dnr, homecoming and why not ?

The patient was a 55 y/o aborigine lady. She was a case of lung cancer with brain metastasis. She was placed at I3 when I saw her in the ICU. She was admitted to the ICU for SOB and was quite ok when I saw her. Her condition was unstable with episode of dyspnea from time to time. However she had noted with abd distension one morning when I did the round. Her abdomen was very distended with diffuse tenderness. Clinically , ileus was impressed and KUB was ordered. The KUB confirmed my thought and both WT and I had agreed that she had ileus which might be due to ischemic bowel syndrome. The underlying causes were obvious as she is a case of cancer and had been bed-ridden for sometimes. A surgical consult was done. I had the impression that DNAR was signed but the nurses told me that the family wanted to do whatever we could. I was reluctant to comply so but since I am not her attending physician, I had to comply with the medical plan. 2 hrs before I left, her BP had started to crushed and acidosis was noted over the arterial blood gas. Her dyspnea had worsen and hypoxia was noted in addition to the acidosis. I intubated her under sedation and inserted a jugular central line.

It is a hard decision for me….. I expect her to leave with all the tubes. But sometimes, I could be wrong, there was this lady with lung cancer which admitted for pneumonia and the family had decided to go all out even though I had explained the prognosis. She was lucky and she was discharged later. However with the peritonitis condition, I double this lady would make it…..

In Taiwan, DNAR order is clearly defined and guarded by the law. DNAR order would have to be sign by 2 specialists and only eligible to cancer patients and those with disease which is fatal in the near future… to breath out one last breath in his/her own house is very important for Chinese. There is this Chinese custom that those who “die” outside cannot set the altar in the house and could only set up the altar outside the house (so as the coffin)….It doesn’t look nice and many of the family would request us to informed them to “bring” the patient home when the time is up (just before patient going to die: the actual way of saying it : “retained the last breath and sent home”  …)… that was definitely impossible as we are not god….but however there is still some alternate ways to do so…

1.   Go home and really “swallow the last breath”(Chinese way of speaking it – should be exact: breath out the last air”) – this need a little bit of luck. Usually the patient is hypotensive(on 20ug/kg/min of dopamine with acidosis and sodium bicarbonate drip) and intubated. When the MAP is below 40mmHg, it would be quite safe to do so as the patient would pass away in a very short while when everything is removed.  However sometimes things just doesn’t go that way – sometimes, the patient would drag on for a few hours and the families were unable to tolerate the scenario and sent the patient back to ED…timing is so important.

2.   But sometime, accident do happen and patient just passed away suddenly and we still hook the patient to the ventilator and tell the families, they could bring the patient home with the ETT and ambugging, in a way that , the patient is still having his/her last breath...some dirty move but of the families would still be grateful if we had planned to do so….

 

Just life and death…. And if everyone could be happy(I mean including the patient), then why not ?