Premature End of Life Care

I had returned to the Hospital following my longest-ever vacation, four weeks in Portugal and Southern Spain and was renewing my “management by walking around” skills when I dropped by our Medical Intensive Care Unit (MICU).  There was a buzz in the air, a friend and colleague of mine had just signed-off as the physician of an 87 year-old woman who was intubated and had been on a ventilator for several weeks. 

This was a transitional time in the history of critical-care medicine.  We were moving from open to closed units.  At that time general internists were allowed to admit and care for their own patients with or without consultation with a pulmonologist or cardiologist. Inpatient medicine has evolved, and most MICU’s are now closed, and critical care specialists manage nearly all MICU patients. 

 The day of my visit was during the good-old days of the open unit.  My colleague caring for this elderly woman was an excellent general internist and a truly humanistic individual.  He had been confronted with a seemingly insoluble end-of-life crisis.  He, along with concerned medical and nursing clinicians, believed that her endotracheal tube should be removed so that she could die.  She was unresponsive and a feeding tube, intravenous lines and a bladder catheter were also supporting her.

When I learned that she had no physician, I volunteered to take over her care.  In my formal medical training in the 1960’s there were no critical care units.  Unstable patients were cared for in the usual four-bed rooms.  Curtains separated the beds, the respirators were primitive, but the nurses were the best, although not formally trained in critical care.

Standards have evolved over the last quarter-century:  the physical units changed and now patients have private rooms; there is one-on-one care by specialty trained and certified nurses; the physicians are Board Certified in critical care; there are clinical pharmacists who help manage complex regimens of medications; and respiratory therapists are on site. 

Importantly, healthcare ethics has evolved along with critical care, and the clinicians are familiar with ethical principles.  If necessary, expert consultation is available.  Families are encouraged to come to the bedside and to talk with the nurses and physicians. When I volunteered to help that day, a quarter of a century ago, critical care had impressively evolved, but most certainly not as far as today.

This woman posed an ethical dilemma.  The hospital staff agreed that the current care that was sustaining her life was futile.  Her three children disagreed and wished to continue the intubation, ventilation, nutrition and hydration.  The major family decision-maker was a physician daughter, an academic pediatrician, who lived an inconvenient distance from Portland.  The son was a postal worker and the other daughter was the caregiver for the mother.  Their home was in a pleasant middle-class neighborhood.  End of life decisions had been appropriately delegated to her family, as she had been unresponsive since her admission for pneumonia weeks earlier. 

That was the stage set as I opened the sliding glass door to her room.  At her bedside I confirmed her physical exam, and then I attempted to arouse her:  “Mrs. X wake up…open your eyes”.  There was no response.  I then took a hearing assistance device that resembles an old-fashioned hearing aid from the pocket of my starched white coat, placed the buds in her ears, hooked up the leads and turned it on. 

Again I asked, “open your eyes Mrs. X”, and this time she did.  She looked directly up at me, and I asked her what she wanted.  She bent her right elbow and put her hand to the endotracheal tube and motioned it forward.  It was obvious that she wanted the tube removed.  After consultation with the nursing staff, all agreed that she clearly had the capacity to make decisions for her self.  We did as she directed. 

After we removed the tube she was certifiably awake.  She went home and lived for many months with the care of her daughter and son.

Deafness is a major problem in the care of the elderly.  I have helped manage more than one patient who had been thought demented but instead were extremely hard of hearing, and who, like our seemingly comatose patient, had simply tuned-out of life.