ICU Ethics

ahhh the joys of the ICU....
This week I was again in the ICU treating patients with cardiorespiratory problems. we had 2 patients to see this day, however we were both under the direct supervision of our supervisor.
'The Patients'

• A 52 y/o lady who was found unconscious at a local beach floating face down. She was dragged to the beach by lifeguards who provided CPR and was then transferred to the hospital via ambulance. Currently she is in an induced coma, intubated and ventilated on Bipap. CXR show an ARDS picture with bilateral diffuse areas of opacity and bi-basal infiltrates. Chest expansion was obviously reduced as the Bipap was operating on pressure control of 12mmHg. The patient was unable to initiate BR so the ventilator was also set to allow this. Ausc- clear BS in apical, diminished BS in middle and barely audible BS in the basal lobes. I was unable to hear any additional sounds but according to our supervisor there was. Rx included Manual hyperinflation with a PEEP of 8 + vibes, 2 cycles of this for about 3 mins per MH and then suctioning. Positioning and repositioning was also critical for this patient however all we did was move from supine to an upright sitting position and back down to supine. our supervisor told us about Prone lying and side lying postures and that these were performed by the "turning team". As yet this patient had not been prone and was unlikely to even be put into prone.

• The second patient was a 29 y/o male who for some reason decided that IV drug using was a good past-time. However on this occasion he used a 'dirty needle' and had an epileptic seizure. He is HEP -B and HEP- C with a ?? on HIV. He is also in an induced coma and ventilated on BIPAP, he is currently unable to take spontaneous breaths so the ventilator is performing all the work. He has been on constant renal dialysis for the last week and has shown signs or cerebral injury due to a four beat clonus. CXR and Ausc both showed areas of the left mid and lower lobes having areas of consolidation or infiltrates. The Rx was very similar to the previous patient however positioning was altered due to the presence of femoral arterial lines were being used for dialysis and a upright posture would have "kinked" the lines ending in disaster.

Now I pose this question for response as I am still unsure myself, ethically and morally and medically both cases are similar in terms of chest physio (at current status) however the gentleman is unable to take spontaneous breaths and shows signs of cerebral injury, what is the likelihood that this person will either function as he would have prior to the incident, without intensive 24hr care as opposed to the lady? Now I'm not 100% clear with each patients SHx but I have never seen any family or friends visiting the gentleman in the last week.

Now over the duration of treating these patients I have reflected on the ethics of treating these patients. One who seems to have a loving family and a future outside to ICU and another who seems to have a bleak existence ahead of him if he is able to pull through. I know that ethically and professionally both parties are entitled to the same treatment and care but i wonder if retrospectively each party would choose it for themselves??

Ryan Ridley