So the end of life saga continues. I guess in the MICU “end of life” is just our way of life.

Two more “firsts” for me as a nurse – my first Family Meeting and my first unplanned decannulation (Mom- this means that my patient ripped his trach tube out and subsequently could not breath).

I capitalize “Family Meeting” because there are two types:

family meeting = the docs update the family and discuss ongong issues related to treatment.

Family Meeting = when all of the patient’s organs are failing, the patient is zoinked out on the ventilator, and there is little chance for recovery. The Family Meeting’s purpose is really just to say “Look, your family member is dying and on life support. So you want us to pull the plug, or what?” (But of course not in those words, and certainly not in that tone.) This Family Meeting was slightly unconventional in that it was held at the patient’s bedside, and the patient was able to participate.

So this patient, I’ll call him Fred. Fred’s reputation preceded him. I had been peripherally hearing for weeks that Fred has “had enough and he wants to die.” I did not know why his wish was not granted. He was dependent on the ventilator but was very much awake and cognitive, and could communicate with hand signals, writing and mouthing words. He was in his eighties and had numerous comorbidities. On this day Fred was to be my patient, and there was a family meeting scheduled.

It was a trying assignment. My other patient had a “difficult family” that kept summoning me to her room. Fred was continuously calling me into his room asking me to reposition him. I felt as though no matter what I did, I could not make him comfortable. He wanted a pillow under his feet. He wanted the pillow removed. He wanted the pillow back again. And he also also kept pointing to his trach area asking me to do something to it. I could not figure out what this something was.

So onto the family meeting, at the patient’s bedside. Let me paint you a picture. The rooms of the Medical Intensive Care Unit at the Greatest Hospital Of All Time are roughly the size of a walk-in closet. Picture a turquiose painted walk-in closet containing a patient on a bed, an IV pole, a ventilator, a continuous dialysis machine, a sink, wall suction, a supply cabinet. Now place an entire family inside the room. Add a social worker, two doctors, and myself. Kind of like stuffing clowns in a volkswagon.

One thing they like to tell you at these palliative care workshops is that you need to be present at these Family Meetings, so you can advocate for your patient. The docs will want to do everything, the family is too distraught to know what to do. You, the mercy-killing, Kevorkian loving, morphine pushing nurse, has got to be there to say, “Come on people! What are we doing to this poor patient anyway? Let’s all come to our senses!”

So here I was in my first family meeting, ready to step up and advocate for my poor dying patient, and all I could get was a back row seat.

Meanwhile his vent kept alarming so add a respiratory therapist to the mix. I could barely hear a thing.

What I managed to eak out from the back row was this: The attending explained to the family that there was very little hope of getting their father off the ventilator. The family said they agreed, they had discussed this with him, they know he wants to die. So they will withdraw care. On Friday (this was a Monday).

So is that what the patient really wanted? As the attending and the family were discussing things, the patient just kept zoning out. As much as he had the ability to understand what was going on, it was unclear if he actually did. It didn’t help that his vent kept alarming.

So after everyone left, my patient suddenly “woke up.” He kept motioning at his trach again. I couldn’t figure out what he wanted me to do. Finally one of my colleagues said, “He wants you to pull his trach out.”

“Really?” I asked him. “Is that what you me to do? Pull out your trach?”

He nodded vigourously.

“Well I simply can’t do that.” This exchange was repeated over and over again.

I was going to go to the docs to let them know of his wishes, but then I wondered, does he know what it means if his trach is removed?

I told him that removing the trach would mean he would most certainly die.

“Is that what you want?”

His eyes glanced off in the distance.

“It’s important that you realize that. Do you understand what I’m saying?”

Again he looked away and refused to answer me.

Later he was trying to tell me something else. I couldn’t understand it so I handed him the tablet.

“Get me a nurse, ” he wrote.

What the hell. By that point I was ready to withdraw on his ass. Instead, I left his room. All of his basic needs were met, I had just repositioned him, I swabbed out his mouth, there was really nothing more I could do except sit there and argue with him. I had tried to therepeuticly communicate with him, but he kept waving his hand in my face. And besides that, my other patient was calling me.

Finally, I got my other patient settled. It was now 15 minutes before shift change and I was free to sit down and do a day’s worth of documenting.

Then I heard the alarm. The vent alarm that is. I just knew it was Fred.

(I will tell you that there are about 100 different alarm sounds in the MICU. When I was a student the biggest challenge was in knowing which alarm to respond to. If you responded to every single alarm you would be running around like a headless chicken. You learn pretty quickly that the vent alarm is the one to respond to EVERY TIME. Protect the airway and all that…)

So I ran down to Fred’s room. Sure enough he had pulled out his trach. I absorbed that initial moment of shock and panic for exactly two seconds then sprung into action. Thankfully a fellow RN was in the room with me so together we intervened. I paged the respiratory therapist and got my ambu-bag. A resident came in. “Page ENT!” I said.

Before I started to bag I had a moment of confusion. He pulled his trach out. He wants it out. He’s been saying for weeks he wants to die. What the hell are we doing here? And besides all that, what orifice am I bagging? I recalled a story from last week when a patient decannulated and the RN started bagging the trach stoma! Was this story relayed to me because it was correct or incorrect? Bag the stoma? bag the mouth? AHHH! I looked down at the stoma, it didn’t look like something I could bag so I bagged his mouth. Within moments there were doctors and nurses in the room, as well as the ENT doctor and and the anesthesiologist. I was bagging his mouth and someone had put an occlusive dressing over his trach stoma. His sats (which were in the 40’s) came up to the 80’s. I asked the resident, “So what are we going to do here?”

He said, “What do you mean what are we going to do? There was a family meeting. We have to put in a new trach.”

“He pulled it out.”

“Are you sure?”

“He’s been begging me all afternoon to pull it out.” Either he pulled it out or an evil MICU elf jumped up on chest and pulled it out.

Meanwhile the ENT doc put in a new trach, within seconds. When it’s an airway you’re talking about, there’s not exactly time to debate ethics.

The resident asked Fred, “Sir, did you mean to pull out your trach?”

Fred refused to answer.

“Was it a mistake, Fred?”

Fred looked up and nodded weakly.

The resident said that there was nothing we can do.

“Well you have to do something.”

“I’m not withdrawing care on him.”

“I’m not saying you should, but unless you either order mechanical restraints, chemical restraints, or a 24 hour sitter, we will be reliving this drama on a daily basis until Friday.”

“I don’t want to restrain him.”

“I don’t want to restrain him either. Order a sitter. Get him sedated.”

A sitter was ordered and some midazolam was added to his regimen.

All the nurses who knew Fred were pretty pissed off. “That man has been begging to die for weeks. What the hell are we doing?”

Someone suggested I call an ethics consult.

I had considered it. But despite his kamikaze reputation, I found him to be ambiguous. He would not convey to me that he actually wanted to die, just that he wanted the trach out. And he denied that he meant to rip it out himself. Not that I’m blaming the man for being ambiguous. I mean, it’s death we’re talking about here. No small decision.

I gave report to the night nurse. I told her that I kind of panicked when he decannulated, and was confused because someone had just told me about the nurse who had bagged the stoma instead of the mouth.

The “nurse who bagged the stoma” just happened to be in the room. “Oh that was me. The reason I bagged the stoma was that it was so huge. It was bigger than her mouth. I guess I was just following my instincts.”

At any rate, next time I will know exactly what to do.

Cover up the stoma and begin bagging with the mask. It bears repeating: Cover up the stoma, bag with the mask. Cover up stoma, bag with mask. And page ENT. And call for help.

The night nurse said, “Oh that’s such a great learning experience. I’ll bet there’s lots of new nurses that need to be reminded of what to do. You should write a piece for the MICU Fly By.” (the MICU Fly By = our incredibly archaic xeroxed quarterly newsletter.)

MICU Fly By my ass, I thought to myself. This one’s for my blog.