You are a junior Medical doctor on call for ward cover.
Mr X , an 80 year old man has been admitted to the hospital with a dense left hemispheric stroke resulting in aphasia and a right sided hemiparesis.
He has a background history of prostate ca , left ventricular failure , atrial fibrillation and COPD / chronic Obstructive Pulmonary Disease.
His GCS has fallen to 7 / 15 ,
E 2 , M 4 , V 1which is presumed to be due to extension of his stroke.
The patient has been reviewed by the Consultant who feels that ICU care / Intensive care unit is inappropriate for this patient and the patient should not be resuscitated in case of cardio pulmonary arrest.
Your task :
Explain to the family what has happened and why it would be inappropriate to attempt resuscitation in the event of cardio pulmonary arrest.
Key issues to explore :
Obtain as much information as possible about patients co-morbidities and functional level before his stroke.
This can be done by asking the staff / nurse taking care of the patient.
It is also important as this will help build trust of the relatives in the doctor as they will trust a doctor who knows their patient more than just another doctor who thinks he was just another patient who had a massive stroke.
Ceiling of care
The scenario says ITU / ICU or invasive care is not appropriate
It is important to establish a ceiling of care eg if the patient develops a chest infection , can he be given intravenous antibiotics ? ie Ward based care
Hence it is important the medical and nursing teams reach an agreement of which treatment can or cannot be given before proceeding to the relatives for a discussion.
What does the family know already and what are their expectations.
It could be that they were expecting Mr X will make a full recovery soon and go home.
Setting
Ideally there should be
A quiet room adjacent to the ward
Room should have plenty of tissue papers supply
A landline telephone
Leave your bleep with another colleague to avoid distrurbance
Keep your mobile off
Take a senior ward nurse with you for your own support and that of the family as well.
Good lighting
Introduction
Introduce yourself to the family
Your role in the hospital care team
Also introduce any nurse accompanying you.
Check Identity of the patients family
You should make sure you are speaking to the correct family and establish the relationship of the family members with the patient.
Explain to the family members what happened correctly and exactly .
Patient had a massive stroke and now has become paralyzed and is unable to speak and despite the best possible management deteriorated quickly and is now in a subconscious state.
Be clear and explicit about your treatment plan:
We will ensure he is comfortable by giving him proper intravenous fluids and make sure he is not in pain by giving analgesics.
We need to maintain his comfort and dignity.
Be explicit about the limits and level of care your consultant thinks will be best for him.
Eg CPR would unlikely to be of any use, rather will cause pain and distress to the patient.
Also intubation and invasive ventilations will not be suitable for him as well.
Usually many people themselves do not want any painful or distressing treatment in last stages of life of the patient and are very understanding in this matter.
Give the patient and their damily plenty of time to understand the information given and answer to any concerns or questions they may ask.
Discussion
Why has this happened:
As a result of stroke / CVA, a part of patients brain has stopped functioning following loss of blood supply as a result of blood vessel occlusion or haemorhage
As a result brain stops its normal function s and patient is unable to speak and has developed weakness of his body ( right side in this case).
With time the brain may become more swollen and the patient becomes unconscious and will deteriorate further.
Is he going to get better:
I am afraid to say that I do not think so
He has had a very massive stroke and things are likely to get worse.
Although I would be delighted if I am wrong.
But I honestly believe he would probably deteriorate and may even die soon.
Is he in any pain?
I don’t think he is in pain
He is unconscious and not aware of what is happening nor be able to feel any pain.
Our priority is to keep him comfortable and pain free.
If we had believed or though he is in pain, we would have given him analgesics and pain killers to prevent any distress or pain.
If he gets worse, will you resuscitate him ?
Usually CPR / Cardio pulmonary resuscitation and ventilator support is given only in case of patients who have a reversible condition and there is a chance of recovery
However in his case considering the massive stroke and reduced recovery potential as well as advance age, it is unlikely that any of such modalities will cause any improvements.
Rather these interventions will cause him more pain.
Our priority at the moment is to make sure to keep him pain free and comfortable so we will not proceed with CPR.
No comments:
Post a Comment