Death in the ICU

As an EMS coordinator at a local hospital, I try to provide patient follow-up for our EMS providers. Since we are not a trauma center, the two calls people most want to know the outcomes about are STEMIs (ST-Elevation Myocardial Infarctions) and resucitated cardiac arrests.

After doing this for over two years now, I have observed the calls almost always follow the same predictable pattern. The STEMIs are rushed up to the cath lab where they are discovered to have 100% blockages of a major coronary artery. The blockages are cleared and stented, the patients do remarkably well, and are discharged within a few days with instructions to eat heart healthy diets and stop smoking.

As part of our quality assurance process, I praise the crew for identifying the STEMI and providing the hospital with early notification. I sometimes show them before and after photos of the affected artery.

The cardiac arrests rescuitations are admitted to the ICU on ventilators. A few wake up in a day or two and ask for the New York Times but, in most cases, they don’t. With grim prognoses, their families, in consultation with their doctors, often make the difficult decision to let them go. The patients are made comfort measures only, extubated, given morphine for pain, and they die peacefully with their families gathered around them.

I am a firm believer in evidence-based medicine and looking at outcomes. Particularly in a time of tight budgets, what we do should be proven to actually work. I try to stay up on the latest research and in my role as a member of our regional medical advisory council; I use that research to support proposed changes in our care guidelines.

It is often said that the only outcome that matters in cardiac arrest is survival to discharge with intact neurological recovery. A recent study of IV drugs in cardiac arrest showed they made no difference in survival, but did lead to higher rates of return of spontaneous circulation (ROSC) and admission to the ICU. Once in the ICU, those who received epinephrine were three times as likely to die as those who did not. This study and others like it have caused some to consider eliminating IV drugs from our cardiac arrest arsenal along with other items that don’t lead to the ultimate outcome of a patient walking out on their own power. It is as if to say if the person is going to die anyway, let them die where they fall rather than spending so much money on them only to have them meet the same outcome a week later in the ICU.

While I find these arguments persuasive, I am conflicted. Yes, outcomes are vital and yes, we should always avoid unnecessary health costs. At the same time, I do not believe that this means the efforts of those who worked so hard to resuscitate a patient only to see them die in the ICU should be viewed as futile. Our primary job is saving lives, but we are also here to provide hope and comfort, and to be present to act in time of need. Showing a family that help was there, that everything possible was done, and then giving them time to gather and say goodbye to a loved one is something to be proud of. It is hard to measure its worth.

That is what I tell the crews.

3 Comments

  • SuziB says:

    Having the unique prospective of being in EMS and spending some time living in a funeral home (hubby was a funeral director), I learned to appreciate the value of the family being able to say goodbye. It helped me to help families on scenes that there was no resuscutation to be done start to deal with the grief. How we speak to these family members makes a difference in the grief process. I tell my newbies at that minute the family are the patients and we need to make sure they are OK. You are truely helping your crews understand the value to the families.

  • Our primary job is saving lives, but we are also here to provide hope and comfort, and to be present to act in time of need. Showing a family that help was there, that everything possible was done, and then giving them time to gather and say goodbye to a loved one is something to be proud of. It is hard to measure its worth.

    I find I can’t completely agree. While I don’t think that it makes sense to stop giving drugs in the field, I do think it makes sense not to transport those without ROSC to the hospital. It’s not a matter of costs, at least not to me. It’s a matter of the potential for injury to the EMS personnel and even to civilians who we might be involved an MVC with while transporting.

    I think the truth is that for patients without ROSC, we gain nothing by putting them on a back board or scoop stretcher, carrying them down stairs (they’re always on the second or third floor), and trying to do CPR en route to the hospital. Since the CPR is probably ineffective and we rarely if ever have more than two people in the back of the ambulance, the whole thing is futile.

    I can’t see the risk being worth the benefit of allowing the family to say good bye.

    • medicscribe says:

      Thanks for the comments. I agree with you that if a patient cannot be resucitated at the scene, then, in general, it is best not to transport. Obviously sometimes the scene, family and other bystanders require you to transport. It is easier to cease resucitation on an elderly person found alone in her apartment than a young person who has dropped in the middle of a supermarket. Where I work, most of my codes are either in a nursing home or a private home. Asystole after 20 minutes and I call them there. The only ones I transported this year were those with ROSC on scene and a small child.

      Thanks again for your thoughful comments,

      Peter

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