For ethics I have to read two positions on this. Funny thing is is that I have personal experience with this - outside of my role as a nurse.
About 3-4 years ago my mom's good friend Jane (not her real name) - her husband Joe (again not a real name) was walking about 15 minutes from home to go to the local coffee shop (Tim Horton's for us Canadians) where he would meet up with his chums for a morning pick-me-up. He reached the traffic light, pressed the button and when told to cross he did so. Unfortunately at the same time was a young girl who went through the (green for her) light and struck Joe. He was thrown about 15-20 feet and landed in a snow bank. EMS showed up and rushed him to the local hospital. He was stabilized and was discovered to have a massive head injury that required immediate surgery. We live in a (smallish - approx. 75, 000 pop) community that does not have a brain surgeon so he was air lifted to the closest center that could perform this - happened to be in the US. So there he went. Well his wife was notified and off she went to the US to be with her husband. She permitted them to do brain surgery and he was intubated (naturally) and was ventilated for his surgery. The surgery went according to plan and he was brought back to the ICU. He was touch and go for several days and when they tried to take him out of the medically induced coma he would not regain consciousness. He was in an actual coma. He remained this way for several weeks. When he finally DID come out of the coma he was found to have major brain trauma which stripped him of his ability to function - approx. 25% of what he was previously. It took him almost 2 years to be able to even slightly talk (remembered how to curse though which is hilarious) but he had a feeding tube and ended up also needing a catheter. He was wheelchair bound and required support 24 hours a day. He was put into a nursing home for this care but his family also provided for him additional care during the day hours so that his therapists could work with him more personally and often and TRY to regain some function. Then he started to get complications upon complications. This inevitably caused his death. During some part of this his wife was notified that she was NOT allowed to make decisions in regards to his health OR expenses because they had had NOT created a power of attorney, living will or advance directives and so someone else had to make these decisions PLUS she had to go to court in order to get these right given to her (as it should have been).
Because I've seen this and what Jane and Joe had to go through - from this side - and seeing what patients and their families have to go through when these things aren't put into place..... as well as when they are (it's wonderful when they have been). I would like to make it known what I would want or not want.... husband and I tend to disagree on some of it. He would like me to be kept alive (on a ventilator and everything else) so that he could be with me. I on the other hand would NOT want to be kept alive if I were to be incompacitated or diagnosed brain dead.
I had a conversation with my BFF about some of these things and we talked about scenarios because I told her in no uncertain terms that I would NOT want a tracheostomy. Well she made me realize that I would ONLY want it if it could come out - and I would only allow it for 30 days (ever seen the episode of Grey's anatomy - 30 days and that's all I get - if you can't figure it out by then I'm being taking off support) then take it out and if I live then i live - if not I die and I'm ok with that. Clearly I wasn't meant to live.
Now the ONLY time I want to be on a ventilator and kept alive is if I were pregnant and the fetus could be viable and NORMAL (no cerebral palsy due to hypoxemia) then keep me alive until I could "give birth" then take me off life support.
Now if I were expected to live but have some deficits - if I could be expected to be at least 75% of who I was previously (mental faculty wise) then do extradinary measures. If I need antibiotics - please give - I completely agree with them. Don't give him a G/J or any other kind of tube to extend my life. I see enough of this at work and do NOT agree with it. I WANT to be able to drink and eat the "normal" way and if I would die if I didn't have a tube going into my body then that's not the way I would want to live. Again if it's longer then 30 days - let me die! When it comes to tests - do them, do as many as you can to try to figure out what's wrong with me and try to fix it - I'm ok with that - I like tests, it makes treatment easier and WAAAY more effective. When it comes to CPR it's a bit trickier - inately I agree with CPR. However, the longer that CPR is done, the less likely it is that mental faculties will be back to 100% so really, would I want extended CPR?! I suppose I will have to ask a doctor about this to truely know what my answer is to this one. I agree 100% with dialysis and pain medication - I think these things are totally important. I can't think of other things that should be included but I will totally update these kinds of things as I learn and see more.
I think MORE people should put it in writing what they want. And try to think of ANY and ALL kinds of situations.
Showing posts with label coma. Show all posts
Showing posts with label coma. Show all posts
Monday, February 3, 2014
Friday, September 23, 2011
NEVER EVER give up hope! 1% chance at living
Ok so I will preface this post by saying that this is about an actual patient of mine but am following PHIPPA rules and will not disclose information that someone can accuse me of violating confidentiality rules.
So a couple of weeks back I was given my patient assignment and one of them had to do with a woman who had a stroke. Now I work on a neurology unit so this isn't anything new to me. What WAS new for me was this patient was in a coma. That's not normal! Even in a stroke patient, it's VERY rare to get a patient on MY unit who is comatosed.
I spoke with the neurologist to explain to me why my patient is comatose and what the chances were of this patient #1 surviving and #2 waking up.
His answer to my question was this:
#1 - he asked me what I defined as "surviving" - which I told him, was living - with or without deficits (which I told him I knew she was going to have)
#2 - he then showed me her CT scan....
HOLY SHIT BALLLS!!!!!!!!!!!! If you saw this woman's CT scan you would have to wonder how this woman was even alive at this point!!! The neurologist showed me the CT scan from when she was first seen in ER and then the most recent one that was 4 days after.
COMPLETE right sided necrosis - the right sided artery that feeds that side was 100% blocked - the swelling had caused a midline shift (which even I knew was BAAAAAAAAD) of almost 2cm - please remember that one's head is NOT very big and therefore this equals BAD!!!!! Also, any space that the brain had (pockets if you would cause I don't know the exact terms), were taken up by swelling.... her brain had herniated DOWNWARDS and was pushing on her brain stem... again NOT GOOD!!!
When I assessed this patient - she had NO gag reflex, was aspirating her saliva, had no pain reflex, left pupil was blown, was in a DEEP coma.... I explained to this family that if she didn't die from her heart stopping or her breathing stopping, that she would die from aspirating the saliva. Let's just say that the family took the news HARD!!!!
Now it doesn't seem to me that the family is necessarily religious but BOY did that family absolutely believe this woman would pull through and survive. They understood that even IF she did survive that there would be GLOBAL, CAATASTROPHIC deficits, they were OK with this!!! When this was all happening, they were asking if they could take her back to her hometown.... but that they would NOT make her a DNR.... something that did NOT sit well with MANY of the nurses - or neurologists/physicians that have been involved with this lady's care. But hey, we're not here to pass judgement, but to give INFORMED choices!!!
Now, I haven't been able to be her nurse much since I had her as my patient but have kept tabs on her - the family and I have really bonded... they love me!!! LOL
They felt like I was the only one who was supporting them without judgement - which is exactly what I was doing. The other day her daughter saw me in the hall and told me that her mom was moving.... I could hardly believe it. So I asked her to demonstrate it for me.... I followed her into the room and SURE ENOUGH... she friggin moved! Now mind you, she could ONLY wiggle her fingers and toes - but would only do it if the family was speaking her language - a specific dialect. But move that woman did!
Well ladies and gents - I had this patient again - and was able to see her most recent CT scan - and no wonder she has come out of the coma - her herniation has decreased, not completely but certainly dramatically. Also, the midline shift has decreased significantly - which explains why her coma has lifted. Now, that's not to say that it's completely lifted, she can still barely open her eyes, hardly move her unaffected side and certainly can't speak yet - but she's reacting.... which just goes to show that even when clinically the picture indicates that this patient is a hopeless cause - DON'T GIVE UP HOPE!!!!!!!!!!! And ALWAYS, ALWAYS, give support and love and care for your patients AND their families!!!!
So a couple of weeks back I was given my patient assignment and one of them had to do with a woman who had a stroke. Now I work on a neurology unit so this isn't anything new to me. What WAS new for me was this patient was in a coma. That's not normal! Even in a stroke patient, it's VERY rare to get a patient on MY unit who is comatosed.
I spoke with the neurologist to explain to me why my patient is comatose and what the chances were of this patient #1 surviving and #2 waking up.
His answer to my question was this:
#1 - he asked me what I defined as "surviving" - which I told him, was living - with or without deficits (which I told him I knew she was going to have)
#2 - he then showed me her CT scan....
HOLY SHIT BALLLS!!!!!!!!!!!! If you saw this woman's CT scan you would have to wonder how this woman was even alive at this point!!! The neurologist showed me the CT scan from when she was first seen in ER and then the most recent one that was 4 days after.
COMPLETE right sided necrosis - the right sided artery that feeds that side was 100% blocked - the swelling had caused a midline shift (which even I knew was BAAAAAAAAD) of almost 2cm - please remember that one's head is NOT very big and therefore this equals BAD!!!!! Also, any space that the brain had (pockets if you would cause I don't know the exact terms), were taken up by swelling.... her brain had herniated DOWNWARDS and was pushing on her brain stem... again NOT GOOD!!!
When I assessed this patient - she had NO gag reflex, was aspirating her saliva, had no pain reflex, left pupil was blown, was in a DEEP coma.... I explained to this family that if she didn't die from her heart stopping or her breathing stopping, that she would die from aspirating the saliva. Let's just say that the family took the news HARD!!!!
Now it doesn't seem to me that the family is necessarily religious but BOY did that family absolutely believe this woman would pull through and survive. They understood that even IF she did survive that there would be GLOBAL, CAATASTROPHIC deficits, they were OK with this!!! When this was all happening, they were asking if they could take her back to her hometown.... but that they would NOT make her a DNR.... something that did NOT sit well with MANY of the nurses - or neurologists/physicians that have been involved with this lady's care. But hey, we're not here to pass judgement, but to give INFORMED choices!!!
Now, I haven't been able to be her nurse much since I had her as my patient but have kept tabs on her - the family and I have really bonded... they love me!!! LOL
They felt like I was the only one who was supporting them without judgement - which is exactly what I was doing. The other day her daughter saw me in the hall and told me that her mom was moving.... I could hardly believe it. So I asked her to demonstrate it for me.... I followed her into the room and SURE ENOUGH... she friggin moved! Now mind you, she could ONLY wiggle her fingers and toes - but would only do it if the family was speaking her language - a specific dialect. But move that woman did!
Well ladies and gents - I had this patient again - and was able to see her most recent CT scan - and no wonder she has come out of the coma - her herniation has decreased, not completely but certainly dramatically. Also, the midline shift has decreased significantly - which explains why her coma has lifted. Now, that's not to say that it's completely lifted, she can still barely open her eyes, hardly move her unaffected side and certainly can't speak yet - but she's reacting.... which just goes to show that even when clinically the picture indicates that this patient is a hopeless cause - DON'T GIVE UP HOPE!!!!!!!!!!! And ALWAYS, ALWAYS, give support and love and care for your patients AND their families!!!!
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