code blog: tales of a nurse

Sorry to have not posted in awhile; it's been busy around here what with all the home improvement projects we've been undertaking :-)

At work, we've had a few patients that we've withdrawn treatment from. It's always a really sad sort of affair. Usually a patient will come into the hospital after some sort of catastrophe, we work really hard to get them back for about a week, and if no significant improvement occurs, we "withdraw" treatment (with the family's consent, of course!)

Withdrawing typically consists of discontinuing any pressors that we're using to keep the patient's blood pressure up, extubating (removing the breathing tube; taking them off life support, "pulling the plug" so to speak), and stopping antibiotics. The family always wants to have an answer to the one question that is most important to them, and the hardest to answer for us: "How long will it take for the patient to die?"

I've had patients on maximum doses of pressors when the decision is made to withdraw. Usually pressors (Dopamine, Neosynephrine, Levophed, Epinephrine) are weaned off. We "titrate" the dose to get the desired effect (usually a blood pressure over 90) and then try to fix the cause of the low BP. Once that occurs and the patient starts to stabilize, we wean the pressors off little by little. Turning them off cold turkey could cause a relapse. We always wean according to how well the patient is tolerating the process. It can take hours to days to wean drips off. When withdrawing a patient from treatment, we shut them off cold turkey.

I've had two responses to this: patients have both died very quickly (within ~10 mins) and very slowly (days). So when families ask me how long it will take when the pressors come off, I can't honestly tell them. It's frustrating for all.

The ventilator is another component. When withdrawing, we shut the vent off and extubate no matter how much support the patient is receiving. It could be maximum support, or it could be just a little extra pressure to completely inflate their lungs with each breath. This follows a more predictable path - the more support a patient is getting for ventilation, the more quickly they will pass away when the vent is removed. I myself have only been involved in withdrawing treatment from comatose or semi-comatose patients. Semi-comatose patients are those that usually appear to be "sleeping" unless they are touched or talked to... then they might stir a bit or open their eyes. They rarely talk or answer in any way.

Sometimes when the vent is removed, patients have a hard time breathing (hence the need for it in the first place). To help relieve this, we typically give Morphine IV. Morphine helps relax the smooth muscles of the respiratory tract and depresses the drive to breath. It can be given both intermittently and as a continuous infusion that we titrate for the patient's comfort. We can assess how a patient's doing by their breathing pattern. Some breath just fine, some don't. It's usually pretty hard for the family to watch. Fortunately, morphine works quite quickly. Soon, the patient's carbon dioxide level rises and if they weren't already unconcious before, they certainly are now.

There isn't much of a point to this post beyond what I've already written. Like I said, we've withdrawn from several patients lately and it's always a tough thing to deal with, even if the only place you're dealing with it is in the back of your mind.