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CHAPTER 17: ISSUES CONCERNING COMATOSE AND CRITICALLY ILL PATIENTS

A comatose patient is one who is generally regarded as exhibiting little or no spontaneous self-generated activity, apart from breathing, and being unresponsive or poorly responsive to the outside world. Coma can arise in the setting of an advanced brain tumor, severe TBI, brain hemorrhage, and so forth. The care of a comatose patient is complex. Significant and meaningful recovery may indeed be delayed by weeks to months, and at times there may be no meaningful recovery. In the best interests of comatose patients, the medical team generally tends to be aggressive with the care of such patients, whenever such a stance is appropriate and potentially beneficial. The level of care offered may evolve according to the progress of the patient as time passes. It is expected that any significant change in the level of care offered to a patient will only be set in place after a thorough and informed discussion between the physician and the patient’s family members is undertaken, reaching a mutually acceptable “consensus”.

There are many aspects of comatose patient’s care worth considering:

·  Advance directive (AD): An AD is some form of legal document such as a Living Will or a special hospital AD form signed and dated by a patient, licensed health care provider and a witness. Alternatively, it may be a Health Care Power of Attorney (POA) Plan. An AD provides some direction to health care workers regarding the patient’s desired level of care should certain circumstances arise making the patient unable to communicate or provide health care directives. Such situations include coma or significant cognitive impairment following admission, from any cause. It is important for a patient to plan ahead by making an AD and discussing it with his or her spouse and other family members and doctor. In considering the following, a patient should be sure to obtain the up-to-date and location-specific recommendations that apply to him or her self. What follows are general points. First, an AD can be changed or revoked by the patient at any time. The cognitively unimpaired patient has the capacity and right to decide regarding the type of treatment he or she may wish if certain critical circumstances arise. Life-sustaining treatments he or she should consider include mechanical ventilation, dialysis, blood transfusion, antibiotic therapy, and artificial nutrition and hydration therapies. Second, ADs may include a status order such as “do-not-resuscitate” (DNR) or “do-not-intubate” (DNI) in the event of cardiorespiratory arrest, that is, when heart and/or lung function ceases, or if other major clinical decline occurs in a patient rendering him or her critically ill and unable to appropriately provide directives at that time. Note that a physician directly involved in a patient’s care can write a DNR status for a comatose or seriously ill and severely incapacitated patient but this should be discussed with family and colleagues and the appropriate consensus reached. Third, a Living Will should clearly state the circumstances and details of health care that a patient does or does not wish to have. This document should be signed and dated by the patient and a notary. Here, an appropriate notary is an independent person who is not a beneficiary of the patient’s Will, and not his or her health care provider, POA, guardian, surrogate or next of kin. A Health Care POA document should be signed and dated in a similar manner. Finally, when considering ADs, the patient’s wishes and best interests should always be put first. To the best of their abilities, physicians and family should try to determine what the patient would desire if he or she was able to make ongoing care decisions. The preferences of the patient should prevail.

·  Chest percussion therapy (CPT): This is provided by one or more respiratory therapists, nurses, and also certain modern ICU beds themselves. It involves vibrating or clapping on a patient’s chest in order to break up secretions that can build up after prolonged periods in the supine or lying down position encountered in comatose patients. It is an important part of preventing or minimizing collapse in the lungs referred to as atelectasis, which can be a breeding ground for inflammation and/or infection of the lungs, that is, pneumonitis or pneumonia.

·  Feeding and Nutrition: If a patient is comatose, it goes without saying that he or she will not be able to voluntarily eat. As a result, a feeding tube, which is a thin and soft plastic tube, may be passed by a physician or nurse from the nose of a patient into the patient’s stomach for feeding and oral medication administration purposes. After a significant period of time, such as a few weeks, this tube may be converted by a general surgeon or gastroenterologist to a “PEG” or “PEJ”. This is a percutaneous gastrostomy or jejunostomy, respectively, which is essentially a tube directly inserted from the abdominal skin surface into the stomach or adjacent small intestine for long-term feeding purposes. The type of feeding formula provided through either a feeding tube or a PEG or PEJ varies according to the hospital’s practices and recommendations of the hospital Nutrition Service.

·  Ventilation and airway support: A comatose patient is unable to safely support their own airway and may be unable to generate enough airway pressures and volumes to effectively breathe. In such circumstances, they are placed on mechanical ventilators or breathing machines until they reach a point at which they no longer require the apparatus, or use of the apparatus is discontinued. In order to keep the airway of a comatose patient open, an ET tube is used. If still needed after about one week, this may be converted over to a tracheostomy tube, or “trache”. A tracheostomy is a very short-tube airway inserted directly through the throat into the windpipe. It is placed in order to prevent pressure-related injury from an ET tube to the patient’s airway tissue. In order to talk with a tracheostomy tube, the tube needs to be manually “capped” at the throat surface. With recovery, the tracheostomy can be removed and the throat opening sutured close.

·  Repositioning and skin care: Changing a comatose patient’s body position and vigilant monitoring of the patient’s skin for signs of pressure-related injury are essential in preventing skin breakdown and infection. Such infection can even spread to the blood stream, an event referred to as wound-related sepsis. Nurses and physical therapists (PTs) are particularly attentive to this. Should pressure-sores develop, they are treatable, but perhaps the best treatment is prevention. Sometimes treatment requires the input of a skin care nurse specialist or a plastic surgeon.

·  Toileting and hygiene: A comatose patient typically still has bowel and bladder function. The IV fluids are eventually excreted by the kidneys and out through the urethra, into a urinary or Foley catheter tube. The catheter is periodically changed to prevent infection, while urine samples are periodically sent to the laboratory to evaluate for signs of infection. Regarding the passage of feces in comatose patients, although defecation may be less frequent, this may occur directly onto bed sheets. Clothing and linen are typically immediately changed by the nursing staff to prevent infection and maintain optimal patient health and hygiene. Further, regular bed baths, including sponge or cloth baths in addition to hair, skin and oral hygiene are provided by nursing and paramedical staff. All of these are important in, among other things, maintaining the dignity of comatose patients.

·  Bedside PT: This is discussed in detail elsewhere (Chapter 20).

·  Prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE): A deep venous thrombus is a blood clot that develops usually in a deep or major leg vein, but sometimes also in a deep arm vein. Such clots may develop because that limb is not working normally, spending most of the time lying dormant in a comatose patient, despite efforts of nursing staff and PTs. DVT usually presents with limb swelling in comatose patients, while awake patients frequently report limb aching discomfort. A limb ultrasound usually confirms the presence of the clot. The major risk of DVT is migration of clot fragments into the circulation and lodging in the lung. This event is referred to as pulmonary embolism (PE), which can be fatal. Treatment options that may be required in the setting of new DVT/PE include IV blood thinners if deemed safe enough to use or if there is no effective alternative to their use, and placement of a vena cava filter. Such a filter is a small umbrella that collects clot material before it can reach the heart and lungs. To prevent DVT/PE in the first place, medical teams usually use thigh or knee-high thromboembolic disease (TED) stockings/hose in bedbound patients, and sequential compression devices (SCDs). The latter are automatically reinflating devices that squeeze the calf muscles to circulate blood in this region, thereby attempting to minimize hemostasis or slowed blood circulation that otherwise promotes the occurrence of DVT. Also, many doctors will use subcutaneous (SQ) shots of low dose blood thinners, such as SQ heparin or Fragmin or Lovenox, or some equivalent. Early mobilization of a patient is also very helpful, but hard to do if the patient is comatose.

·  CSF drainage: Matters related to EVD and lumbar drain placement have been discussed in detail elsewhere (Chapter 13).

·  Disposition: This refers to the appropriate “placement” for comatose patients. It generally refers to their place in an ICU, as their vital functions cannot be adequately monitored and supported in any other setting. However, for comatose patients in whom ICU status is no longer deemed effective or appropriate and therefore withdrawn after appropriate discussions, disposition may then be a hospital ward, or a hospice or nursing home facility, or home. This depends on the medical condition of the patient and other factors, including logistic factors such as bed availability and the family’s resources. Disposition may be guided by the medical condition of the patient, ADs of the patient, and family members’ wishes, with the aid of nursing staff and a Social Worker.

·  Withdrawal of support (WOS): WOS issues are very important considerations in those patients who are deemed by physicians and family members alike as being in so poor a neurological condition that a meaningful recovery is essentially not likely to occur. WOS must take into consideration the patient’s documented or perceived expectations under these conditions. WOS generally means that all life-sustaining treatments, investigations, and supportive therapies will cease, including ventilator and supplemental oxygen support, blood and imaging tests, IV hydration, all medications other than pain medications, and all nutrition. In the place of these, physicians will usually prescribe “comfort care” measures, including only a regular dose of SQ or IV pain medication such as Morphine or Fentanyl and humidified air for a patient’s breathing comfort. The goals of a WOS scenario are to continue to relieve pain and suffering and to provide and promote dignity in the patient’s last few hours or days. A WOS scenario may forseeably hasten death as opposed to prolonging a patient’s “life” in a persistent vegetative state. Physicians and family members alike must feel that the WOS status is appropriate, with adequate levels of informed communication between physicians and family members. Sometimes there arises a need for institutional, that is, hospital-based, or judicial, that is, legal body-based, intervention. This may occur if there is no significant family member or surrogate available, or if a dispute occurs among significant family members in the absence of ADs, or if a doctor feels that there is a conflict between a family’s interests and a patient’s best interests in absence of an AD. A hospital Ethics Service Consultation or Ethics Committee may be asked to provide input, but this is generally not legally binding. Rather, it serves more of an advisory role. Such a committee or Service may consist of an independent doctor, nurse, Justice of the Peace or attorney, a hospital administrator, a social worker, and a chaplain.