I'm at stage 4 kidney failure with a transplanted kidney, had it for 35 yrs. So I've been down that road before. I will need Palliative, I won't be able to handle Dialysis for long. I have my legal living will done so there's no conflict. Thank God for people like y'all there to help.

I was dying from internal bleeding and in tremendous pain. The doctor needed to get an IV into my juggler before he would administer pain relief. I was begging for pain relief and finally I got it and they flew me to a big city hospital. I am grateful for the "palliative" care I received and was on morphine for most of my 21 days in the hospital. Doing ok now, it just took some time for the doctors to stop the bleeding, I'm 71 years old and want morphine if I am dying like that again. Pain just sucks, so there.

Thank you for the video. It help me understand what my mother went through.

Thank you so much for this information my grandfather is passing away in the icu and i'm scared for him.. this makes me feel a bit better

Thank you for posting this. It was very informative and helpful. I really wished that my mothers critical care team wpuld.have discussed this with me. I asked for realistic outcomes but no answers were given. It have been frustrating to say the least. This will help me approach the topic. Thanks again.

I am studying health care aide and this was really helpful thank you!

Helpful and clear. Thank you.

Great video. A situation that is all too common in the ICU. Can be a very difficult situation when the pts. Wishes aren’t familiar to those that become the pts. Voice when they are in this position.

Transcript - for easy reading! Welcome to another MedCram video. We're going to talk about palliative care in the intensive care unit and what we call a terminal extubation or terminal weaning, and as we talked about it in the first video, these are the type of patients in situations where we've done full force, full code, everything that we've got, all the stops pulled out and these are on patients who are really sick and have responded halfway in terms of, we're supporting the pillar of the heart pillar that's fallen down. We've supported the pillar of the lungs, for instance, which has fallen down and also let's say that the patients on dialysis, because the kidney pillar has fallen down and let's say that the patient is on antibiotics because the immune system pillar has fallen down, and so what we're doing in these situations is the patient's very sick and we're holding up the positions of these pillars to keep this patient viable in the ICU. The problem is, is that we hold up these areas, there's risks with that, right? So, the longer we have vasopressors on, the more likely the patient is going to get tissue breakdown and necrosis in the extremities, the longer that the patient is on a ventilator, that increases the risk of ventilator associated pneumonia. The longer the patient is on hemodialysis, that can cause infections in the dialysis catheters, and the longer the patient is on antibiotics, that can cause other issues as well and side effects, thrombocytopenia, elevated LFT's, etc. So, we're holding up the patient here, but the pillars which we ultimately need to have come up are not coming up. It should be coming up, but they're not coming up. We're stuck holding up the roof and sometimes what can happen, you know, some people have different values than others. The family would say, "Look, he would not want to be on this ventilator for more than a week or two and it's already been three weeks, so we just can't stand the way he suffering anymore. He would not want to be in this situation. What do we do?" And so what we do in that situation is we have to pull back the supports of these positions that are holding up the roof, with the understanding that what's going to happen is this roof is going to fall and the patients going to pass away in the intensive care unit. But the way we want to do that is in the most gentle and the most dignified way that we possibly can. And the one I want to focus on specifically is this lung pillar. Because pulling out an endotracheal tube out of somebody could cause them shortness of breath and discomfort, things that we exactly don't want to do in the intensive care unit. So, if we're in that situation, what I tell patients is that, "Look, we've been here in the intensive care unit. We've been trying to do everything that we can to make him better from a bodily standpoint and we haven't been able to do it." So instead of trying to make the patient better from a bodily pathophysiological standpoint and at the same time trying to treat his pain in a way that doesn't interfere with our blood pressure and things of that nature, now what we're gonna do is we're going to switch to making him perfectly comfortable and not worry about those secondary side effects of morphine or dilaudid or benzodiazepines, and that's called palliative care. So we always want to make sure the patients are comfortable, but the problem is, is sometimes the medications that we use to make patients comfortable have negative side effects, for instance, they could drop the blood pressure. When we get to the situation where we cannot make the patient better and we've come to that decision, then we can concentrate fully on making the patient comfortable as possible. And now what we're doing is we're going to treat to the fullest extent that the patient is comfortable and not be worried about a drop in blood pressure and not be worried about a drop in consciousness and things of that nature. So what are the things that we're looking at? We want to treat pain. And the way we can look at pain is we can look at heart rate because sometimes the patient can't talk to us, so we can look at heart rate, we can look at facial expressions, so a furrowed brow or a look of pain. We can look at the respiratory rates. All sorts of things that we can look at to see for pain. So what we'll do is we'll treat the patients, we can take off things that are not comfortable but are not necessarily supportive. We can make sure that the patient is pain free, so that would mean starting a morphine drip or a versed drip, a fentanyl drip, what have you. And then what we start to do is we look at the ventilator and we start to pull back the support. So if the patient is on AC mode ventilation, we'll start to back off, we'll maybe you put the patient on SIMV mode ventilation and we'll start to back off on the rates. We may back off on the pressure support and we do it in a step wise fashion. And every point along the way, we're always checking heart rate, facial expressions, respiratory rate, and if we start to see that those are going in a direction of pain, so if the heart rate's going up, if there's facial expression of pain, if there's respiratory rate that's going up, we stop at that point, we don't go any further and we make sure that we're increasing the pain medication to make sure that those heart rate, facial expression, respiratory rate go back to normal. Once they go back to normal, we continue to pull back the support from the ventilator until finally, in a step wise fashion, the ventilator's completely off, and then we can pull the tube out. And I always tell family, "Look, the purpose here is not to have your loved one pass away in the intensive care unit. The purpose of this is to make sure that the patient is comfortable." And I can tell you sometimes in my experience, I've seen patients pass away even before we've taken the endotracheal tube out. And sometimes we've seen situations where the endotracheal tube comes out and the patient does well and actually lives for a number of days or weeks afterwards, but the point of this is not to have the patient pass away. The point of this is to make sure that the patient is comfortable and if the patient is able to support themselves after we pull off the support from the ventilator or the vasopressors or the dialysis or whatever it is, if the patient is able to support themselves, so be it. The point is the patient's going to be comfortable, the patient doesn't want to have any more of these invasive measures and the patient should be in control. And the part of all of this that's sort of granting all of this is the ethical principle of autonomy. So autonomy is big, especially in western culture. Autonomy means that patients themselves are able to determine for them self what medical treatment they should have and what medical treatment they don't want to have. So it's okay for them to refuse medical treatment, even if it means that they're going to have a shortened life expectancy. This has to be mitigated with your understanding of course, of whether or not the patient is in their right mind. Point is, is that what we believe in, in Western culture, is that patients should have the ability to determine for themselves what treatments they have and what treatments they don't, realizing that these treatments sometimes have a lot of side effects. They're painful, they're uncomfortable, so this is a discussion that I think has to be open minded. In the final analysis of all of this, when we wrap all of this up, the point is this, is that the medical doctor, the medical professional, the healthcare professional needs to come to the family with realistic expectations about how things are going and the family needs to bring in the patient themselves if they can, need to bring information to the healthcare decision makers about what the values are of the patient, what they would've wanted given those set of prognosis and then together both family and the professional need to come up with a decision about what the direction is for the patient. Sometimes I notice that healthcare professionals don't bring up these alternatives, and so the family doesn't feel that this is a alternative that they can actually go down. So it's important as a healthcare professional to bring up these different options in a dignified way so that patients and families can make their decisions. So I hope this was helpful in terms of understanding what DNR means, what DNI means, CPR, palliative care, what it is that we do in the intensive care unit, and I hope that this will further your medical experience in the intensive care unit and your dealings with patients about this very difficult discussion. Thanks for joining us. NAssink Transcriptions nassink.transcribe@gmail.com

Thank you for this video. This topic is so important in our culturally complex world. As new nurses join the ICU we have to continually educate them on this process. Being able to speak to our patients/families in synch with our physicians is so important. This tool will be used to help develop our team's comprehension of palliative care. THANK YOU!!!

Greatly appreciated. Thank you!

Realistic expectations from day one are the name of the game. I always lay them out by saying "I hope he/she surprises me, but I'll tell you what wouldn't surprise me after an injury like this..." This weekend a parent told me that the last three weeks of their kid being in our neuro ICU have been more manageable for the family because I talked about the potential challenges the very first night.

Lovely video Each year New technology and drugs come along.

Great explanation, Ty 🤗

Thank you ❤🙏🏾

going for first nursing placement at the palliative unit next month.

Thank you Dr..m

Very educative video

Thank you

thanks for the video

Many comfort care patients get sent to my unit. They usually on oxygen and family present. Unfortunately it's noninvasive and only drawback is a dry nose, so when I tell the family we are removing the oxygen the only real reason really is to hasten the dying process. Dying patients on oxygen can last days, but once stopped they usually pass within 0-10 hours. No family wants to sit in the hospital and watch their unresponsive loved one dying for days. Also the hospital nurse educator told us to stop the oxygen bc it increases anxiety...I don't really believe that and can't find any sources to support it. i think it just makes them pass quicker

Nic

I'd like to know stuff that was obviously NOT discussed. I want to know more medical perspective. So let's say an elderly gentleman is dying in ICU. He's not on a ventilator. He's not on advanced therapies such as ECMO, IABP. He's on a pulse oximeter, ECG monitor, and the ECG monitor incorperates Respiratory Monitoring. Let's say, this patient is an elderly gentleman dying due to Sepsis. His Vasopressors were removed a couple of hours ago. His family is there, by his side. The alarms have been turned down to a low volume. The pulse beep has been turned off. What are the most common end of life rhythms you would see in such a case? Like how often will yo see tachycardia go into V-Tach, then V-Fib to Asystole? What are some other rhythms, you might see in this patient, near death? Do you always see the agonal rhythm, right before Asystole? And does the Agonal come between V-Tach, and V-Fib, or does it come before the V-Tach? I want to know some common rhythms, you might see in these end of life cases.

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People have to be taught Western values in medical school...why isn't the U.S. producing more doctors? Why do we have to import them?