Critical Care Medicine - List
http://www.pitt.edu/~crippen/

CASE#9: The accidental tourist

A thin 35 y/o male appears in the emergency department at midnight, cyanotic and acutely short of breath. He is brought in by car accompanied by another male friend who says that the patient is visiting from San Francisco and suddenly developed respiratory distress while watching TV. The friend says the patient has no history of any past illness and he does not know what the problem can be. You note that the visitor makes poor eye contact while giving the history, with an occasional Nixonian Shift. The patient is unable to converse effectively with a respiratory rate of 60 and acute air hunger. He is in acute respiratory distress even on 100% face mask oxygen. The patient refuses to let you draw a blood gas and his Sa02 is unobtainable except for an intermittent reading of 80%. Through gasps he manages to get out one word: "tube!". The x-ray technician is tied up on an emergency in the operating room and there will be a 15 minute delay.

You elect to intubate him to stabilize his respiration until you can sort this situation out. However, every time you try to lie him down he quickly sits bolt upright and screams loudly. The nurse finally gets an IV access. You are confident that you can intubate and so you give the patient an appropriate bolus of vecuronium followed by fentanyl and midazolam. Shortly thereafter, he is intubated without difficulty, good expansion of both lung fields and the Sa02 monitor settles down to 85% on 100%. You figure you will have to keep him down for a while to get things settled down and so you begin a vecuronium/midazolam infusion. CVP and Arterial line in. CXR finally shows virtual white out of both lung fields. No exudate noted on intubation. Other initial lab tests are essentially unremarkable. He is transferred to the ICU where PEEP is added, followed by inotropic support to counter blood pressure drop. The patient ends up on 100% Fi02, 20 PEEP and his peak pressures are 80 cm H20. Pressors and inotropes are adjusted to maintain MAP over 60. Patient paralyzed, sedated and relatively stable. At this point, the friend appears at the bedside bursts into tears. The story then comes out.

The patient has been treated with numerous medications for active AIDS, has been intubated a total of three times for acute exacerbations of PCP over the last year. His physician recommended no further intubations after the firts one. The pateint continued to demand intubation when he became short of breath. He was weaned with great difficulty the last time around, and told by his attending physician that there would be no more ICU admissions for PCP because the treatment would not be effective and he would ultimately die on the vent. The patient was effectively told that the next PCP episode would be the last and that he should consider hospice. The patient then began a tour of the United States in an effort to gain some enjoyment for his last few weeks or months. The touring party made it as far as Pittsburgh before he developed dyspnea again. The two men decided to report to the nearest hospital and fabricate a story that would likely get the patient intubated again, instead of relating the true picture. The last coherent words from the patient (to the friend) was: "I want to live!". Pulmonary service and cardiology service sees the patient and each shakes their head sadly. Possibilities of ever coming off the vent are nil.

After some reflection, the friend then states that he feels the patient really wouldn't want to live "attached to a machine" and he suggests that you remove the vent while the patient is sedated and paralyzed, to "let him die with some dignity". Your senior attending drops by and vehemently disagrees. "You are obligated to wake this patient up and let him decide for himself since he would presumably be competent.

Here are your options:

  1. Discontinue the therapeutic paralysis and sedation, explain the situation to the patient and let him sign palliative orders.

  2. Take the most proximal word of the only surrogate available, the friend. Increase the sedation, turn the Fi02 to room air and nature take it's course.

What would you do?

  1. You can steadfastly refuse to make any decisions about appropriateness of care and use of resources. Your job is to treat the sick and that's what you do. Whatever they think is good for them is necessarily the best thing for them. If they have a headache, and desire you to drill holes in their skull to let out evil humors, that'sno problem. Take out their appendix in the absence of symptoms just because it will relieve the worry of ever getting appendicitis- schedule an OR. Prescribe 100 Percocet tabs for a cut finger? How many refillswould you like?

  2. At some point you can limit care if the cost/benefit or thecomplication/benefit approaches some level that rings a bell in your clinical judgement. It doesn't matter if they want it or not; you ain't drillin' no holes in skulls because it's stupid and ridiculous.

You can adhere to one or the other of these philosophies but not both.If you are an affectionado of (A), it's hard to argue with you. The onlyway for you to run up against an effective argument is when the bank no longer holds enough money for you to continue. However, if you are a (B)man, you are in a much more malleable position.

If you are prepared to draw some kind of limit, then each of these decisions becomes a function of your individual bias (since there islittle or any national guidelines). Obviously, different individuals willdraw these lines in different places. Therefore, the authenticity of your righteous indignation at where others draw the line become subject to some relativity. Remember the old joke: "We already establish what you are....we now haggle about price!".

How many heart valves should society have to provide for drug addicts that continue to abuse drugs knowing the consequences? Should patientswith a life long self destructive alcohol habit we wheeled to the OR for new livers with alcohol on their breath? How long should 50 year, fourpack a day smokers have access to chronic ventilator dependency? I'm not asking how many angels can dance on the head of a pin. These are legitimate questions that we are someday going to have to face squarely.Should ANYONE be empowered to decide how long to go down the road with noncompliant and self abused patients? If so, Who? I don't want to do it.

  • From: David W Crippen: As always, Marj Lazoff presents a lucid and compelling case. She is truly a caring person. It is a genuine shame that there are not enough resources available to care for everyone in the style they would desire. Inaddition, it is a definite potential shame that the political climate is changing to ward a group of folks that are tired of providing blank checks to the poor and downtrodden.

    Even though it would be more comfortable for us if it were not so; thefact is that is too expensive to provide blank check medical care on demand for anyone. Eloquent oratory does not diminish this painful fact that a submerged class of medical consumer has been created by our unwillingness to make painful choices. For every drug addict that continues to get multiple heart valves because of noncompliance, there are working families of four who cannot afford even rudimentary health insurance, putting them at risk to be burdens on the system as well, but with no self abuse and noncompliance component.

    There I've said it: willful self abuse and noncompliance. In a perfect world it shouldn't be an issue. Although provoking screams of righteous indignation and bursts of blood from leaky hearts, the fact remains that these things happen and they are responsible for equal heartbreak elsewhere, just not as well advertised. If we insist on a strict medicaid definition of need, we will necessarily pour resources into areas of patient desire rather than patient need because for the non-compliant,desire invariably equals need.

    Preventive medicine, especially for the organically non-compliant,doesn't work well enough to generate any real meaning. The drug and alcohol unit was located near my office for a few years, and I know someof their physicians well. Their track record for preventive methods is so low as to be practically worthless. These patients have infinitely more incentive to use emergency facilities after a non-compliance related problem because they know they have to be dealt with and they don't haveto take any responsibility for any of it. There is virtually noincentive for preventive measures because they are uncomfortable and require forethought. It is a self fulfilling prophesy. The reason that they persist is for the occasional isolated patient who is able to remove themselves from an environment conducive to that kind of behavior, and because that's really all they have to offer.

    We have two choices here. We can issue blank checks and suffer theconsequences elsewhere or we can, as a society, draw limits on how much rope we are willing to dole out to the non-compliant (and suffer those consequences as well). There are no easy outs here. Marj, your eloquent dissection of this problem tugs on everyone's heart strings.In a perfect world, we should be able to accommodate everyones desires as well as their needs. In our world, the time is coming when we are goingto be faced with difficult choices. My purpose in this thread is not to proselytize one way or the other, but simply to get you used to the idea that difficult choices are on the way; choices that YOU and I are goingto have to participate in, like it or not. Dignity is not going to be an issue. Money is going to be an issue, as it always is in the end.