Ethical Issue: Chronic Obstructive Pulmonary Disease - Math Problem Example

Ethical Issues Order No. 357724 No. of pages: 6 Writer: 653 A 65 year old woman with advanced COPD is admitted to ICU post respiratory arrest. She has been diagnosed with bi-basal pneumonia and is intubated and fully ventilated. While you are documenting her belongings you discover a recently signed copy of an Advanced Directive in which she has stated that in the event that her condition deteriorates she does not want active treatment to be performed, in particular intubation and ventilation. What implications does finding this Advanced Directive have for the care of your patient? Discuss briefly. Chronic Obstructive Pulmonary Disease (COPD) is a disease of the lungs which makes it very difficult for the patient to breathe. COPD is of two kinds – 1. Chronic bronchitis, where mucous blocks the chief airways within the lungs causing swelling for a long and indefinite period. 2. Emphysema, where air sacs are destroyed resulting in lung disease. COPD mostly occurs in smokers, but even passive smokers who inhale dust and smoke on a regular basis are likely targets for severe bronchitis. Air pollution and other allergies could worsen the situation. Inhalation of gases or other fumes in the absence of proper ventilation leads to bronchitis. Some of the symptoms seen in patients suffering from bronchitis are Wheezing, shortness of breath, cough with mucus which at times could have blood streaks, fatigue, headache and swelling of feet and ankles. Our patient of 65 years of age is diagnosed with advanced COPD after being examined by the Physician with a stethoscope. Her condition was critical as she has been diagnosed with bi-basal pneumonia and so is intubated and completely ventilated in the ICU. Though lung disease is not completely curable, yet treatment can be given to the patient to help him breathe differently in order to stay active. In order to begin the treatment for our patient, the patient’s condition was assessed through blood samples, CT scans, BP and checking her breathing rate. However, when her belongings were being documented, an Advanced Directive was found stating that in the event of her condition worsening, active treatment should be terminated. Advanced Directives are legal documents pertaining to the reference of treatment for the patient when not in a position to take medical decisions by themselves. In such a scenario, the patient appoints or designates a surrogate decision maker also called a ‘Heath Care Proxy’ in her place. In the case of our patient, the Advanced Directive stated that in event of her disease being irreversible and incurable and her physician is sure that the disease is terminal, then the life sustaining measures such as intubation and ventilation should be discontinued immediately. ‘Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefits but imposes heavy burdens on patients, families, clinicians and the health care system.’ (Camhi, S., Mercado, A., Morrison, R., Qingling, M., Platt, D., August, G., & Nelson, J. (2009). Considering the scenario of our patient who is in a critical condition and understanding that her disease cannot be cured, my role as a patient advocate puts me in a very responsible position to see that everything is carried out according to the patient’s desire. Before beginning any treatment, a letter of consent is obtained from the patient because she would be in no position to take any kind of decisions because her condition was quite critical. 2. When brain death occurs in a ventilated patient a period of haemodynamic instability invariably occurs. With reference to the pathophysiology of brain death briefly discuss why the patient becomes unstable and outline the specific medical and nursing interventions designed to restore and maintain haemodynamic stability under the following headings • Ventilation • Circulation • Metabolism Haemodynamic instability takes place due to an acute escalation of a patient’s pulmonary vascular resistance caused by embolic thrombosis. The greater the degree of mechanical obstruction leads to brain death of a ventilated individual. Studies have shown that Pulmonary Embolism (PE) is a disorder that occurs regularly in hospital settings. In the United States, PE affects about 600,000 patients causing about 50,000 to 200,000 deaths approximately. (Dalen J.E., 1975, Lilienfield D.E., et al., 1990) The condition of our patient Mrs. Mg is deteriorating due to haemodynamic instability. She is rapidly losing consciousness due to poor blood flow caused by embolic thrombosis. Though an urgent CT scan has to be taken, other important factors have to be taken into consideration due to other complications that may arise. It is important to activate the lipoxygenase pathway following PE, but this does not necessarily or directly contribute to the rise in PVR. (Perlman M.B., Johnson A., Jubiz W., Malik A.B. 1989) However, it is critical to remove the mechanical obstruction by making use of vasoactive mediators and antagonists to ensure haemodynamic instability. Ventilation Once a patient is considered to be brain dead, the nurse makes use of different interventions to try and revive the patient on the ventilator. Since the brain is the centrifugal point for the proper functioning of the body, the nurse uses the intervention of stimulation of the brain. Where ventilation is concerned, sympathetic stimulation helps to keep the air flowing through the body. Circulation and the Metabolism of the body depend largely on the ventilation the body receives. Circulation By giving the patient sympathetic stimulation, the air that travels through the body ensures that the blood in the body that circulates has enough oxygen to keep the patient alive and the organs in good condition. Without proper circulation, the cells and tissues of the organs would deteriorate and die. The nurse has to ensure that the Blood Pressure, Cardiac contractility, heart rate are in proper order by activating the sympathoadrenal axis. Metabolism Metabolism Takes place following proper ventilation and circulation of blood that in the body. ‘Platelet aggregation takes place accompanied by serotonin release.’ (Herijgers P, et al. 2004) causing vasospastic effects reducing the blood flow in the coronary artery. For proper metabolism, thermoregulation is vital and so the nurse maintains the correct body temperature of the patient keeping it at 36.5 degrees C to 37.5 degrees C. Question 3 Our patient Mrs. Ng was admitted for E. Coli Sepsis and is the ICU for the past one week following a urinary tract infection which was neglected. Her condition is not only unstable but critical. Mrs. Ng is intubated and ventilated on SIMV 10 x 400, Pressure Support of 10 and 5 cm PEEP, FiO2 of .50. Her MAP is being maintained >70 mmHg with Noradrenalin and her urine output is > 30 mls/hr. She has a right PAC and radial arterial line in situ. Total Parenteral Nutrition is running on a separate dedicated central line and she has a jejunostomy with enteral feeding running at 40mls/hr. Her conscious state has deteriorated and an urgent CT has been ordered. E. Coli Sepsis is a non-pathogenic bacterium that commonly resides in the intestines of humans and animals. Being non- pathogenic they do not cause any disease within the intestines, but they could do so if they find their way out of the intestines. Some of the diseases that could be caused when the bacterium live outside intestines are bladder and the infections that are triggered through the urinary tract. When these bacteria get into the bloodstream, it triggers a disease called sepsis. E. Coli in the intestine causes diarrhea by releasing a lot of toxins into the body. Sometimes, the intestines said the fluid from the lining and the colon causing a lot of inflammation and pain in the process. Our patient Mrs. Ng was admitted for E. Coli Sepsis and was placed in the ICU for the past one week following a urinary tract infection which was neglected. Her condition is not only unstable but critical. Mrs. Ng is intubated and ventilated on SIMV 10 x 400, Pressure Support of 10 and 5 cm PEEP, FiO2 of .50. Her MAP is being maintained >70 mmHg with Noradrenalin and her urine output is > 30 mls/hr. She has a right PAC and radial arterial line in situ. Total Parenteral Nutrition is running on a separate dedicated central line and she has a jejunostomy with enteral feeding running at 40mls/hr. Her conscious state has deteriorated and an urgent CT has been ordered. Before taking the CT scan many important things had to be taken into consideration. For example, her health condition, body resistance and the present condition of the patient are assessed to see if the patient was in a position to withstand the treatment. In our patient’s case she was administered Noradrenalin a reuptake inhibitor that enhances adrenergic neurotransmissions which includes psychological and physiological effects such as altering of the consciousness, stimulation, alertness, endurance and also increases the energy levels of the patient. Sepsis is life threatening and occurs because of the bacteria in the body. Our patient Mrs. Ng’s condition is critical and hence before the CT scan, she has to be stabilized. The nurse has to closely monitor the elevated heart rate of the patient and maintain a balance in the temperature which may at times be high and at times low. The patient’s rate of respiration has to be watched due to the presence of carbon- di- oxide in the blood. The patient may also experience an abnormal increase in white blood cell count. All the above criteria should be brought under control before the patient is taken for the CT scan because it may prove fatal if not considered. Since the patient is already in a very critical condition, the CT scan should be taken only when other factors are brought under control or it may worsen the patient’s condition. References Advanced Medical Directives Definition – Medical Dictionary www.medterms.com/script/main/art.asp?articlekey=2158 Anthonisen N. Chronic Obstructive Pulmonary Disease. In: Goldman L, Auseillo D. Goldman: Cecil Medicine. Philadelphia, PA: Saunders Elsevier; 2007:chap 88. Brain Death and Organ Procurement www.nursingcenter.com/prodev/ce_article.asp?tid=698333 Camhi, S., Mercado, A., Morrison, R., Qingling, M., Platt, D., August, G., & Nelson, J. (2009). Deciding in the dark. Advance directives and continuation of treatment in chronic illness. Critical Care Medicine 37(3) pp919-925 Chronic Obstructive Pulmonary Disease: Medline Plus Medical Encyclopedia. www.nlm.nih.gov/medlineplus/ency/article/000091.htm Dalen J.E., Alpert J.S. Natural history of pulmonary embolism. Progr Cardiovasc Dis (1975) 17:259–270. Doug Elliott , Leanne Aitken , Wendy Chaboyer, ACCCN’s Critical Care Nursing, Publisher: Mosby (Elsevier Health Sciences) 1st Edn. 2007 www.surgimed.com.au/product.php?productid=16352&cat=253&page=1 E. Coli – Causes and Symptoms, Diagnosis and Treatment. www.medicinenet.com/e_coli__0157h7/article.htm Herijgers P, et al. Endothelial activation through brain death? J Heart Lung Transplant 2004;23(9 Suppl):S234–9. [Context Link] Lilienfield D.E., Chan E., Ehland J., Godbold J.H., Landrigan P.J., Marsh G. Mortality from pulmonary embolism in the United States: 1962 to 1984. Chest (1990) 98:1067–1072. Perlman M.B., Johnson A., Jubiz W., Malik A.B. Lipoxygenase products induce neutrophil activation and increase endothelial permeability after thrombin-induced pulmonary microembolism. Circ Res (1989) 64:62–73. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176:532-555. Read More