PALLIATIVE CARE BY THE SURGEON Palliative Care in the Surgical Intensive Care Unit

Seventy-year-old Mary was admitted to the surgical ICU immediately after surgery for repair of a thoracoabdominal aneurysm and renal artery stenosis. Within 24 hours of postoperative care, it became clear she had become paraplegic, unresponsive, and was in acute renal failure. What was the likelihood she would survive all this? And if she did, would she be in a nursing home for her remaining days. Should she be started on dialysis? What would Mary, who now could not say, want for herself if this was the end of her life? Interview with her family revealed that Mary had initially refused operative intervention for her aneurysm but agreed to serial surveillance. Then she developed increasing abdominal pain. Evaluation revealed a marked increase in aortic diameter with significant risk of rupture. Mary was frightened living with this “time bomb,” but worried about undergoing such major surgery at her age—especially an operation with risks of mechanical ventilation, renal failure, paralysis, or even death. After a lengthy discussion with her surgeon and family, she hesitantly consented, but made it clear that “if the worst happened” she did not want to “be kept alive by machines.” Now, in the ICU, was this “the worst” that Mary had alluded to, or not? The surgeon met with her husband and daughters to discuss this question. Much of her organ failure was potentially reversible, perhaps she would recover with aggressive care. But the paraplegia seemed unlikely to resolve. The family agreed to hemodialysis on a shortterm basis. Her family was reassured that she would be given adequate pain relief with a continuous morphine drip. In 2 weeks, Mary’s renal function improved, and hemodialysis was discontinued. She remained ventilator dependent. She now suffered from incontinence and diarrhea that caused a nonhealing sacral wound. She was still being “kept alive by machines” that she had not previously wanted, but this seemed appropriate because she was now more responsive and enjoyed interacting with her ever vigilant family. She smiled at photos of her grandson’s first communion, but coughed and gagged as she tried to talk around the oral endotracheal and orogastric feeding tube. She was embarrassed by her continual incontinence. A third family meeting was held to discuss her physical and psychological discomforts. Even though Mary had not wanted more surgery, in an effort to palliate her extended recovery period, a tracheostomy, gastrostomy feeding tube, and diverting colostomy were performed. Mary’s husband was an attentive daily visitor, spending hours at her bedside. Her daughters, both held full time jobs and had young children, but alternated daily visits and brought her grandchildren to visit on Sundays. For a brief time Mary rallied, slowly weaning from the ventilator, tolerating feedings, and healing her wounds. She watched her “soaps” on TV and told her family she wanted to go home. But she became septic from breakdown of an enteric suture line. Delirious, she no longer recognized her worried husband. Pressors were initiated to support her blood pressure, and she developed arrhythmias. Surgery was indicated for intraabdominal sepsis but after a fourth family meeting, her family declined operative intervention. They agreed to CT-guided drainage and antibiotic therapy. A do-not-resuscitate order was placed in the event of a cardiac arrest, but the ventilator and pressors were continued. Mary became agitated, grimacing and bucking the ventilator. Her opiate dose was increased, intravenous sedation was added, and ventilator parameters were adjusted. Again, her kidneys failed. At a final meeting with the surgeon, her daughters insisted that Mary’s wishes “not to be kept alive by machines” be honored. Soon thereafter, pressors and ventilator support were withdrawn. She died an hour later surrounded by her family after a 6-week ICU stay.