persuading the family to withdraw care to the point of getting the ethics committee involved. I mean you can only do so much, but in the end, it IS the family's right to determine care for their loved one. Also, how do you "refuse" to code a patient if that is the family's wish? I would think that could be interpreted as abandonment and/or neglect.

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Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I don't disagree that often times, the families aren't ready to let go and we end up basically torturing their loved ones until they die. I also agree that it is completely appropriate to present the facts to the family, the expected course based on our prior experiences, and discuss comfort/palliative care/hospice with them. However, it sounds like you are very aggressive in persuading the family to withdraw care to the point of getting the ethics committee involved. I mean you can only do so much, but in the end, it IS the family's right to determine care for their loved one. Also, how do you "refuse" to code a patient if that is the family's wish? I would think that could be interpreted as abandonment and/or neglect.

*** I am my patent's advocate, and their family's too, but advocating for my patient comes first. I am never advocating withdrawing care, mostly I want them to make the patient DNR so that we (health care people) don't have to cause pain and harm to our patient needlessly.

Refusing to code is simple. I put my hands up and say "I can not in good conscious take part in coding this patient" or something similar and stand aside. I remain available to answer questions. I will call the code but not take part. I have done it several times when coding was known by all to be futile and (I believed) painful. I learned to do this from one of my real life mentors and heroes, and old trauma surgeon.

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Specializes in CVICU/SICU.
How many times have you had patients like this?

80+ yr old patient coded on the floors, unknown downtime, lungs are trashed, in ARDS, on 100% O2, PCV, PEEP 12, rate of 24; kidneys are shot, on CVVH, heart only works because he's on dopamine, epi, levo, vasopressin and isoproteronol drips. I have no idea what the doc's tell the family but the family "wants everything possible to be done".

Of course, we all know the eventual outcome . . . a week, two weeks, a month later . . . the patient codes and we can't bring him back.

Of course, we have to care for all patients . . . but, I don't get a lot of satisfaction taking care of these patients . . . some of my cynical colleagues call them "test dummies" for the interns and residents. Your thoughts?

See it all the time. Add in ECMO/LVAD/RVAD/Nitric/etc. for even more futility.

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We have a hopeless case right now, he's young, previously healthy, but he got a bad TBI in a car accident and I think he nicked his respiratory center. He was on the occillator about a month ago, and he's been on 100% duo-pap+ since then with four chest tubes. His family wants everything done, and he just isn't waking up. People aren't supposed to be on duo-pap for that long, and even with that his PaO2 is 75 on a good day.

I see this all the time. Even in cases that aren't so desperate, we bring people back to life for what cost? What sort of a quality of life do they have in a vent facility? We had a 70 year old that weighed more than 600lbs come in with respiratory failure. 2 months later, we discharged him with a trach to long term care. I wouldn't want to live like that. I am seriously thinking of going into inpatient palliative care when I get my advance practice degree, and spread awareness of death. It happens. We all have to die someday, and just because we can do all these crazy, miraculous invasive things does not mean we should.

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I like to believe that because we work in the ICU, we have an inaccurate view of dying in our society because we often see the "futile care" cases. I know of many of my friends and relatives with loved ones that died peacefully in hospice or at home. Also, once in a while, a dying patient is admitted and we start in with the ICU heroics, intubation, lines, drugs, etc . . and a family member rushes in, puts a stop to everything. Then, with family at bedside, nature takes it course.

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Specializes in Not too many areas I haven't dipped into.
This is a common situation in many ICUs. It is a result of poor or inadequate communication between physicians and the family. The physicians are simply not doing their job in helping the family to clearly understand the situation. I find a good hospital Chaplin can be very helpful in these situations.

In the absence of good physician to family communication I feel perfectly free to help the family understand myself. I will explain the chances of their loved one, our available palliative care unit, what happens when we code grandpa, I will share my past experiences with similar patients. If all this fails I try to get the ethics committee involved. I have also refused to code patients several times.

I completely agree! I think if you are very honest and caring with the family and explain the circumstances, I would say 99% of the time, my family's change their mind. It is so hard on a family to feel as if they have not done everything possible. But, everything possible means something different to each person. If you open a good dialog with the family, you can find clues and cues as to how to get them to a feeling of "right" in their hearts.

Hang in there

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Specializes in floor to ICU.

One of our docs recently went to an intensive training session to become palliative care certified. I am hoping that with his help we can stop some of these futile care issues. We treat animals more humanely than humans sometimes.

Just because we can, doesn't mean we should.

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Specializes in icu/er.

my biggest issue with having many "hopeless case" pts in the unit is that many times they take up most of your time and man power cause they are often complete and total care. this is time that you are taking away from other pts that have a real chance of recovery.

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