The thin line

I am currently on my first medicine ICU or MICU month of residency. And not only that, but it is at the VA where all the patients are already knocking on deaths door, and just waiting for the final say so to move on. Yeah, its pretty intense.

We had our first almost code situation today. And I say almost not because it was a close call---he did pass away---but it was almost called a "code."

He was a 60 something year old man who had perfed his bowel and required extensive surgery to remove the damaged small intestine and then got an infection in his blood which then gave him a really bad infection in his lungs and he started to down spiral around 3pm today. He was actually on the surgery team, we were just the medical help out. His blood pressure dropped and then his oxygen saturation dropped to the 60s (we want most patients above 90) and the highest we ever got it back was the mid 70s even after turning up his ventilator all the way. When his pressures dropped again, we were about to flip on the code button--which announces to all the pagers that someone is in a "code blue" situation and everyone comes running. Thats when someone decided to call his wife and verify his "code status."

We were told we were not to do chest compressions. So we turned off the code blue announcements and continued with increasing his pressures and such. Then there was a discussion what exactly his status was: increase pressures? start drips? chest compressions? withdraw all care? withdraw only some care? give shocks? only do CPR? It has gotten so specific of all the different choices a person has that it got me thinking about the thin line of what each person wants and how it can make such a difference---I needed to know how this whole DNR stuff actually started.

In a basic search on the internet it appears that the history of a person being able to decide what forms of resus they wanted started in 1976 with the case of Karen Ann Quinlan v New Jersey in which a 21 year old woman was found comatose after taking tranquilizers and ETOH. Her family wanted to withdraw life support but the medical team just flat out refused and the case was brought to supreme court where they ruled in favor of the family ruling "Karen's "right of privacy" included a right to refuse medical treatment and that her father, under the circumstances, could assume this right in her stead."

It wasn't until 1991 when the Patient-self Determination Act that mandated hospitals honor a patients desire in their healthcare. And now today's occurrence is so common place across the US.

In the middle of us giving a stronger pressure medication we were told to stop doing what we were doing. What does that mean? Stop the medication? Turn off the vent? The surgeon was running back and forth from where the family remained asking each specific question. Finally an understandable conclusion was given: Stop the pressure medication all together. Then 5 minutes later: turn of the ventilator.

He passed within minutes, hopefully at peace with the decision his wife made for him.