KL – Cardiac Arrest
He is 82 years old and lying in a critical care hospital bed on a life-support intra-aortic balloon pump for cardiogenic shock after a myocardial infarction. The treating cardiologist suggests removing all equipment and allowing Kenny to die peacefully. The family nick-named her “Dr. Death.”
Do you know what all of the medical terms used above mean? Do you know what the implications are? If you knew or were explained these terms, could you then make a decision to be merciful and let Kenny pass in peace? The first inclination may be to say “yes.” It seems like there is little hope. (Pause here and consider your thoughts)
Let me help you. First, an explanation of the medical terms:
- Cardiogenic shock – failure of the heart muscle to pump enough blood (and therefore supply enough oxygen) to the tissues of the brain and body
- Intra-aortic balloon pump – a medical mechanical device that helps the heart pump blood. The aorta is the largest blood vessel in the body exiting the heart and feeding larger branches to the head, torso and extremities.
- Myocardial infarction – generally known as a “heart attack” which occurs when blood flow through the arteries to the heart muscle, and therefore oxygen delivery to the heart muscle, is decreased or interrupted completely, resulting in severe damage or death to portions of the muscle of the heart
So, KL developed a heart attack (reason to be discussed later) which resulted in severe damage to the heart muscle rendering it ineffective to pump blood the brain and body. The intra-aortic balloon pump was inserted though a vessel in the groin, and up into the aorta in order to compensate for loss of the pumping pressure of the heart. Can you now make a decision to let Kenny go peacefully? Perhaps, but if he recovers, what will be his quality of life? (Pause and think again)
More information: Prior to this life-threatening incident, Kenny, other than suffering from COPD (chronic obstructive lung disease) from many years of smoking and exposure to industrial cleaning chemicals, was fairly healthy. He had no prior history of heart disease, was ambulating and driving without problems, and his mental acuity was above average for his age. Still, we have this massive heart failure and need for mechanical support to his heart. Need more information or is it time to “let go?” Again perhaps, but is the picture less dire than at first thought? Will more information help you reconsider or affirm your initial conclusion to let go?
More information: The night before this life-threatening episode evolved, Kenny was feeling fine. When he awoke the next morning, he told his daughter that he was not feeling well and had pain in his chest. Concerned that this may be a sign of a heart attack she and her husband took Kenny to the emergency room. After noting normal vital signs and a normal ekg (electrocardiogram) he was placed on nasal oxygen and allowed to rest. One-half an hour later Kenny went into cardiac arrest and could not be resuscitated. He was intubated (that is, a breathing tube was placed and he was attached to a machine to ventilate his lungs) and he was transported by ambulance to a nearby heart hospital. The situation is grave. Why would a person with a normal ekg, blood oxygenation and blood pressure suddenly go into cardiac arrest? I was contacted by telephone at this point and was totally perplexed and noted to the family that something had to have been missed. Perhaps some event related to the lungs, such as a major pulmonary embolism (blood clot in the lungs lead to poor oxygenation). The picture became very clear within minutes. Upon taking a chest x-ray it was noted that Kenny’s trachea (the major windpipe to the lungs) was deviated to the side and the lung tissue on the right side was completely collapsed! A classical TENSION PNEUMOTHORAX! This is a diagnosis that an emergency physician should be able to pick up in seconds and completely relieve within a minute or two!!
Role of Proxy: In emergency situations stress/anxiety levels are quite high for the patient if they are conscious, and certainly for the family members if they are to make decisions which can alter the outcome for the patient. A critical decision had to me made – should KL’s treatment be terminated, and he allowed to “go peacefully”, or are there further alternatives with reasonable chances of success for a favorable outcome with a expectations of a “reasonable’ existence? The alternatives of treatment as recommended by her physicians were discussed along with pros and cons of each recommendation, the potential and expectations for a successful outcome, and the known status and desires of the patient prior to their demise
