Catastrophic Brainstem Stroke and Massive Hemorrhage (Case History).

A reader sent me a story of a patient who experienced a catastrophic brainstem strokeas a result of massive hemorrhage and hematoma.  Here is their story:

Dear Happy, I wanted to share with you a patient  I saw as a resident in  internal medicine.  He had just had his 90th birthday and decided to celebrate it with a catastrophic case of brainstem hemorrhage.  This man had reached end of  life with an abrupt, massive and catastrophic event.  Unfortunately, his family didn't feel the same.  They were waiting for a sign that never came.   

After three weeks in the hospital trying to help this family understand what happened, I'm sad to report that we  trach'd and PEG'd him and sent him on his way for the rest of his unresponsive life. Two days after leaving for the nursing home, he died after a 45 minute resuscitation attempt with advanced cardiac life support.  Yes.  He got CPR.  They tried to perfuse a dead brain for 45 minutes.  Why you ask?  Because he was full code status and in America that means you get what you want.  

I think the Miracle here would have been for the family to realize futility and to let him be at peace instead of letting him die of a decubitus ulcer.    They  wrote me a letter several months later thanking me for trying everything I could to bring back grandpa. I don't know.  It just doesn't feel good.   What you have here is not a catastrophic brainstem stroke.  These things happen frequently.  Most patients either die immediately or their families allow a natural death.  

What we have here is a catastrophic case of not letting go.  For these types of families,  I usually help them understand what their futile efforts mean.  If that fails, I don't fight a battle that can't be won.  If these types of families  choose to put their loved ones through the pain and suffering  of continued life support using invasive means (such as tracheostomy and PEG tube) while waiting for the Man to show up with a sign, there is no way little 'ol Happy can compete with that.

I oblige, not because I agree with their requests, but for no other reason than to allow hospital discharge planning to proceed.  In patients who aren't brain dead, for me to unilaterally pull the tube against family objections would probably constitute some kind of felony.  In patients like this, doctors have nothing further to offer in the hospital. Only a Miracle can happen.  And miracles don't pay nursing salaries.

The only two forks in the road are to allow a natural death or to implement a heavy dose of pain and suffering in the nursing home, at the request of the family.   You can't discharge a patient with an endotracheal tube.  But you can if you convert that ET tube to a tracheostomy and send them forever to a ventilator  unit at the nursing home. I used to let this kind of thing get under my skin.  Not any more.

Facebook discussion:

-->Someone found my blog from Google typing "Will Medicare pay for brain dead patient?"  Yes. Yes they will. Sad, isn't it? They also pay for futile care, irrational care, unethical care. Immoral car, bad care, good care, care that's makes you want to pull your hair out and Crestor in 108 year olds.

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