A few days before I wrapped up, we had an interesting encounter. My first-year calls me up to let me know that we have, in her words, "a patient that got made into an ICU admission." This woman had been discharged from St. Elsewhere's earlier in the day and still had her DNR bracelet on when she came to our ED with a sudden onset of seizure activity and unresponsiveness. Our ER physician, for whatever reason, urged by her unknowing family, felt she had agonal respirations and popped a tube down her throat. Before we got there, without trying more aggressive noninvasive measures. So then we have a patient with bad lung disease, maybe some CHF, a brand-new golfball-sized bleed in her right temporal lobe, and oh-by-the-way we've confirmed with the rest of her family, who knows her well, that she wants to be a DNR, and now she's on a ventilator and what do you do now?
In an ethical sense, withdrawing care and withholding it are equal. In a very real and patient-in-front-of-you sense they're two different things. But several long discussions with the family later about how we had no idea what was going to happen if we took her off the vent, but we suspected it would not be good, they decided that she would never have wanted to be on it, and that it was right and good to take her off. So after 2342359784353 people filed by to say goodbye, we extubated her and waited. And waited. She was initially apneic, dropped her sats to 0-9%, and then started breathing spontaneously and brought them back up to the 80's on her own.
And she's still on my computer census, days later.
We've been discussing this at some length, intermittently, because the question remains: what might-have-been? It's unclear what kind of quality of life she'll continue to have - our neurosurgeon suspects she'll be aphasic, or unable to speak, at the least. It's unclear what would have happened if she hadn't been ventilated for 36 hours. A lot of things are terribly mucky in this situation, and I can't help but wonder whether we're prolonging her suffering or whether we've done some accidental good. She told her family, just before she collapsed, that she was "ready to meet Jesus", so my suspicion is that we have been unfair, but I don't suppose I'll ever know for sure.