The ICU intubated patient: Don’t Wait Until You Can’t Have The Conversation

The palliative care physician was asked by the ICU attending physician whether she might begin some discussions on end-of-life issues with a 46-year-old man who’d been on a ventilator for six weeks following multiple traumas in an automobile accident. The ICU attending doubted that the patient could survive off the ventilator, and doubted that he would leave the hospital alive. Luckily, the patient was usually alert enough to communicate by nods or mouthing words, although he could not write.

The palliative care physician met with the patient and his wife, explaining that in the last couple of months there had been a lot of attention paid to his lungs, bones, kidneys, digestion, infections, and skin, but that she was hoping to help them take inventory on "the rest of what makes him who he is". She showed them the Go Wish cards and asked the wife to show the patient each card and help him sort out what was important to him. The physician came back the next day and found that in the "not important" pile were all the cards that had any mention of death. But there were plenty of cards in the very important pile, and the couple was asked to sort through the "very important" cards to rank the top ten.

Following the exercise, both the patient and his wife said that it brought out conversations they should have had, but, since they were young, they never expected they’d be dealing with it so early, and therefore hadn’t gotten around to the discussion. However, from this, the patient’s "wild-card" was to help his teen-age son to cope; noting that his son had been left out of prior discussions about what had been going on.

The results of his exercise were used to identify issues that were important to quality of life more generally. Within the top five were "to be free of pain", "not being short of breath", and "to be free from anxiety." The patient's priority for improved symptom control was communicated back to the ICU attending. The social worker was asked to arrange a family meeting that would include the son. Since preparing for death was clearly not the patient's chosen agenda, that topic was dropped, and in fact he was later successfully weaned from the ventilator and sent to an inpatient rehabilitation program.