Dr Husel trial begins

[dpmd]

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So some of you are ok with extubating someone *with the purpose of hastening their death* but are going to split hairs about the doses used to keep them comfortable while this death is happening? In case it speeds up their death?? Which is exactly what taking them off the vent does???

I just don't get the hand-wringing over the dose. The ethical dilemma here is academic and manufactured. Give me the big dose if it ever comes to that. And if you're worried that the dose might not be big enough, give me a bigger one. The only real failure here is if the dose is too small.

I have seen some docs order 2 mg morphine pushes q whatever interval the floor nurses bother to check the patient at and no other symptoms management meds for terminal extubations and seen it take weeks for the patient to finally die. Apparently that is the legally preferred strategy? I call it torture for the patient and for the family.

 

[lunaire]

I don't get it. While there may be some variations on withdrawal of care, for these acute cases, aren't the patients intubated, on pressors etc?

Don't y'all titrate opioids until the patient is at a reasonable resp rate, with all hemodynamic support still going & uptitrated as needed, then when you have the sedation depth you need, pull the tube & stop all gtts? I/we generally have the patient either spontaneously breathing over vent at a slow rate, or not breathing/not sedated (if brain dead confirmed) before we pull the tube.

With this management, I don't know how you could possible require a couple mg of fentanyl to get someone comfortable enough.

The whole thing seems like care that is somehow not standard practice. If I was a jury, I'd want to hear some convincingly extraordinary circumstances that led to this management.

 

[chessknt]

I don't get it. While there may be some variations on withdrawal of care, for these acute cases, aren't the patients intubated, on pressors etc?

Don't y'all titrate opioids until the patient is at a reasonable resp rate, with all hemodynamic support still going & uptitrated as needed, then when you have the sedation depth you need, pull the tube & stop all gtts? I/we generally have the patient either spontaneously breathing over vent at a slow rate, or not breathing/not sedated (if brain dead confirmed) before we pull the tube.

With this management, I don't know how you could possible require a couple mg of fentanyl to get someone comfortable enough.

The whole thing seems like care that is somehow not standard practice. If I was a jury, I'd want to hear some convincingly extraordinary circumstances that led to this management.

The ICU has limits on drip rates for safety built in to all the pumps they will often preclude someone looking pretty at end of life when the oh is 6.x hence the supra therapeutic pumps given just prior to extubation to help people die with less discomfort. Do you actually get people that sick breathing slowly on fentanyl at 250/hr which is what the pumps max out at everywhere I have ever worked?

 

[ToliBro]

The ICU has limits on drip rates for safety built in to all the pumps they will often preclude someone looking pretty at end of life when the oh is 6.x hence the supra therapeutic pumps given just prior to extubation to help people die with less discomfort. Do you actually get people that sick breathing slowly on fentanyl at 250/hr which is what the pumps max out at everywhere I have ever worked?

Most pumps have a basic infusion/override mode that allows for mL per hour administration, no drug library to get in the way. Calculate mL per hour, set basic infusion mode on the fent to, say, 50mL an hour for 500 mikes and you're golden.

 

[narcusprince]

The problem with terminal weaning is we cannot ask the patients did they suffer with his regiment versus someone else’s. Its dicey. A protocol would have helped ratified by the medical staff. Albeit we hate protocols they help shield liability.

 

[pgg]

So some of you are ok with extubating someone *with the purpose of hastening their death* but are going to split hairs about the doses used to keep them comfortable while this death is happening? In case it speeds up their death?? Which is exactly what taking them off the vent does???

The fundamental difference is that extubating someone is withdrawing care, and giving a drug is the opposite of withdrawing care.

Stopping tube feeds might result in death. Giving a cyanide smoothie via peg tube also might result in death. But the two are not the same.

I just don't get the hand-wringing over the dose. The ethical dilemma here is academic and manufactured. Give me the big dose if it ever comes to that. And if you're worried that the dose might not be big enough, give me a bigger one. The only real failure here is if the dose is too small.

2 mg of fentanyl given in one slug is a lethal dose. Morally and ethically I'm totally OK with that. I favor physician assisted suicide. But the law varies state by state, and there's a trial underway because it sure looks like someone broke the law.

I just don't get the confusion over this case. Yes, the laws should change. Hopefully it'll be determined that he gave smaller doses, titrated to effect, that totaled to the large numbers, and the jury will understand that was appropriate. But if he really was slamming 20cc syringes of fentanyl into these people, he's got no defense, and the best we can hope for is a judge that is as compassionate in sentencing as he was in his palliative care.

 

[chessknt]

Most pumps have a basic infusion/override mode that allows for mL per hour administration, no drug library to get in the way. Calculate mL per hour, set basic infusion mode on the fent to, say, 50mL an hour for 500 mikes and you're golden.

Nurses aren't allowed to do that and I do not have the time to sit there and titrate their pumps for them which is probably also against the hospital bylaws. The OR and the ICU are different places.

 

[chessknt]

The fundamental difference is that extubating someone is withdrawing care, and giving a drug is the opposite of withdrawing care.

Stopping tube feeds might result in death. Giving a cyanide smoothie via peg tube also might result in death. But the two are not the same.


2 mg of fentanyl given in one slug is a lethal dose. Morally and ethically I'm totally OK with that. I favor physician assisted suicide. But the law varies state by state, and there's a trial underway because it sure looks like someone broke the law.

I just don't get the confusion over this case. Yes, the laws should change. Hopefully it'll be determined that he gave smaller doses, titrated to effect, that totaled to the large numbers, and the jury will understand that was appropriate. But if he really was slamming 20cc syringes of fentanyl into these people, he's got no defense, and the best we can hope for is a judge that is as compassionate in sentencing as he was in his palliative care.

We never 'withdraw' care in medicine. We shift our emphasis from life-prolonging care to comfort-oriented care. The ETT is uncomfortable so we take it out; the patient is in pain so we give a drug. We have an obligation to provide care oriented to that goal and using tiny doses out of fear that someone misinterprets the situation (as is happening in this very thread by physicians who dont practice ICU medicine) is not benefiting anyone, certainly not the patient. I dont dose fentanyl at end of life because I use morphine but I do use much bigger doses than I do in non-end of life situations. For the law to have been broken you need to prove that the medication and not the pH of 6.x + stopping pressors caused the death because this is a criminal trial so we need to go beyond a reasonable doubt. Good luck with that.

 

[drmwvr]

Euthanasia is legal in a couple of states but the patients must have a very short life expectancy and initiate it, the patient must be counseled about alternatives eg palliative care, and give consent. Finally the patients need to be able to self administer the medications.

Maybe it's quibbling about definitions, but euthanasia, per se, is not legal in any state while 'assisted suicide' may be. I think it's an important distinction to make anyway...not that either one doesn't give me the creeps....

 

[deleted87051]

Maybe it's quibbling about definitions, but euthanasia, per se, is not legal in any state while 'assisted suicide' may be. I think it's an important distinction to make anyway...not that either one doesn't give me the creeps....

It’s funny that we euthanize our pets because we want what’s best for them and don’t want them to suffer unnecessarily.

 

[drmwvr]

We never 'withdraw' care in medicine. We shift our emphasis from life-prolonging care to comfort-oriented care. The ETT is uncomfortable so we take it out; the patient is in pain so we give a drug. We have an obligation to provide care oriented to that goal and using tiny doses out of fear that someone misinterprets the situation (as is happening in this very thread by physicians who dont practice ICU medicine) is not benefiting anyone, certainly not the patient. I dont dose fentanyl at end of life because I use morphine but I do use much bigger doses than I do in non-end of life situations. For the law to have been broken you need to prove that the medication and not the pH of 6.x + stopping pressors caused the death because this is a criminal trial so we need to go beyond a reasonable doubt. Good luck with that.

If someone had a burr under their saddle (and it seems that there might be some with the case at hand) using a larger dose of IV narcotic in an obtunded, previously intubated gravely acidemic patient might not be so easily defensible.

 

[drmwvr]

It’s funny that we euthanize our pets because we want what’s best for them and don’t want them to suffer unnecessarily.

That's certainly one way to look at it. We also eat animals that some people might keep as a pet. I don't personally draw an equivalency to the life of my short hair pointer and my wife, though. And I believe that intending to keep someone comfortable and intending their death don't have to be the same thing. As an aside, I don't think I've ever seen ketamine used in end of life analgesia/sedation. Is that a thing?

 

[chessknt]

If someone had a burr under their saddle (and it seems that there might be some with the case at hand) using a larger dose of IV narcotic in an obtunded, previously intubated gravely acidemic patient might not be so easily defensible.

But is it beyond a reasonable doubt an intentional act to kill the patient? Can you not think of any scenario where this was done without the intention to kill the patient? I think we are so used to the trashcan medmal standard of 'more likely than not' that we forget how rigid the criteria are for murder trials. More importantly can the prosecutors prove this?

 

[drmwvr]

But is it beyond a reasonable doubt an intentional act to kill the patient? Can you not think of any scenario where this was done without the intention to kill the patient? I think we are so used to the trashcan medmal standard of 'more likely than not' that we forget how rigid the criteria are for murder trials. More importantly can the prosecutors prove this?

I see your point...and jury selection is more art than science...

 

[dpmd]

I don't get it. While there may be some variations on withdrawal of care, for these acute cases, aren't the patients intubated, on pressors etc?

Don't y'all titrate opioids until the patient is at a reasonable resp rate, with all hemodynamic support still going & uptitrated as needed, then when you have the sedation depth you need, pull the tube & stop all gtts? I/we generally have the patient either spontaneously breathing over vent at a slow rate, or not breathing/not sedated (if brain dead confirmed) before we pull the tube.

With this management, I don't know how you could possible require a couple mg of fentanyl to get someone comfortable enough.

The whole thing seems like care that is somehow not standard practice. If I was a jury, I'd want to hear some convincingly extraordinary circumstances that led to this management.

I have never done it the way you describe nor have I seen anyone else do it that way. Once the decision is made I don't futz around titrating up while upping the pressors to keep a blood pressure while expecting them to look comfortable eventually. They get a bolus, tube comes out, and all drips except a comfort care option drip comes off.

 

[itwasalladream]

The fundamental difference is that extubating someone is withdrawing care, and giving a drug is the opposite of withdrawing care.

Stopping tube feeds might result in death. Giving a cyanide smoothie via peg tube also might result in death. But the two are not the same.


2 mg of fentanyl given in one slug is a lethal dose. Morally and ethically I'm totally OK with that. I favor physician assisted suicide. But the law varies state by state, and there's a trial underway because it sure looks like someone broke the law.

I just don't get the confusion over this case. Yes, the laws should change. Hopefully it'll be determined that he gave smaller doses, titrated to effect, that totaled to the large numbers, and the jury will understand that was appropriate. But if he really was slamming 20cc syringes of fentanyl into these people, he's got no defense, and the best we can hope for is a judge that is as compassionate in sentencing as he was in his palliative care.

It's just my opinion that the "fundamental difference" is manufactured by ethicists. It's sort of like saying yanking a life preserver away from someone drowning is fundamentally different than pushing them in. Or that removing oxygen from the patient's air is different than giving cyanide. The actions are superficially different, but I think calling it a fundamental difference to make us feel better about our actions is mental gymnastics. The goal is "comfortable death." One cohesive concept. To then split the actions by whether they achieve "comfort" or "death" feels very artificial, and "arm-chair ethicist" to me.

I'm less familiar with the specific laws so I'm not sure we even have an argument there, but I feel like the majority of the discussion taking place on this forum is focused on the ethics. And if the day comes when I have to do that (again), I'll again do what I think is right for the patient and their family without checking the penal code. If someone would then testify "500mcg of fentanyl totally doesn't hasten death in a 85 yr old 45kg malnourished, recently extubated ICU patient, but 2000 is murder," I think my head will explode.

 

[dpmd]

The patients that were dismissed from charges in this case were those he used doses on that he was able to show didn't immediately kill other patients. The existence of those patients who survived for days despite higher than what some people consider ok doses shows how there is variation in response and to me explains why he would resort to even higher doses if those survivors seemed to suffer in those days.

 

[deleted87051]

That's certainly one way to look at it. We also eat animals that some people might keep as a pet. I don't personally draw an equivalency to the life of my short hair pointer and my wife, though. And I believe that intending to keep someone comfortable and intending their death don't have to be the same thing. As an aside, I don't think I've ever seen ketamine used in end of life analgesia/sedation. Is that a thing?

I doubt it is common but it is if your palliative care doctor came from an anesthesia background. Worked very well in opioid tolerant cancer patients. This particular attending did both a chronic pain fellowship and a hospice and palliative care fellowship at Stanford.

 

[Southpaw]

The fundamental difference is that extubating someone is withdrawing care, and giving a drug is the opposite of withdrawing care.

Stopping tube feeds might result in death. Giving a cyanide smoothie via peg tube also might result in death. But the two are not the same.


2 mg of fentanyl given in one slug is a lethal dose. Morally and ethically I'm totally OK with that. I favor physician assisted suicide. But the law varies state by state, and there's a trial underway because it sure looks like someone broke the law.

I just don't get the confusion over this case. Yes, the laws should change. Hopefully it'll be determined that he gave smaller doses, titrated to effect, that totaled to the large numbers, and the jury will understand that was appropriate. But if he really was slamming 20cc syringes of fentanyl into these people, he's got no defense, and the best we can hope for is a judge that is as compassionate in sentencing as he was in his palliative care.

There is confusion over this case, rightly so. While it isn't normal or typical to bolus 20cc of fentanyl I don't know that you can PROVE it hastened death in someone who was going to die within seconds to minutes without the fentanyl. I would not have bolused that fentanyl and I don't do end of life care. But I do know the decision had been made by family to give up invasive efforts and move to comfort care. The patients may have all lost the ability to communicate with family in an effective manner. They all likely had sedation on board making communication ineffective. Even if there was no sedation on board they were so sick that they may have mentally passed already.

My understanding is that he asked family if he could ease suffering and give something to make the patients more comfortable. He did that. Maybe it isn't what you or I would do, but it's what he did. I honestly believe itd be very hard to PROVE that he hastened death in people actively dying or already dead.

 

[Southpaw]

The patients that were dismissed from charges in this case were those he used doses on that he was able to show didn't immediately kill other patients. The existence of those patients who survived for days despite higher than what some people consider ok doses shows how there is variation in response and to me explains why he would resort to even higher doses if those survivors seemed to suffer in those days.

If that data exists I don't know how he can be found guilty.

 

[drmwvr]

The goal is "comfortable death." One cohesive concept. To then split the actions by whether they achieve "comfort" or "death" feels very artificial, and "arm-chair ethicist" to me.

I'm less familiar with the specific laws so I'm not sure we even have an argument there, but I feel like the majority of the discussion taking place on this forum is focused on the ethics. And if the day comes when I have to do that (again), I'll again do what I think is right for the patient and their family without checking the penal code. If someone would then testify "500mcg of fentanyl totally doesn't hasten death in a 85 yr old 45kg malnourished, recently extubated ICU patient, but 2000 is murder," I think my head will explode.

I don't think its difficult to avoid crossing the line for most folks. And it's a line worth not crossing if cases like the one being discussed is any indicator. It isn't an either they die or they're not comfortable choice. But if someone is bolusing IV narcotic to the type of patient we're talking about, disproportionate doses are both unnecessary and attract attention. It begs the question "what's the hurry?" and that leads to trouble best avoided....while the phrase 'intent is 9/10ths of the law' isn't a law, it is definitely something some attorney will argue.

 

[Neopolymath]

It's asinine that this is being analyzed at such a microscopic level to me for one reason alone. The patients described are basically all unoffical corpses. Everyone in healthcare worth a damn knows it. Families that have been properly educated know it. The reactionary people who rescind hospice and DNRs on their loved ones or yell at the TV because they don't understand anything about death (American problem specifically?) don't get it. There is also usually at least one really weird ICU nurse everyone knows about on the unit that doesn't get it unlike all the other ones. Am I really going to put a guy in prison for doing something I hope someone does to me when I am dead for all intents and purposes but don't have the government stamp of approval and must wait in limbo. These people are literally in death purgatory. Who cares how much fentanyl was marked in the EMR? I'm just not seeing how it's material at all. Not seeing how someone thinks it reaches threshold for malpractice. Not seeing how someone thinks it reaches threshold for criminal activity. It doesn't meet burdens IMO.

 

[Southpaw]

I don't think its difficult to avoid crossing the line for most folks. And it's a line worth not crossing if cases like the one being discussed is any indicator. It isn't an either they die or they're not comfortable choice. But if someone is bolusing IV narcotic to the type of patient we're talking about, disproportionate doses are both unnecessary and attract attention. It begs the question "what's the hurry?" and that leads to trouble best avoided....while the phrase 'intent is 9/10ths of the law' isn't a law, it is definitely something some attorney will argue.

I agree on the ‘attract attention’ part. And that alone is why 99.9% of physicians wouldn’t do what Husel did. We all mostly want to show up, earn the check, and go home. Still, I don’t find fault with what he did. If it is proven that he gave similar dosing to patients who didn’t immediately die, or lived for days, it’ll be impossible to prove he hastened death.

Also, Husels lawyer can easily show his ‘intent’ was to ease suffering and not hasten death.

 

[pgg]

We never 'withdraw' care in medicine. We shift our emphasis from life-prolonging care to comfort-oriented care. The ETT is uncomfortable so we take it out; the patient is in pain so we give a drug. We have an obligation to provide care oriented to that goal and using tiny doses out of fear that someone misinterprets the situation (as is happening in this very thread by physicians who dont practice ICU medicine) is not benefiting anyone, certainly not the patient. I dont dose fentanyl at end of life because I use morphine but I do use much bigger doses than I do in non-end of life situations. For the law to have been broken you need to prove that the medication and not the pH of 6.x + stopping pressors caused the death because this is a criminal trial so we need to go beyond a reasonable doubt. Good luck with that.

I don't know if we're talking past each other or what 🙂 but there is a clear, fundamental, legal difference between removing an endotracheal tube that results in death and giving a drug that results in death.

One is respecting the patient's (or POA's) wish to refuse futile care, and one is not stopping care.

It's the difference between taking your hands off the patient and putting your hands on the patient.

Now again, I don't have a moral or ethical opposition to actual bona fide euthanasia for end-of-life care. But the legal difference between pushing 2 mg of fentanyl and extubating a moribund patient is starkly clear, even if they both die 5 minutes later, and anyone who does the former shouldn't be surprised in the least if he finds himself in court at some point.

 

[dpmd]

If that data exists I don't know how he can be found guilty.

I think for the higher doses they didn't have examples of survivors. Maybe he will have remembered some or his lawyers will have found some examples from other doctors. If I had any cases I thought would help him I would be contacting him or his lawyers. Hopefully other docs will have done so.

 

[dpmd]

It's asinine that this is being analyzed at such a microscopic level to me for one reason alone. The patients described are basically all unoffical corpses. Everyone in healthcare worth a damn knows it. Families that have been properly educated know it. The reactionary people who rescind hospice and DNRs on their loved ones or yell at the TV because they don't understand anything about death (American problem specifically?) don't get it. There is also usually at least one really weird ICU nurse everyone knows about on the unit that doesn't get it unlike all the other ones. Am I really going to put a guy in prison for doing something I hope someone does to me when I am dead for all intents and purposes but don't have the government stamp of approval and must wait in limbo. These people are literally in death purgatory. Who cares how much fentanyl was marked in the EMR? I'm just not seeing how it's material at all. Not seeing how someone thinks it reaches threshold for malpractice. Not seeing how someone thinks it reaches threshold for criminal activity. It doesn't meet burdens IMO.

The one that doesn't get it is likely who started this whole affair. Wonder if they are happy their colleagues have lost their jobs and this guy is on trial.

As for why it is being looked at as criminal is because those of us who really get it know that at times we play a little fast and loose with the principle of double effect and technically the law doesn't allow that. I can't know what was in his heart and mind when he picked those doses but I know what is in mine (but if anybody asks it is not the hastening death thing all right, because I don't want to go to jail)

 

[dpmd]

I don't know if we're talking past each other or what 🙂 but there is a clear, fundamental, legal difference between removing an endotracheal tube that results in death and giving a drug that results in death.

One is respecting the patient's (or POA's) wish to refuse futile care, and one is not stopping care.

It's the difference between taking your hands off the patient and putting your hands on the patient.

Now again, I don't have a moral or ethical opposition to actual bona fide euthanasia for end-of-life care. But the legal difference between pushing 2 mg of fentanyl and extubating a moribund patient is starkly clear, even if they both die 5 minutes later, and anyone who does the former shouldn't be surprised in the least if he finds himself in court at some point.

I agree with you but wish it wasn't the way the law worked for this.

 

[Southpaw]

If Husels attorney looked hard enough he could find anesthetic records with patients getting 500 of fentanyl or more for routine surgery. More, at times much more, for opioid tolerant patients. That’s not even counting all the other crap we throw at patients hoping something sticks (versed, lidocaine, ketamine, precedex, etc.). If his attorney looked at some spine surgery records, looked at the sufenta gtt totals and calculated the fentanyl equivalent, it could be massive. I think his actions are easily defendable.

I don’t do ICU but I wouldn’t be shocked in the least if a patient were on fent 250/hr for vent tolerance. Much more for opioid tolerant patients. Plus maybe a versed/prop/precedex gtt.

If a patient is comfort care and it’s believed they’ll die within minutes you have one chance to make them comfortable and relieve suffering. I don’t think what he did should be considered euthanasia, not close.

Maybe if he threw a stick of propofol at them. But not fentanyl - it’s not even an amnestic.

 

[Neopolymath]

The one that doesn't get it is likely who started this whole affair. Wonder if they are happy their colleagues have lost their jobs and this guy is on trial.

As for why it is being looked at as criminal is because those of us who really get it know that at times we play a little fast and loose with the principle of double effect and technically the law doesn't allow that. I can't know what was in his heart and mind when he picked those doses but I know what is in mine (but if anybody asks it is not the hastening death thing all right, because I don't want to go to jail)

You are correct but my defense would be that no one can say beyond a shadow of a doubt that the patient didn't just die, like they were trying to do all along, at a time that just happened to coincide closely with med administration. I don't see how someone can prove otherwise when the whole premise is that they are about to expire and that's the justification for his treatment in the first place. I say just make it as muddy as possible because these people are grasping at straws.

 

[chessknt]

The level of disagreement here on whether or not this constitutes murder from doctors is really sad for me to see but hopefully shows hell get off easily because he only need one juror to not agree that it was murder.

 

[Iso4ane]

One is respecting the patient's (or POA's) wish to refuse futile care, and one is not stopping care.

I’ve had the trial in the back group so Ove heard snippets. But, this recalls the talkings about DNR-CC. I hope we can agree that just because someone is DNR-CC does not mean we stop all care.

 

[chocomorsel]

pH 6.5😳

Had no idea that was compatible with life. Lowest I have seen was 6.75 or so. And I take care of Covid.

 

[Southpaw]

The level of disagreement here on whether or not this constitutes murder from doctors is really sad for me to see but hopefully shows hell get off easily because he only need one juror to not agree that it was murder.

Honestly I think a ‘jury of his peers’ works against him. They aren’t his peers, they’re his patients. To understand what he did is reasonable would require one of several things, or more. One may perhaps need to witness years and years of futile care and suffering during death. Another may need to bolus massive doses of fentanyl to awake patients and watch them talk through it like nothing happened. Another may need to infuse ridiculous doses of sufenta and watch patients wake up still in agonizing pain. Or maybe all of the above.

But my point is that it’s very easy to write off his actions as euthanasia. In fact it’d be pretty easy to convince the public of it. But if you actually work and care for patients in this awful god forsaken system we call American healthcare, you don’t really need to even strain your eyes to see his actions and choices were not unreasonable. Definitely not criminal.

 

[dpmd]

You are correct but my defense would be that no one can say beyond a shadow of a doubt that the patient didn't just die, like they were trying to do all along, at a time that just happened to coincide closely with med administration. I don't see how someone can prove otherwise when the whole premise is that they are about to expire and that's the justification for his treatment in the first place. I say just make it as muddy as possible because these people are grasping at straws.

I'm with you. But I also kinda wish it didn't matter as long as the decision to change to comfort care status is made appropriately.

 

[dpmd]

Had no idea that was compatible with life. Lowest I have seen was 6.75 or so. And I take care of Covid.

Lots of crazy **** is compatible with life in the short term at least.

 

[lunaire]

I have never done it the way you describe nor have I seen anyone else do it that way. Once the decision is made I don't futz around titrating up while upping the pressors to keep a blood pressure while expecting them to look comfortable eventually. They get a bolus, tube comes out, and all drips except a comfort care option drip comes off.

Well then there's the problem. If you have no objective goal for "comfort," then what are you titrating to?

"futz" ing around to make sure someone is comfortable and not in distress, especially if family is present at bedside, is probably warranted, IMO. Our job as physician includes making sure the patient has a dignified death.

Plus, if you titrate the sedative/opioid to an objective goal, the nurse/pharmacy/lawyer would have less cause to accuse you of euthanasia.

 

[GassYous]

Well then there's the problem. If you have no objective goal for "comfort," then what are you titrating to?

"futz" ing around to make sure someone is comfortable and not in distress, especially if family is present at bedside, is probably warranted, IMO. Our job as physician includes making sure the patient has a dignified death.

Plus, if you titrate the sedative/opioid to an objective goal, the nurse/pharmacy/lawyer would have less cause to accuse you of euthanasia.

Being in a hospital means you're not going to have a dignified death basically by definition. Especially when you've already died 5 times and have a ph in the 6s

 

[lunaire]

Being in a hospital means you're not going to have a dignified death basically by definition. Especially when you've already died 5 times and have a ph in the 6s

Disagree. Holy ****, some of you here need to find Jesus, or talk to a therapist or something.

 

[coffeebythelake]

Being in a hospital means you're not going to have a dignified death basically by definition. Especially when you've already died 5 times and have a ph in the 6s

When the family wants "everything done" and is in denial the patient won't get a dignified death. Maxed out on pressors, lines and tubes everywhere, without any meaningful outcome except to extend the life of their shell of a body.

 

[dpmd]

Well then there's the problem. If you have no objective goal for "comfort," then what are you titrating to?

"futz" ing around to make sure someone is comfortable and not in distress, especially if family is present at bedside, is probably warranted, IMO. Our job as physician includes making sure the patient has a dignified death.

Plus, if you titrate the sedative/opioid to an objective goal, the nurse/pharmacy/lawyer would have less cause to accuse you of euthanasia.

Futzing around while continuing aggressive life sustaining treatments rather than just bolusing to ensure comfort does nothing for the dignity of their death. If things last beyond the moments after extubation then I titrate to maintain HR and RR within certain parameters and avoid grimace or other signs of discomfort.

 

[coffeebythelake]

Futzing around while continuing aggressive life sustaining treatments rather than just bolusing to ensure comfort does nothing for the dignity of their death. If things last beyond the moments after extubation then I titrate to maintain HR and RR within certain parameters and avoid grimace or other signs of discomfort.

I wonder how many of these patients were conscious enough to have perceived pain and suffering. Gasping, grimacing, signs of discomfort are probably more reflexive and distressing to observers than to the patient.

 

[e30ftw]

Disagree. Holy ****, some of you here need to find Jesus, or talk to a therapist or something.

What do you find dignifying about prolonged ICU care in a moribund patient?

Personally my idea of a dignified death is living a full life and on a cold night being brought out conscious and alone to a field to breathe my last while staring at a clear dark sky.

People have a right to live and to die.

My nightmare would be causing poorly-paid healthcare workers to suffer needlessly cleaning organic waste after my cerebrum consolidates.

 

[deleted875186]

I don’t think you can push large doses of meds just because ethically you can justify it, legally it can be seen as killing somebody. We could make the same argument that doing an abortion at 25 weeks is really no different than doing one at 15 weeks, but our society has decided that it is not legal.

 

[deleted87051]

I don’t think you can push large doses of meds just because ethically you can justify it, legally it can be seen as killing somebody. We could make the same argument that doing an abortion at 25 weeks is really no different than doing one at 15 weeks, but our society has decided that it is not legal.

You can push large doses of meds to relieve pain,dyspnea, suffering, and if that happens to also hasten death, I thought that is okay.

 

[lunaire]

What do you find dignifying about prolonged ICU care in a moribund patient?

Personally my idea of a dignified death is living a full life and on a cold night being brought out conscious and alone to a field to breathe my last while staring at a clear dark sky.

People have a right to live and to die.

My nightmare would be causing poorly-paid healthcare workers to suffer needlessly cleaning organic waste after my cerebrum consolidates.

When did I ever said anything about prolonging ICU care? All I'm saying is have a protocol for withdrawal of care based on objective signs, like resp. rate. Unless your nurses are completely incompetent, this shouldn't take much more time/effort versus the alternative.

I find the statement that patients automatically will get an undignified death just because they are in the ICU to be ridiculous. Seems like I'm in the minority here.

 

[GassYous]

When the family wants "everything done" and is in denial the patient won't get a dignified death. Maxed out on pressors, lines and tubes everywhere, without any meaningful outcome except to extend the life of their shell of a body.

Yeah I'd rather be in my own bed, at the age of 80, with a belly full of wine

 

[deleted87051]

When did I ever said anything about prolonging ICU care? All I'm saying is have a protocol for withdrawal of care based on objective signs, like resp. rate. Unless your nurses are completely incompetent, this shouldn't take much more time/effort versus the alternative.

I find the statement that patients automatically will get an undignified death just because they are in the ICU to be ridiculous. Seems like I'm in the minority here.

Having spent time in an ICU as a patient, it’s not a dignifying place. The beeps and alarms among other noises are enough to make you crazy. Lights can be dimmed but are still on all night. Patients don’t get a single moment of serenity or peace and quiet. I suppose it could be made more dignified if you turn all the monitors and alarms off.

 

[deleted1130227]

Yeah I'd rather be in my own bed, at the age of 80, with a belly full of wine

You left out the best part of the line.

 

[dpmd]

I wonder how many of these patients were conscious enough to have perceived pain and suffering. Gasping, grimacing, signs of discomfort are probably more reflexive and distressing to observers than to the patient.

I see nothing wrong with comfort care comforting the family along with the patient.

 

[Robotic Wis-Hipple]

When did I ever said anything about prolonging ICU care? All I'm saying is have a protocol for withdrawal of care based on objective signs, like resp. rate. Unless your nurses are completely incompetent, this shouldn't take much more time/effort versus the alternative.

I find the statement that patients automatically will get an undignified death just because they are in the ICU to be ridiculous. Seems like I'm in the minority here.

I don’t think we are saying nobody in the ICU gets a dignified death. But many don’t as hospital systems and family wishes lead to multiple little more than life prolonging procedures and therapeutics are added.

Then on top of that the withdrawal and comfort care parts of management are only ever more scrutinized as evidenced by this case. If Husel gets found guilty no pt in the icu gets more than 500mcgs of fentanyl for comfort ever again. So while we all know 2000mcgs is apnea inducing in likely 99.999% of patients the context is important and to litigate limits into comfort care because society needs to split hairs and blame someone will certainly only result in more patients’ last few minutes to hours being excruciating (if they have an intact cortex). Is that justice?