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    (Original post by Egypt)
    Now that's an interesting thought. Would they not be discriminating against the patient unless they found another surgeon to do the operation assuming the operation is in the patients best interests?
    As a doctor you shouldn't do anything that you don't feel comfortable with, even if it is in the patient's best interests. In practice, few doctors would actually deny such a patient treatment, but they do have the right to refuse it if personal health and safety are at risk.
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    How do you know it is due to the effects of the sedatives and not the brain injury?
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    Assuming that 1. a DNAR order has been signed 2. We are still in agreement that the brain injury is not survivable and that she is therefore to be extubated and that she will die shortly as a result 3. this had been fully discussed with the family, then she should not be resuscitated. It's not easy when the family are there beside you, but from the hx they had been told that she would die within the next couple of hours. The fact that she still has sedative drugs in her system doesn't change any of the above. Doctrine of double effect probably applies here. A DNAR order is usually made because to attempt CPR would be futile (in the legal sense of the word) and that certainly applies here. Equally you wouldn't announce to family that she's dead because there's been a respiratory arrest but you've not assessed her fully, she could feasibly still have a pulse. Obviously you'd get seniors back etc etc.

    However, if you were every in a situation where it was entirely unclear whether CPR was appropriate (such as validity of a DNAR or advanced directive) then you always start CPR anyway whilst calling the cavalry including some senior people.
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    (Original post by birduk)
    How do you know it is due to the effects of the sedatives and not the brain injury?
    Because the brain scan is not consistent with a sudden death. She would die eventually over a couple of hours, but her sudden apnoea can only be explained by the sedative drugs not having worn off yet.
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    (Original post by junior.doctor)
    However, if you were every in a situation where it was entirely unclear whether CPR was appropriate (such as validity of a DNAR or advanced directive) then you always start CPR anyway whilst calling the cavalry including some senior people.
    You haven't got time for any of that. She stops breathing there and then. The DNAR form hasn't been done.

    (Original post by junior.doctor)
    The fact that she still has sedative drugs in her system doesn't change any of the above.
    Doesn't it?
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    (Original post by junior.doctor)
    ...then she should not be resuscitated.
    The family start screaming "Do something."
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    (Original post by electricjon)
    Because the brain scan is not consistent with a sudden death. She would die eventually over a couple of hours, but her sudden apnoea can only be explained by the sedative drugs not having worn off yet.
    Run out of ratings today, but would say thanks!

    So essentially if you don't intubate now, her death will be as a result of the sedatives? If you do intubate and resus, then she will die anyway?

    I personally would rather intubate and resus, bring her back and let her die of the brain injury later please- preferably with someone a lot more senior around, just to be certain! If she is making respiratory effort on her own, then her brain has not gone yet? Hence, why I would make that decision?

    Usher the family outside whilst doing this however. Then have a chat with them over the next couple of hours so they do know what to expect.

    PS Medical student-to-be and current army medic
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    (Original post by electricjon)
    You are asked to see an elderly lady brought in unconscious having fallen and sustained a head injury. She is promptly intubated and placed on a ventilator, before being rushed to CT for a brain scan. It shows a massive brain haemorrhage, clearly non-survivable.

    The family are told and all agree that she should be extubated and allowed to die peacefully over the next couple of hours. As the family wait outside, the intensivist switches off the infusion pumps keeping her asleep and removes the tube. She is now breathing spontaneously and appears stable. The intensivist tells you “I’ll be right back” and leaves the department.

    The family are called back in to her side. After a few seconds she suddenly stops breathing and her oxygen levels start to plummet. You realise that this is due to the effects of the sedative drugs still in her system and nothing to do with the non-survivable brain injury. The family look at you anxiously.

    What would you do?
    Administer saline IV, keep a close eye on her BP, any improvement in condition?

    Obviously a good idea to re-intubate.
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    (Original post by birduk)
    Run out of ratings today, but would say thanks!

    So essentially if you don't intubate now, her death will be as a result of the sedatives? If you do intubate and resus, then she will die anyway?

    I personally would rather intubate and resus, bring her back and let her die of the brain injury later please- preferably with someone a lot more senior around, just to be certain! If she is making respiratory effort on her own, then her brain has not gone yet? Hence, why I would make that decision?

    Usher the family outside whilst doing this however. Then have a chat with them over the next couple of hours so they do know what to expect.

    PS Medical student-to-be and current army medic
    The family want to stay. How long would you continue CPR for?
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    (Original post by Dekota-XS)
    Administer saline IV, keep a close eye on her BP, any improvement in condition?
    ABC. Airway, breathing, circulation.

    She has stopped breathing. Her BP is irrelevant. She will suffocate to death if you focus on setting up IV saline.
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    (Original post by Dekota-XS)
    Obviously a good idea to re-intubate.
    Obviously?
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    (Original post by electricjon)
    The family want to stay. How long would you continue CPR for?
    Tough luck- family out. Nobody needs to see that thank you. Friendly matron please usher them out.

    (Run out of medical knowledge here) but continue CPR until it is clear there is no response, or she comes back- crash call required I think. Then senior crash doc/registra calls it (even if that is you).

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    (Original post by birduk)
    Tough luck- family out. Nobody needs to see that thank you. Friendly matron please usher them out.
    The family refuse to leave. They are aware that she is dying but they insist on being there during her last moments. They don't want to come back in later to see a lifeless corpse.
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    Ok, I get that the form wasn't done, but just as a randome musing - why on earth wasn't a DNACPR form done before extubation in a patient who is absolutely expected to die within the next 2 hours? Plenty of time to do it before pulling the tube out!

    To me, the situation is pretty clear - a consultant has established (no doubt via talking to neurosurgeons) that The brain injury on CT is not survivable. That's pretty concrete. As a result, CPR is futile / not in the patient's best interests. Usually when I / others talk about DNACPR to relatives, we make sure that they understand what it means, and that other rx will be given up to the point of the 'heart stopping', and if needed I gently explain what a resus team does and how it would be undignified. Armed with those facts most people would say "don't jump on granny's chest and break all her ribs".

    We know that she will die within 2 hours and that nothing can reverse that. I would still therefore say that CPR now would be futile and inappropriate. However a lot of this rests on being clear yourself what the discussion was that happened between the consultant and the family.

    The other option, of you really thought it appropriate, would be CPR whilst some narcan / flumazenil was given. But I think it would be difficult to justify CPR in this patient's case when she has been extubated to die.

    However, I'd reiterate that as a junior if you are unsure in a CPR situation, start CPR. In this situation, it is going to give very conflicting messages to the family though. The other option, in an ITU unit, is to pull the red button and people will come running within a few seconds.

    I'm a bit confused by you refering to the drugs "keeping her asleep" though. It says she came in unconscious.
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    (Original post by electricjon)
    The family refuse to leave. They are aware that she is dying but they insist on being there during her dying moments. They don't want to come back in later to see a lifeless corpse.
    Is this where I get silly and suggest I am bigger than they are and rugby tackle them out? Or can we at least have a curtain?
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    (Original post by birduk)
    Tough luck- family out. Nobody needs to see that thank you. Friendly matron please usher them out.

    (Run out of medical knowledge here) but continue CPR until it is clear there is no response, or she comes back- crash call required I think. Then senior crash doc/registra calls it (even if that is you).

    CPR for the sake of CPR, 20mins probably and then reasess with seniors present. Family could be present..the friendly matron would be too busy in her office to deal with them.
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    (Original post by junior.doctor)
    Ok, I get that the form wasn't done, but just as a randome musing - why on earth wasn't a DNACPR form done before extubation in a patient who is absolutely expected to die within the next 2 hours? Plenty of time to do it before pulling the tube out!

    I'm a bit confused by you refering to the drugs "keeping her asleep" though. It says she came in unconscious.
    Yes, admittedly a DNAR form should have been done, but in this situation, it wasn't.

    Yes she is unconscious, but she is/was spontaneously breathing.
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    (Original post by Subcutaneous)
    CPR for the sake of CPR, 20mins probably and then reasess with seniors present. Family could be present..the friendly matron would be too busy in her office to deal with them.
    Lets say it's 4am, and you are the most senior doctor around. The family just want her to die with dignity.
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    (Original post by birduk)
    Is this where I get silly and suggest I am bigger than they are and rugby tackle them out?
    Unless you want to get charged with assault.
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    (Original post by electricjon)
    As a doctor you shouldn't do anything that you don't feel comfortable with, even if it is in the patient's best interests. In practice, few doctors would actually deny such a patient treatment, but they do have the right to refuse it if personal health and safety are at risk.
    It's not as simple as that. Take abortions for example. You are entitled to refuse ti be involved in them however you are obliged to refer to somebody who can help. I suppose it's just your example I disagree with. If it was an aggressive patient I would say yes, refuse. A communicable disease however I do not think would be sufficIent justification to not act in the patients best interests.
 
 
 
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