A 79-year-old man was treated at his home for chest pain. Acute myocardial infarction code was triggered and he was transfered to an hospital in a medicalised helicopter.
He went through cardiac hemodynamic study which objective occlusion of the right coronary artery, placing an stent with optimum result. He was admitted in the ICU and within hours persisted with low blood pressure and elevated lactate. A thoracic and abdominal scan showed signs of intestinal ischemia, so the surgeons were consulted and an exploratory laparotomy was performed. Descending colon ischemia was observed, so 30 cm were resected and a colostomy was performed. In the immediate postoperative period he returned to the ICU where he developed shock, respiratory and renal failure. 14 days of torpid evolution with need for sedation, mechanical ventilation, broad-spectrum antibiotics, renal support, and artificial nutrition. We started waking up and disconnecting the respirator without success for muscle weakness.
A morning in which the responsible physician had been on 24 hour shift, he askmed me to give informed consent to his wife to perform a percutaneous tracheotomy the next day. Thus, at the time of the visit, I looked for his wife, one elderly woman sitting next to the patient who was seizing his swollen hand.
– Good Morning, I’d like to request permission to make her husband a tracheotomy to facilitate the disconnection of the respirator, I’m going to explain this technique…
She stands up with difficulty from the chair and with watery eyes tells me: “Doctor, I’m very happy for everything you are doing for my husband. You are excellent professionals and people, but as I see that you already have some years of experience I dare to say: NO, I will not let you do more things to my husband, not more holes or more machines.”
I will explain you: we lived for 55 years well married at home, away from the village with our sons, and our common tasks. My sons moved to the city and three years ago my husband suffered a stroke and he was paralyzed on the right side. I have been caring him all this time in which we could love ourselves and recognize each other.
I know that Medicine is very advanced and whenever you have proposed me a treatment has been based on scientific criteria that I do not quite understand, so I’ve approved everything, but now sincerely I have seen you older, and with the appearance of having parents in the same situation so I want to tell you I don´t allow you to do more things to my husband and I am asking God to stop suffering”.
Based on this experience and I am sure you would have other very similar, I would like to propose that in the patient´s admission note at ICU should be established, in addition to the reason for admission, the pathological history, current disease, etc, we will add a required section that can be called:
In the treatment plan we should always write to where we will get with our techniques whether to perform resuscitation maneuvers or not, if the patient has expressed intention to donate organs, and most importantly, if we have talked and agreed these decisions with the team and family.
We should “humanize” the critical patient admission note evaluating those aspects of their life and their wills, so the team of professionals responsible for clinical, scientific and technical decisions, were always aligned with the life decisions of patients and their families.
Dr. Josep-María Sirvent
Intensive Care Unit.
Hospital Universitari of Girona Doctor Josep Trueta
Jsirvent.girona.ics@gencat.cat
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