TD, a 52-year-old male with diagnosed stage IV colorectal cancer, was admitted to the intensive care unit after surgical debulking of a metastatic tumor, which was recently found in the liver and caused intractable pain and bleeding. TD developed aspiration pneumonitis after surgery, necessitating reintubation and mechanical ventilation. Secondarily, atrial fibrillation developed with subsequent hemodynamic instability. On rounds, one of the new graduate nurses who recently finished orientation questioned whether the patient was being treated too aggressively in light of his original diagnosis. This sentiment echoed throughout the unit in some of the more experienced staff, and the clinical nurse specialist was called regarding institution of an ethics consult.
As the CNS for the unit, the necessity of sorting out the issues at hand was apparent. Was this a true ethical dilemma for the patient and staff? Questions needed answering, such as, what were the patient's wishes? What did the family and staff know and understand about this case?
TD was sedated to improve efficacy of mechanical ventilation, and an advance directive completed some months earlier listed TD's wife as his power of attorney for healthcare. Mrs. D was extremely attentive to her husband's needs when she was present at the hospital. On one occasion, Mrs. D was at the bedside during rounds and chose to participate in her husband's care planning. Mrs. D said that, although her husband's cancer was advanced, his will to live was strong. He would not want to be kept alive on machines, but a short course of therapy was agreeable. His surgery, she understood, was palliative and would not cure his disease, but was thought to provide some relief from the pain and bleeding problems he had been having. It appeared TD and Mrs. D were clear on the medical treatment plan and it was consistent with his wishes and advance directive. The ethical questions were truly staff preference issues-no ethical dilemma was present. However, the staff remained conflicted in their feelings on the case.
The CNS consulted the palliative care team for suggestions on how to proceed. Palliative surgery is intended to improve the patient's quality of life or ameliorate symptoms. Selection of patients for palliative surgery must be carefully planned after gaining complete knowledge of the disease, including its progress and severity. Common indications for palliative surgery are unrelieved pain and bleeding.1,2 It was clear that TD fit this criteria.
The palliative care team began to make rounds in the ICU and began discussions with the nursing staff regarding palliative care principles and treatments utilized. After several discussions and some brown bag lunch sessions, the staff felt more comfortable verbalizing their concerns about caring for patients approaching end of life and were able to apply what they had learned about TD's case to other patients experiencing unrelenting symptoms, such as dyspnea, nausea, constipation, and agitation.
TD was eventually weaned from mechanical ventilation. His atrial fibrillation converted to sinus rhythm, his hemodynamics stabilized, and he was transferred from the intensive care unit to the oncology unit, where he briefly stayed before discharge to home hospice. TD died peacefully at home a few months later in his favorite chair close to those he loved.
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