To intubate and chest tube …. or not

Had to make a tough decision on a 88 year old cancer patient deemed to be DNR due to intra-abdominal cancer with liver mets but neurologically intact who presented with hypoxia and respiratory distress in the setting of no previous lung disease, lung cancer or COPD. He was a good 88 with functionality of a 65 year old who still road a bike daily for his groceries. He had signed a DNR because he was told he had incurable colon cancer. When he presented to us, there was an empyema with surrounding pleural effusion. It was pneumonia season and he had been visiting a nursing home where a few friends were residents. He had respiratory fatigue and if we were going to decompress this empyema and infected pleural effusion which had nothing to do with his malignancy we were going to have to intubate him and put in a chest tube. Would you cancel the DNR? The patient was not understanding all this due to his condition, PCO2 of 100, temp of 39.5 with tachypnea and altered level of cognition (related to infection). I was convinced that this man’s respiratory illness was curable and nothing to do with the malignancy from which he was slowly dying. What would you do?

2 thoughts on “To intubate and chest tube …. or not

  1. That’s a difficult situation. I think it depends on the patient’s understanding of “DNR” when he decided upon it. Often when their code status is initially being determined, the situation is presented to them in a black and white manner: “if your heart or breathing ran into trouble, would you want us to do everything possible to keep you going?”. They may not have been explained the variety of situations that could arise, including reversible situations where they may benefit from intubation and other intensive measures. The patient may have established the DNR specifically with regard to events stemming from the terminal cancer disease process. On the other hand, the DNR may have been all-encompassing. As the ED physician seeing the patient for the first time, it’s hard to know what the patient was thinking. I think it would be important to get a better idea of their wishes and goals of care with regard the specific situation; I would try to quickly contact the POA/SDM (given that the patient is incapacitated currently) to understand what their wishes would have been given the circumstances.

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  2. This man has several things working against his survival – he is 88, he does have metastatic colon cancer, and he now has presented with hypercapnic respiratory failure from a severe pneumonia. Though he was a good 88, in this moment, he is not. And I think he is unlikely to return to that pre-morbid state given his current illness burden. I would guess his chances of survival through this admission for his severe pneumonia quite low. It is interesting that you say his pneumonia has nothing to do with his cancer. When I think of this patient, I think of the pneumonia as part of his cancer – his immunocompromised state may have increased his pneumonia risk. I am thinking of the two as closely related (perhaps wrongly so), and this may be why I am not thinking of the pneumonia as highly curable.

    With that being said, I would try to temporize this situation as much as I could to buy time – non-rebreather, CPAP/BiPAP, usual sepsis stuff, etc. while I try to have a discussion with family to clarify his “DNR” and his feelings behind what that meant. If clarity is achieved, I would go down that path. If not, and I am sure that he has a previously signed DNR, I would do everything I could to improve his outcome within the restraints of his DNR wishes, but I would not act against them.

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