1 00:01:41,384 --> 00:01:43,801 (chattering) 2 00:01:46,639 --> 00:01:48,914 - Good afternoon, Beth Israel Patient Information. 3 00:01:48,914 --> 00:01:50,870 May I help you? - Room 616. 4 00:01:50,870 --> 00:01:54,601 He's in room 588, take the blue elevators there 5 00:01:54,601 --> 00:01:58,768 to the fifth floor, when you get off, take a left. 6 00:02:08,774 --> 00:02:11,941 (relaxed flute music) 7 00:02:39,718 --> 00:02:42,968 (relaxed guitar music) 8 00:02:53,950 --> 00:02:55,809 - [Nurse] Kim to the cardiac room. 9 00:02:55,809 --> 00:02:57,809 Kim to the cardiac room. 10 00:03:10,672 --> 00:03:13,895 - Maybe just to adjust to get his respiratory 11 00:03:13,895 --> 00:03:16,068 settings changed in such a way that he 12 00:03:16,068 --> 00:03:17,776 doesn't look like he's breathing so hard. 13 00:03:17,776 --> 00:03:19,660 I think it's a little bit disconcerting for 14 00:03:19,660 --> 00:03:21,646 the family to come in here and see him struggling like that. 15 00:03:21,646 --> 00:03:24,127 So that's just an idea, just a passing idea. 16 00:03:24,127 --> 00:03:25,906 - What we should try is if we think 17 00:03:25,906 --> 00:03:28,209 he stands any chance of being estivated, 18 00:03:28,209 --> 00:03:31,021 I'm gonna call his family and tell him that 19 00:03:31,021 --> 00:03:33,148 this is a situation, I'm spoken to 'em before. 20 00:03:33,148 --> 00:03:34,961 They know the situation. 21 00:03:34,961 --> 00:03:37,153 Tell them that it seems as though he's breathing on 22 00:03:37,153 --> 00:03:40,601 his own and we should make an attempt, take out the tube, 23 00:03:40,601 --> 00:03:43,329 leave it in God's hands, see what happens. 24 00:03:43,329 --> 00:03:44,573 - Okay. 25 00:03:44,573 --> 00:03:47,439 I don't know where you're at with that. 26 00:03:47,439 --> 00:03:50,727 He has a heart rate of 140, he's got dependent crackles, 27 00:03:50,727 --> 00:03:53,189 diffused wheezing, he may not fly. 28 00:03:53,189 --> 00:03:56,137 So make sure that you and the family are quite clear 29 00:03:56,137 --> 00:03:58,898 about whether this is sort of a we're gonna stop 30 00:03:58,898 --> 00:04:01,218 ventilating him once and for all or we're gonna 31 00:04:01,218 --> 00:04:03,378 try it and just see but make sure you've 32 00:04:03,378 --> 00:04:05,752 decided before exactly what you're dealing with. 33 00:04:05,752 --> 00:04:08,243 - I want you to understand the situation 34 00:04:08,243 --> 00:04:09,901 and sort of where we stand. 35 00:04:09,901 --> 00:04:13,696 I think what seems to make the most sense 36 00:04:13,696 --> 00:04:16,909 to me at this point is that since his brain, 37 00:04:16,909 --> 00:04:19,019 since he's never gonna wake up, 38 00:04:19,019 --> 00:04:23,770 that it wouldn't make sense to continue on in this state. 39 00:04:25,508 --> 00:04:30,508 Now we could try stopping the ventilator and if he breathes, 40 00:04:30,818 --> 00:04:32,722 then he breathes and if he doesn't, 41 00:04:32,722 --> 00:04:35,139 then it's in God's hands now. 42 00:04:36,870 --> 00:04:37,787 Now I know, 43 00:04:38,901 --> 00:04:40,807 but not knowing really how you felt on this, 44 00:04:40,807 --> 00:04:43,250 I wanted to call and find out and we 45 00:04:43,250 --> 00:04:46,332 hadn't actually spoken in awhile, so. 46 00:04:48,342 --> 00:04:50,545 He is, so he may breathe on his own 47 00:04:50,545 --> 00:04:52,409 and that's certainly a possibility but 48 00:04:52,409 --> 00:04:55,237 it's hard for us to actually know that for sure 49 00:04:55,237 --> 00:04:57,465 and I'm saying if we take it out, we may find out 50 00:04:57,465 --> 00:05:01,173 that he doesn't, in which case he would, 51 00:05:01,173 --> 00:05:04,244 if it were somebody who were alive and well, 52 00:05:04,244 --> 00:05:06,267 we would put the tube back in but I think 53 00:05:06,267 --> 00:05:09,390 given all the situation which you seem to understand, 54 00:05:09,390 --> 00:05:10,924 it wouldn't make much sense to put 55 00:05:10,924 --> 00:05:14,507 the tube back in because his brain is gone. 56 00:05:19,122 --> 00:05:22,289 I know this is a very difficult topic. 57 00:05:23,987 --> 00:05:26,320 - You know what the date is? 58 00:05:27,454 --> 00:05:28,871 What month is it? 59 00:05:34,343 --> 00:05:35,843 Is it winter time? 60 00:05:44,091 --> 00:05:46,747 - [Nurse] I'm gonna just slide you over. 61 00:05:46,747 --> 00:05:48,830 - Ready, one, two, three. 62 00:05:52,053 --> 00:05:54,636 - How you feeling this morning? 63 00:06:00,561 --> 00:06:01,561 What's that? 64 00:06:08,323 --> 00:06:11,906 Can you look over here, look at my fingers? 65 00:06:13,119 --> 00:06:15,286 Can you follow my fingers? 66 00:06:24,999 --> 00:06:27,452 - We'll let you do your work too. 67 00:06:27,452 --> 00:06:30,449 I'm gonna get you weighed Mr. Toomey on a special scale. 68 00:06:30,449 --> 00:06:33,032 Just lifting you up in the air. 69 00:06:36,043 --> 00:06:37,293 - [Nurse] 86.2. 70 00:06:41,284 --> 00:06:43,284 - A special gift for ya. 71 00:06:47,783 --> 00:06:50,200 (chattering) 72 00:06:53,350 --> 00:06:55,850 - [Man] Yeah, I mean whatever. 73 00:06:57,585 --> 00:06:58,917 - I think it's important that everybody 74 00:06:58,917 --> 00:07:00,456 feel comfortable with what we're doing. 75 00:07:00,456 --> 00:07:02,731 I personally think that his antibiotics are, 76 00:07:02,731 --> 00:07:04,231 you know it's like 77 00:07:05,428 --> 00:07:07,471 a pea shooter against an atomic bomb. 78 00:07:07,471 --> 00:07:10,007 I mean the guy is not, if you look at 79 00:07:10,007 --> 00:07:12,389 the natural history of what's happened here 80 00:07:12,389 --> 00:07:15,736 and what his prognosis is and what we know about 81 00:07:15,736 --> 00:07:17,765 the terminal lung cancer, there's not anything 82 00:07:17,765 --> 00:07:19,648 any of us is gonna be able to do and whether 83 00:07:19,648 --> 00:07:22,207 you give him the antibiotics or not I think is 84 00:07:22,207 --> 00:07:24,070 sort of more how you feel personally about it. 85 00:07:24,070 --> 00:07:26,569 I guess the issue that's gonna become 86 00:07:26,569 --> 00:07:28,470 a major issue is that everybody feel 87 00:07:28,470 --> 00:07:30,852 comfortable with sort of withdrawing his care. 88 00:07:30,852 --> 00:07:33,296 I certainly do, I mean I think that on Friday night, 89 00:07:33,296 --> 00:07:36,860 I've never thought that when the guy arrived here 90 00:07:36,860 --> 00:07:40,382 that he had a chance of pulling through but 91 00:07:40,382 --> 00:07:42,782 I do think it's very important for the family 92 00:07:42,782 --> 00:07:45,144 to give them the feeling that we're doing 93 00:07:45,144 --> 00:07:47,544 everything that we can 'til the point that they 94 00:07:47,544 --> 00:07:49,772 come to the realization that, I mean there 95 00:07:49,772 --> 00:07:52,359 are a lot of unresolved issues here. 96 00:07:52,359 --> 00:07:56,277 Never dealt with his feelings with his younger daughter. 97 00:07:56,277 --> 00:07:59,813 A lot of anger on both of their parts evidently 98 00:07:59,813 --> 00:08:04,410 and both, you know he's been married for 34 years. 99 00:08:04,410 --> 00:08:07,058 A lot of other, and I think they all, 100 00:08:07,058 --> 00:08:09,916 they didn't have a chance to say goodbye to him 101 00:08:09,916 --> 00:08:12,642 and that was the thing that was really irking them. 102 00:08:12,642 --> 00:08:14,792 I think they sorta knew intellectually that 103 00:08:14,792 --> 00:08:16,902 he wasn't gonna make it but emotionally on Friday, 104 00:08:16,902 --> 00:08:19,225 they were just not prepared to accept that 105 00:08:19,225 --> 00:08:22,047 and I think now that they've really evolved 106 00:08:22,047 --> 00:08:23,788 to a different stage in their own feelings, 107 00:08:23,788 --> 00:08:28,078 I think that we've gotta sorta take that into account but 108 00:08:28,078 --> 00:08:29,734 always in a situation like this there 109 00:08:29,734 --> 00:08:34,426 are four or five different groups of people here. 110 00:08:34,426 --> 00:08:36,722 The nurses know, knew from the moment he 111 00:08:36,722 --> 00:08:39,082 walked in the door that he wasn't gonna make it 112 00:08:39,082 --> 00:08:41,227 and I think that the family was a bit angry that 113 00:08:41,227 --> 00:08:43,748 they were getting that message from the nurses. 114 00:08:43,748 --> 00:08:46,165 I sorta knew that too but I didn't give 'em the same 115 00:08:46,165 --> 00:08:48,466 message, I sorta said yes, we're gonna do all this stuff. 116 00:08:48,466 --> 00:08:52,043 But everybody's gotta feel comfortable that we're, 117 00:08:52,043 --> 00:08:54,065 before we sort of embark on a course of 118 00:08:54,065 --> 00:08:56,593 action here that we're doing the right thing. 119 00:08:56,593 --> 00:08:58,959 I mean nobody likes to lose. 120 00:08:58,959 --> 00:09:00,290 But this is not something that 121 00:09:00,290 --> 00:09:01,699 we have a lot of control over. 122 00:09:01,699 --> 00:09:03,448 But I think if people feel different about it, 123 00:09:03,448 --> 00:09:06,405 now's the time to say so because I think that we're gonna, 124 00:09:06,405 --> 00:09:08,269 I'm gonna have to talk to the family 125 00:09:08,269 --> 00:09:11,496 sometime today about withdrawing support 126 00:09:11,496 --> 00:09:14,277 and my own personal feeling is that 127 00:09:14,277 --> 00:09:16,437 I don't think that we have, it's just a question 128 00:09:16,437 --> 00:09:19,871 of he's dying today or dying three days from now. 129 00:09:19,871 --> 00:09:21,737 - I mean the acute deterioration on Saturday 130 00:09:21,737 --> 00:09:23,694 is really what turned the family around 131 00:09:23,694 --> 00:09:25,492 and since then they've really, it sounds 132 00:09:25,492 --> 00:09:27,726 like they've just really evolved in 133 00:09:27,726 --> 00:09:30,191 their feelings and in their wishes. 134 00:09:30,191 --> 00:09:31,257 - [Scott] But I was really 135 00:09:31,257 --> 00:09:32,833 asking the question for everybody here. 136 00:09:32,833 --> 00:09:34,753 - Well it was my feeling before he had 137 00:09:34,753 --> 00:09:36,770 this deterioration on Saturday that if he 138 00:09:36,770 --> 00:09:39,095 were to stop bleeding long enough, presumably 139 00:09:39,095 --> 00:09:41,012 he could eventually mobilize that blood, 140 00:09:41,012 --> 00:09:43,849 re-expand and potential come off the vent. 141 00:09:43,849 --> 00:09:45,838 In which case he'd be at XRT and if he 142 00:09:45,838 --> 00:09:48,707 didn't re-bleed, he could have a couple of months. 143 00:09:48,707 --> 00:09:50,157 But now he's showing that he's just 144 00:09:50,157 --> 00:09:52,511 bleeding again back to where he was before. 145 00:09:52,511 --> 00:09:56,012 He's not gonna stand a chance of ever getting off the vents. 146 00:09:56,012 --> 00:09:58,205 - Yeah, as somebody who treats a lot of lung cancer, 147 00:09:58,205 --> 00:09:59,820 I don't think there's anything in the medical 148 00:09:59,820 --> 00:10:04,192 literature that would justify the optimism of the radiation 149 00:10:04,192 --> 00:10:07,282 therapists in terms of what they said even on Friday. 150 00:10:07,282 --> 00:10:09,167 - But the oncologist too. 151 00:10:09,167 --> 00:10:10,944 We've got the oncologist down there. 152 00:10:10,944 --> 00:10:13,156 I mean Annette said "Well, he could've gotten 153 00:10:13,156 --> 00:10:16,105 "three days of XRT by now but now it's too late." 154 00:10:16,105 --> 00:10:17,549 And I said that wouldn't have made any difference. 155 00:10:17,549 --> 00:10:19,632 He bled Saturday morning. 156 00:10:21,370 --> 00:10:22,620 - [Scott] Okay. 157 00:10:24,858 --> 00:10:28,508 Mr. Gavin, he did not report any chest pain yesterday. 158 00:10:28,508 --> 00:10:31,630 His CPK from the previous day is ruled out. 159 00:10:31,630 --> 00:10:34,463 His VEA was at baseline yesterday. 160 00:10:35,971 --> 00:10:38,571 Over the course of the day, he remained on 161 00:10:38,571 --> 00:10:41,204 the drips he was on yesterday, ranged with 162 00:10:41,204 --> 00:10:44,108 dopamine, pyrrobutamine and his nitroprusside 163 00:10:44,108 --> 00:10:46,007 had increased over the course of the day 164 00:10:46,007 --> 00:10:48,623 and tolerated a blood pressure of about 80. 165 00:10:48,623 --> 00:10:53,373 Keep doing that and one dose of diuretics in the morning. 166 00:11:00,097 --> 00:11:01,252 - Hang on. 167 00:11:01,252 --> 00:11:03,865 All right, it's charged. 168 00:11:03,865 --> 00:11:06,698 - [Nurse] Unplug her from the EKG. 169 00:11:08,319 --> 00:11:11,172 Turn it on. - I got it, I got it. 170 00:11:11,172 --> 00:11:15,227 - [Doctor] All right, let's shock, check her blood-- 171 00:11:15,227 --> 00:11:17,227 - [Nurse] Wait a second. 172 00:11:19,626 --> 00:11:20,459 Clear. 173 00:11:24,826 --> 00:11:26,409 - There's no pulse. 174 00:11:27,530 --> 00:11:30,011 - [Doctor] Continue with CPR. 175 00:11:30,011 --> 00:11:30,844 - Towel. 176 00:11:32,007 --> 00:11:33,510 - Wait, I need this. 177 00:11:33,510 --> 00:11:35,051 - [Nurse] Is there something disconnected? 178 00:11:35,051 --> 00:11:35,884 - Yes. 179 00:11:47,186 --> 00:11:49,603 - Full CPR for just a second. 180 00:11:54,398 --> 00:11:56,225 All right, that's it. 181 00:11:56,225 --> 00:11:59,085 - Unless anybody has anymore ideas. 182 00:11:59,085 --> 00:12:00,780 - But he has told us that he 183 00:12:00,780 --> 00:12:02,852 does not want to live on the tube. 184 00:12:02,852 --> 00:12:03,724 - Right. - Okay. 185 00:12:03,724 --> 00:12:06,060 That he's made clear to me, he's made clear to you. 186 00:12:06,060 --> 00:12:08,089 That's been his major concern all along. 187 00:12:08,089 --> 00:12:11,908 So that if at some point you're saying 188 00:12:11,908 --> 00:12:14,908 we can't wean him, then I think that 189 00:12:15,750 --> 00:12:16,583 per se is, 190 00:12:20,160 --> 00:12:23,558 to me at least that per se in an indication to stop, 191 00:12:23,558 --> 00:12:25,217 to DC the tube. 192 00:12:25,217 --> 00:12:28,973 What he is saying, what he has indeed said is 193 00:12:28,973 --> 00:12:31,544 "I do not want to live on the tube, 194 00:12:31,544 --> 00:12:34,697 "I don't want the tube if I can't get off the tube." 195 00:12:34,697 --> 00:12:35,607 - Right. 196 00:12:35,607 --> 00:12:39,550 - So if you hit that point, then yes, you DC him. 197 00:12:39,550 --> 00:12:40,954 - They got in touch with her son 198 00:12:40,954 --> 00:12:42,943 who insisted that everything be done. 199 00:12:42,943 --> 00:12:45,149 So they looked for everything but, 200 00:12:45,149 --> 00:12:50,012 I mean everything, a septus and a ruptured viscous 201 00:12:50,012 --> 00:12:54,241 to explain her acidosis, hypotension and decreasing crit 202 00:12:54,241 --> 00:12:56,909 and it became clear as she became 203 00:12:56,909 --> 00:13:00,428 recurrently hypotensive with this distending 204 00:13:00,428 --> 00:13:04,695 abdomen that this was a ruptured aneurism. 205 00:13:04,695 --> 00:13:05,771 The surgeons-- 206 00:13:05,771 --> 00:13:07,956 - As far as I know, that's not a medical disease. 207 00:13:07,956 --> 00:13:10,411 - The surgeons evaluated her 208 00:13:10,411 --> 00:13:12,661 and Mark Lanser's note said 209 00:13:16,944 --> 00:13:18,444 a short, you know, 210 00:13:19,972 --> 00:13:22,417 HNP impression, ruptured aneurism. 211 00:13:22,417 --> 00:13:25,828 Operation is futile, 100% mortality. 212 00:13:25,828 --> 00:13:27,995 I have spoken with the son 213 00:13:28,911 --> 00:13:32,176 in charge and explained the situation 214 00:13:32,176 --> 00:13:34,619 and he suggested comfort measures. 215 00:13:34,619 --> 00:13:36,402 - His son? - No. 216 00:13:36,402 --> 00:13:39,611 Mark Lanser, the surgical attending. 217 00:13:39,611 --> 00:13:42,315 Comfort measures and no resuscitative efforts. 218 00:13:42,315 --> 00:13:45,042 The son insisted that everything be done 219 00:13:45,042 --> 00:13:48,042 and the son I think is now flying here 220 00:13:48,042 --> 00:13:49,654 from, I don't know where he lives 221 00:13:49,654 --> 00:13:52,237 but he's apparently in a plane. 222 00:13:53,186 --> 00:13:55,623 I think that there are two more, I think there 223 00:13:55,623 --> 00:14:00,290 are two daughters but they haven't been contacted and so 224 00:14:01,245 --> 00:14:06,245 the EW nurses felt too uncomfortable having her downstairs. 225 00:14:06,488 --> 00:14:10,321 She's in the midst of becoming hypotensive and 226 00:14:12,506 --> 00:14:14,993 distending abdomen, she got intubated 227 00:14:14,993 --> 00:14:18,355 which is why she has to be here and she was put on 228 00:14:18,355 --> 00:14:22,180 lots of depressors, now is on Livo and Neo. 229 00:14:22,180 --> 00:14:24,633 - [Scott] Sounds like we're doing everything we can do. 230 00:14:24,633 --> 00:14:28,075 - So I said why does she even have to come to, 231 00:14:28,075 --> 00:14:30,373 but we won't even get into that. 232 00:14:30,373 --> 00:14:32,943 - That's not worth-- - No, it isn't. 233 00:14:32,943 --> 00:14:34,940 - That's fine, I think it's, because 234 00:14:34,940 --> 00:14:36,800 one of the reasons we're having her here 235 00:14:36,800 --> 00:14:38,668 is that we deal with this better than anybody else. 236 00:14:38,668 --> 00:14:42,841 - See the big issue was because the nurses felt that 237 00:14:42,841 --> 00:14:45,674 when she dies, she has to be coded 238 00:14:46,660 --> 00:14:49,001 because the son insisted everything be done 239 00:14:49,001 --> 00:14:53,918 and so they were preparing to do a code on this poor woman. 240 00:14:55,885 --> 00:14:58,185 - I guess the question is 241 00:14:58,185 --> 00:15:00,793 there are lots of definitions of everything. 242 00:15:00,793 --> 00:15:04,310 - She's also gotten four units of blood 243 00:15:04,310 --> 00:15:06,889 and I assume by carb and stuff because 244 00:15:06,889 --> 00:15:09,281 it looks like her gases got a little better. 245 00:15:09,281 --> 00:15:12,090 Crit seemed to stabilize. 246 00:15:12,090 --> 00:15:14,510 - She hasn't had a gas intrusion today. 247 00:15:14,510 --> 00:15:16,174 - She had one a little bit later. 248 00:15:16,174 --> 00:15:19,046 But I mean the bicarbs on her SMA segment, 249 00:15:19,046 --> 00:15:23,376 there are some bicarbs that's getting better. 250 00:15:23,376 --> 00:15:25,357 I guess I don't see the point in doing 251 00:15:25,357 --> 00:15:27,605 any of that because I agree, this is a surgical 252 00:15:27,605 --> 00:15:29,676 disease and if they're not gonna do surgery, 253 00:15:29,676 --> 00:15:32,926 I don't see the point of prolonging it. 254 00:15:34,974 --> 00:15:37,767 - [Doctor] We'll talk to the son. 255 00:15:37,767 --> 00:15:40,517 - Yeah, I mean again I think that 256 00:15:43,655 --> 00:15:48,574 you know, go ahead and take a quick look at her and 257 00:15:48,574 --> 00:15:49,407 I don't, 258 00:15:52,168 --> 00:15:53,251 I don't know. 259 00:15:54,852 --> 00:15:59,792 What's happened with these, the DNR rules and everything 260 00:15:59,792 --> 00:16:04,075 over the last five years really makes, puts you in 261 00:16:04,075 --> 00:16:07,023 a difficult situation, I think that I would 262 00:16:07,023 --> 00:16:09,630 feel very comfortable in terms of everything, 263 00:16:09,630 --> 00:16:12,721 being everything that we've done already. 264 00:16:12,721 --> 00:16:14,010 - Is she awake now? 265 00:16:14,010 --> 00:16:16,246 - [Doctor] She's awake a little bit now more, 266 00:16:16,246 --> 00:16:18,697 she has a baseline dementia so I don't know what her 267 00:16:18,697 --> 00:16:21,463 understanding is but she is a little bit awake right now. 268 00:16:21,463 --> 00:16:23,568 - What's the son's understanding? 269 00:16:23,568 --> 00:16:25,552 - [Doctor] He understands that 270 00:16:25,552 --> 00:16:28,370 basically it's a surgical problem and they 271 00:16:28,370 --> 00:16:30,992 cannot treat it surgically and medically 272 00:16:30,992 --> 00:16:34,159 there's no further thing we can do and 273 00:16:36,182 --> 00:16:37,513 that you know like I said, 274 00:16:37,513 --> 00:16:40,424 "Please understand that she already died." 275 00:16:40,424 --> 00:16:42,165 - Does he want to make plans to come here at all? 276 00:16:42,165 --> 00:16:43,578 - [Doctor] He's coming here. 277 00:16:43,578 --> 00:16:45,824 He's gonna arrive here around 12:30 in the hospital. 278 00:16:45,824 --> 00:16:48,733 He's planning on coming from Chicago at 11:30. 279 00:16:48,733 --> 00:16:49,805 - Do you think she'll survive 'til then? 280 00:16:49,805 --> 00:16:52,220 - [Doctor] I don't think so and he knows that. 281 00:16:52,220 --> 00:16:53,220 - He does? - Yeah. 282 00:16:53,220 --> 00:16:54,468 But I think it might make him 283 00:16:54,468 --> 00:16:55,840 feel better if I had talked with you. 284 00:16:55,840 --> 00:16:57,568 - I'll put a note in there. - Okay, thank you. 285 00:16:57,568 --> 00:16:58,568 - Okay fine. 286 00:17:07,767 --> 00:17:11,934 Mrs. Winter, this is Rabbi Baird, can you hear me? 287 00:17:13,508 --> 00:17:15,786 Just blink your eyes if you can hear me, okay? 288 00:17:15,786 --> 00:17:19,638 Blink your eyes, this is Rabbi Baird. 289 00:17:19,638 --> 00:17:21,556 Can you hear me at all? 290 00:17:28,660 --> 00:17:30,827 I've come by to say hello. 291 00:17:36,235 --> 00:17:37,887 We understand that your son 292 00:17:37,887 --> 00:17:40,804 is going to be coming from Chicago. 293 00:17:47,283 --> 00:17:48,983 Hopefully he'll be here this morning, 294 00:17:48,983 --> 00:17:51,066 later this morning, okay? 295 00:17:52,718 --> 00:17:56,375 And I wanted you to know that I'm here as well 296 00:17:56,375 --> 00:17:59,375 and we're going to be here with you. 297 00:18:01,377 --> 00:18:03,960 We won't leave you alone, okay? 298 00:18:07,851 --> 00:18:09,518 - [Nurse] Thank you. 299 00:18:10,382 --> 00:18:13,215 - [Nurse Operator] Amy, line four. 300 00:18:45,102 --> 00:18:47,269 - She can't hear anything. 301 00:19:11,535 --> 00:19:14,618 Let's take her off this for a second. 302 00:19:15,966 --> 00:19:19,049 (electronic beeping) 303 00:19:37,585 --> 00:19:39,168 - Okay, she's dead. 304 00:19:40,004 --> 00:19:40,837 10:53. 305 00:19:47,022 --> 00:19:48,638 - She's gonna be here for awhile. 306 00:19:48,638 --> 00:19:51,093 - Basically it's not just his middle lobe that's down. 307 00:19:51,093 --> 00:19:55,593 His lower lobe is completely down and his middle lobe. 308 00:19:57,073 --> 00:19:59,280 My general approach in terms of dealing with 309 00:19:59,280 --> 00:20:01,779 the family about something like this is just that 310 00:20:01,779 --> 00:20:04,527 even if they can't hear it, I think it's important 311 00:20:04,527 --> 00:20:08,369 to tell them exactly what is going on 312 00:20:08,369 --> 00:20:13,369 and if they don't, if they don't get it the first time, 313 00:20:13,452 --> 00:20:15,348 it's not so bad. 314 00:20:15,348 --> 00:20:18,712 If it's so frightening to them that they can't hear it, 315 00:20:18,712 --> 00:20:21,283 then that's okay, I don't think you're gonna do 'em 316 00:20:21,283 --> 00:20:25,644 any harm but I think that it's important to be honest 317 00:20:25,644 --> 00:20:29,574 with them and tell them exactly what's going on because 318 00:20:29,574 --> 00:20:34,382 eventually they will start to hear I think what's going on. 319 00:20:34,382 --> 00:20:36,721 I think probably what I'll say is 320 00:20:36,721 --> 00:20:38,536 similar to what I said this morning. 321 00:20:38,536 --> 00:20:40,521 - It's an interesting challenge because while 322 00:20:40,521 --> 00:20:42,457 you've been talking to the mother saying this, 323 00:20:42,457 --> 00:20:44,974 the daughter will be in the background going 324 00:20:44,974 --> 00:20:48,040 like this, it's a very bizarre situation. 325 00:20:48,040 --> 00:20:51,294 I just went on despite what the daughter was signaling. 326 00:20:51,294 --> 00:20:54,382 I just kept saying it but it's unusual. 327 00:20:54,382 --> 00:20:56,465 - Well again I think that 328 00:20:57,388 --> 00:20:58,995 as we said this morning on rounds, 329 00:20:58,995 --> 00:21:00,490 it's a very difficult situation. 330 00:21:00,490 --> 00:21:02,603 The mother says she doesn't want to hear anything 331 00:21:02,603 --> 00:21:06,028 but these daughters that are all fighting for 332 00:21:06,028 --> 00:21:08,058 control but I don't think that reasonably 333 00:21:08,058 --> 00:21:12,475 you can exclude her from the decision-making process. 334 00:21:28,915 --> 00:21:32,077 - In the scope of one to 10 of your lungs, 335 00:21:32,077 --> 00:21:35,812 10 being good and one being bad, you're on a one. 336 00:21:35,812 --> 00:21:38,895 You have really poor, poor breathing. 337 00:21:41,259 --> 00:21:43,427 - That's the condition I'm in. - Yeah. 338 00:21:43,427 --> 00:21:45,796 - How is it, I could breath yesterday, 339 00:21:45,796 --> 00:21:48,057 the day before yesterday. 340 00:21:48,057 --> 00:21:50,626 - Falling, yeah. - Falling. 341 00:21:50,626 --> 00:21:52,773 - And I went home, no care or nothing. 342 00:21:52,773 --> 00:21:54,522 I went home, they took me home. 343 00:21:54,522 --> 00:21:56,424 - Yeah. - All alone. 344 00:21:56,424 --> 00:21:57,257 - Yeah. 345 00:21:58,959 --> 00:22:02,042 But then it's what happened yesterday 346 00:22:03,144 --> 00:22:04,765 that's made you feel bad. 347 00:22:04,765 --> 00:22:08,015 Why did you go to Dr. Axelrod's office? 348 00:22:08,874 --> 00:22:11,569 - My sons took me there. - Yeah. 349 00:22:11,569 --> 00:22:13,631 Yeah, was that because you 350 00:22:13,631 --> 00:22:15,504 were having a hard time breathing? 351 00:22:15,504 --> 00:22:16,633 - No. 352 00:22:16,633 --> 00:22:18,199 - No? 353 00:22:18,199 --> 00:22:19,567 It turns out you were. 354 00:22:19,567 --> 00:22:22,264 - He's my official doctor. - Right. 355 00:22:22,264 --> 00:22:25,340 I understand that, what I'm asking you is what, 356 00:22:25,340 --> 00:22:27,079 did your sons come over and see that 357 00:22:27,079 --> 00:22:28,598 you were a little bit worse and they said-- 358 00:22:28,598 --> 00:22:30,217 - They dropped me off. - Okay. 359 00:22:30,217 --> 00:22:32,398 - My sons dropped me off. 360 00:22:32,398 --> 00:22:36,224 - Did they bring you to Dr. Axelrod's because-- 361 00:22:36,224 --> 00:22:38,045 - I told them to. - You told 'em to 362 00:22:38,045 --> 00:22:40,209 because you were feeling bad? 363 00:22:40,209 --> 00:22:41,577 - No, he's my doctor. 364 00:22:41,577 --> 00:22:42,817 - I know, I know. 365 00:22:42,817 --> 00:22:45,680 Was it a regular appointment or were you feeling, oh. 366 00:22:45,680 --> 00:22:49,000 - It was to be this week. - Oh, I see. 367 00:22:49,000 --> 00:22:52,481 - But I got hurt last week, so he says "Bring him up." 368 00:22:52,481 --> 00:22:54,174 Then from there he brought me over here. 369 00:22:54,174 --> 00:22:56,607 - So it wasn't like a new thing that 370 00:22:56,607 --> 00:22:59,216 you were feeling all of a sudden bad and you went 371 00:22:59,216 --> 00:23:01,198 and called him and said "I need an appointment." 372 00:23:01,198 --> 00:23:03,180 It was already scheduled. 373 00:23:03,180 --> 00:23:04,933 Oh, I didn't know that. 374 00:23:04,933 --> 00:23:07,661 - I went to see him. - Yeah. 375 00:23:07,661 --> 00:23:10,393 - I lost my wife here. - I know you did. 376 00:23:10,393 --> 00:23:13,497 - And I was here in '83. - Yeah. 377 00:23:13,497 --> 00:23:14,330 - Myself. 378 00:23:14,330 --> 00:23:17,243 - Do you understand what intubation means? 379 00:23:17,243 --> 00:23:18,908 - Yeah. - Do you understand? 380 00:23:18,908 --> 00:23:20,042 - Raise you up. 381 00:23:20,042 --> 00:23:21,377 - No. 382 00:23:21,377 --> 00:23:23,184 No, that's not what it means. 383 00:23:23,184 --> 00:23:27,878 Intubation means, it's an act of putting a tube 384 00:23:27,878 --> 00:23:31,078 in your mouth and into your lungs 385 00:23:31,078 --> 00:23:34,305 and we attach it to a machine through tubes 386 00:23:34,305 --> 00:23:36,222 and we help you breathe 387 00:23:37,205 --> 00:23:40,499 and we wait for your lungs to get better 388 00:23:40,499 --> 00:23:43,582 and then we take you off the machine. 389 00:23:44,691 --> 00:23:47,332 As you become better, you're allowed, 390 00:23:47,332 --> 00:23:50,749 you're able to breathe better on your own 391 00:23:52,157 --> 00:23:54,877 and the machine does less and less work. 392 00:23:54,877 --> 00:23:56,877 Unfortunately your lungs 393 00:23:58,607 --> 00:24:01,051 aren't gonna get better. 394 00:24:01,051 --> 00:24:04,826 So the act of putting you on the machine 395 00:24:04,826 --> 00:24:07,537 is almost a futile effort. 396 00:24:07,537 --> 00:24:10,009 The machine is there to help you and then when you 397 00:24:10,009 --> 00:24:13,930 get better, we can take the machine away gradually. 398 00:24:13,930 --> 00:24:17,025 What's gonna happen if we put you on the machine is 399 00:24:17,025 --> 00:24:19,710 that you're not gonna get better. 400 00:24:19,710 --> 00:24:23,545 This is you, it's sad and it's frustrating 401 00:24:23,545 --> 00:24:27,037 and it's anger-provoking but your lungs 402 00:24:27,037 --> 00:24:30,531 are about as bad as they can get. 403 00:24:30,531 --> 00:24:32,891 It tells us from your breathing test, 404 00:24:32,891 --> 00:24:34,382 you know the breathing test? 405 00:24:34,382 --> 00:24:35,868 Not the little aerosol thing but 406 00:24:35,868 --> 00:24:38,077 the breathing test on the big machine 407 00:24:38,077 --> 00:24:39,982 and our blood gases that we do, 408 00:24:39,982 --> 00:24:42,482 that tells us what you're like 409 00:24:43,529 --> 00:24:46,222 and what your body is telling us 410 00:24:46,222 --> 00:24:50,029 is that your lungs don't have much left. 411 00:24:50,029 --> 00:24:51,891 They've been working for 81 years 412 00:24:51,891 --> 00:24:54,166 and now they're working overtime. 413 00:24:54,166 --> 00:24:55,999 - 83 years. - Yeah, 83. 414 00:24:56,856 --> 00:24:58,050 - Well-- 415 00:24:58,050 --> 00:25:01,077 - I think your decision of saying that 416 00:25:01,077 --> 00:25:04,327 you don't want to be intubated, I just, 417 00:25:06,027 --> 00:25:07,940 I think that's a good decision for you but 418 00:25:07,940 --> 00:25:11,092 I don't think you understood what intubation was. 419 00:25:11,092 --> 00:25:15,122 All right, it's the act of putting that tube in, 420 00:25:15,122 --> 00:25:19,318 into your throat and attaching you to a machine. 421 00:25:19,318 --> 00:25:22,300 Now if anything should happen that, 422 00:25:22,300 --> 00:25:24,667 the only reason we would do that 423 00:25:24,667 --> 00:25:27,157 is if you got worse than you were, 424 00:25:27,157 --> 00:25:29,485 remember how bad you felt yesterday? 425 00:25:29,485 --> 00:25:32,017 If you got worse than you were yesterday, 426 00:25:32,017 --> 00:25:34,668 worse, if you can imagine feeling worse, 427 00:25:34,668 --> 00:25:38,305 we'd think about it very seriously and if we 428 00:25:38,305 --> 00:25:42,026 waited too long or things got even worse, 429 00:25:42,026 --> 00:25:43,776 your heart might stop 430 00:25:45,272 --> 00:25:47,906 because without the oxygen in your heart, 431 00:25:47,906 --> 00:25:49,851 your heart doesn't go. 432 00:25:49,851 --> 00:25:51,295 You know that, without oxygen 433 00:25:51,295 --> 00:25:53,042 in your heart, your heart doesn't go. 434 00:25:53,042 --> 00:25:56,122 If your heart doesn't go, your brain doesn't go 435 00:25:56,122 --> 00:25:58,327 and those are the kind of things that we 436 00:25:58,327 --> 00:26:01,398 have to think about, things to start your heart. 437 00:26:01,398 --> 00:26:04,231 But if we don't have that tube in, 438 00:26:05,296 --> 00:26:07,453 it's not gonna really help us much to have 439 00:26:07,453 --> 00:26:09,236 your heart going because your heart still 440 00:26:09,236 --> 00:26:11,073 isn't getting the oxygen that it needs. 441 00:26:11,073 --> 00:26:13,424 So that's why we talk about the heart, 442 00:26:13,424 --> 00:26:18,424 the shocks and the medicines and the tube at the same time. 443 00:26:18,429 --> 00:26:20,631 One hand washes the other. 444 00:26:20,631 --> 00:26:23,503 You can't have one without the other. 445 00:26:23,503 --> 00:26:26,295 - It's like the old saying, we need each other. 446 00:26:26,295 --> 00:26:27,128 - Right. 447 00:26:27,128 --> 00:26:29,795 - We need each other to survive. 448 00:26:30,952 --> 00:26:33,619 You need help, I have your help. 449 00:26:34,838 --> 00:26:37,005 I should help you. - Right. 450 00:26:38,838 --> 00:26:41,381 But what I wanna do is help you. 451 00:26:41,381 --> 00:26:43,650 I want to help you. 452 00:26:43,650 --> 00:26:46,463 But I only want to help you 453 00:26:46,463 --> 00:26:48,854 in the manner that you want to be helped. 454 00:26:48,854 --> 00:26:51,001 I don't want to do too much for you. 455 00:26:51,001 --> 00:26:52,570 - That's the problem. 456 00:26:52,570 --> 00:26:55,987 - I don't want to do more than you want me to do. 457 00:26:55,987 --> 00:26:59,633 I don't want to keep you alive unless you like living. 458 00:26:59,633 --> 00:27:02,019 - That's fine. - Okay? 459 00:27:02,019 --> 00:27:03,602 That's what I want. 460 00:27:07,046 --> 00:27:11,151 - This isn't your body, this isn't your body. 461 00:27:11,151 --> 00:27:12,717 - Right. 462 00:27:12,717 --> 00:27:14,634 - [Patient] Your favor. 463 00:27:16,621 --> 00:27:20,527 - We're asking you, we're telling you what we know. 464 00:27:20,527 --> 00:27:24,047 We're educating you about we know about your body 465 00:27:24,047 --> 00:27:27,186 and asking you to make a decision, 466 00:27:27,186 --> 00:27:28,769 taking how you feel 467 00:27:30,072 --> 00:27:32,491 and what we inform you about 468 00:27:32,491 --> 00:27:35,158 what's going on with your lungs. 469 00:27:36,156 --> 00:27:37,942 I would think it'd be wrong to tell you 470 00:27:37,942 --> 00:27:39,807 that we would put you on the ventilator 471 00:27:39,807 --> 00:27:41,823 and then be able to take you off 472 00:27:41,823 --> 00:27:43,789 because I don't think that's gonna happen. 473 00:27:43,789 --> 00:27:46,206 It may but it probably won't. 474 00:27:47,073 --> 00:27:50,342 The history of people like you 475 00:27:50,342 --> 00:27:52,238 tells us that it won't be easy 476 00:27:52,238 --> 00:27:55,905 if ever able to take you off the ventilator. 477 00:28:00,726 --> 00:28:02,734 - I have two grandchildren. 478 00:28:02,734 --> 00:28:05,020 Two of my eldest ones, 479 00:28:05,020 --> 00:28:08,270 they'll be in Chicago, they're doctors. 480 00:28:09,610 --> 00:28:13,527 Chick Dawes and Mark Dawes, John Stuart's boys. 481 00:28:18,445 --> 00:28:22,849 We just met his sister, the older sister, I saw her 482 00:28:22,849 --> 00:28:25,297 and they were there and they said 483 00:28:25,297 --> 00:28:28,269 we'd see if the physics get better. 484 00:28:28,269 --> 00:28:31,570 I says "I hope so." - That's right. 485 00:28:31,570 --> 00:28:33,843 That's why I think it's good. 486 00:28:33,843 --> 00:28:36,266 I mean you have to talk about this with your family. 487 00:28:36,266 --> 00:28:38,432 It's something you owe them and they owe you. 488 00:28:38,432 --> 00:28:42,021 To listen to you talk about how you feel and how you 489 00:28:42,021 --> 00:28:44,718 want the rest of your days to be. 490 00:28:44,718 --> 00:28:47,955 - I want to be with 'em. - All right. 491 00:28:47,955 --> 00:28:51,331 Do you want any more explanation about what happens? 492 00:28:51,331 --> 00:28:53,639 - No, no. - You know. 493 00:28:53,639 --> 00:28:55,503 - I'm not gonna bore them with that information. 494 00:28:55,503 --> 00:28:59,336 - If they want to speak to anybody, Dr. Jones, 495 00:29:00,652 --> 00:29:04,204 Dr. Taylor and myself, we're all here. 496 00:29:04,204 --> 00:29:06,341 So if you need any explanation or if they 497 00:29:06,341 --> 00:29:08,697 don't understand something, have them talk to us. 498 00:29:08,697 --> 00:29:10,103 - You work in the hospital? 499 00:29:10,103 --> 00:29:13,695 - Yeah I work here, I'll be here 'til seven. 500 00:29:13,695 --> 00:29:14,731 Okay? 501 00:29:14,731 --> 00:29:18,107 All right, it's a hard thing to swallow, you think about it. 502 00:29:18,107 --> 00:29:18,940 Okay? 503 00:29:19,840 --> 00:29:20,960 Okay. 504 00:29:20,960 --> 00:29:22,043 - Mr. Festal. 505 00:29:23,594 --> 00:29:25,003 - [Nurse] Sometimes spontaneously 506 00:29:25,003 --> 00:29:26,816 he will open and close his eyes. 507 00:29:26,816 --> 00:29:29,053 - But not in relation to-- - No response. 508 00:29:29,053 --> 00:29:30,456 - We're gonna take a look in your eyes. 509 00:29:30,456 --> 00:29:33,629 - That's not an uncommon thing, you see that. 510 00:29:33,629 --> 00:29:37,628 - [Nurse] And they roll back and forth sometimes. 511 00:29:37,628 --> 00:29:40,371 - [Doctor] He's responsive, small but responsive. 512 00:29:40,371 --> 00:29:42,038 - [Doctor] Yeah, it's sluggish but responsive 513 00:29:42,038 --> 00:29:43,437 but he doesn't have a corneal stimuli. 514 00:29:43,437 --> 00:29:46,440 - [Doctor] So he has brain stem. 515 00:29:46,440 --> 00:29:49,201 - [Scott] Which is why I say that-- 516 00:29:49,201 --> 00:29:54,013 - [Doctor] I'm gonna turn your head there, Mr. Festal. 517 00:29:54,013 --> 00:29:55,296 - [Doctor] See how they move back to midline? 518 00:29:55,296 --> 00:29:57,296 - Yeah. - When they turn. 519 00:29:58,742 --> 00:30:02,242 That's doll's eyes. - Positive doll's eyes. 520 00:30:04,297 --> 00:30:07,040 - Mrs. Paulette, good morning. 521 00:30:07,040 --> 00:30:10,207 Mrs. Paulette, how are you doing dear? 522 00:30:12,638 --> 00:30:14,388 - Spontaneous cleave. 523 00:30:18,122 --> 00:30:18,955 Posturing. 524 00:30:20,122 --> 00:30:22,955 (patient moaning) 525 00:30:27,380 --> 00:30:31,880 - Good morning, can you open your eyes and look at us? 526 00:30:34,106 --> 00:30:35,106 That better? 527 00:30:42,255 --> 00:30:45,168 She may not be long for this world. 528 00:30:45,168 --> 00:30:46,413 Mrs. Paulette, we're gonna take 529 00:30:46,413 --> 00:30:49,580 a listen to your heart and your lungs. 530 00:30:54,181 --> 00:30:55,945 - The sense I got from the family was that 531 00:30:55,945 --> 00:30:59,052 they appreciate the fact that he is not gonna survive. 532 00:30:59,052 --> 00:31:03,420 They want us to continue to support him aggressively but 533 00:31:03,420 --> 00:31:06,745 they want to make sure that he's comfortable. 534 00:31:06,745 --> 00:31:10,569 So I think you have to temper whatever you do with that. 535 00:31:10,569 --> 00:31:12,896 I think that a lot of what we're doing now is more giving 536 00:31:12,896 --> 00:31:16,454 them another day or two to cope with what's happening. 537 00:31:16,454 --> 00:31:19,322 - What they said when they left yesterday was 538 00:31:19,322 --> 00:31:22,603 "Please try to save him but don't let him suffer." 539 00:31:22,603 --> 00:31:26,290 And that's why I said reversibility is 540 00:31:26,290 --> 00:31:30,533 I think the only indication for any pressures. 541 00:31:30,533 --> 00:31:31,855 - It's just the fact that today we 542 00:31:31,855 --> 00:31:33,461 don't feel any of this is reversible 543 00:31:33,461 --> 00:31:36,084 but they're not quite ready to say it. 544 00:31:36,084 --> 00:31:38,344 - They also, just to pass on this information, 545 00:31:38,344 --> 00:31:41,821 do not want to be called if he deteriorates in any way. 546 00:31:41,821 --> 00:31:43,646 They can't handle that anymore. 547 00:31:43,646 --> 00:31:46,896 They only want to be called if he dies. 548 00:31:57,720 --> 00:32:00,163 - Spoke with him and he was alert and with her. 549 00:32:00,163 --> 00:32:02,156 - He's alert and with her now 550 00:32:02,156 --> 00:32:04,256 and I think he still wants to go ahead. 551 00:32:04,256 --> 00:32:09,065 It's just that I, I just have the feeling we're not-- 552 00:32:09,065 --> 00:32:11,679 - Doing him a favor. - Well, 553 00:32:11,679 --> 00:32:15,477 I mean we can keep doing this but I think that 554 00:32:15,477 --> 00:32:20,006 we'll probably be able to drag it on for a couple weeks. 555 00:32:20,006 --> 00:32:21,510 But that's all right, I think if that's 556 00:32:21,510 --> 00:32:23,427 what he wants, I don't have any problem with it. 557 00:32:23,427 --> 00:32:26,865 It's just that I want to be sure that that's 558 00:32:26,865 --> 00:32:29,260 what we want and I also want to be sure that 559 00:32:29,260 --> 00:32:31,633 we get the cardiologist here and make sure that 560 00:32:31,633 --> 00:32:33,941 we really are doing everything that we can do. 561 00:32:33,941 --> 00:32:38,185 - [Bill] They know him from recent admissions, 562 00:32:38,185 --> 00:32:39,838 so any one on the crew would be fine. 563 00:32:39,838 --> 00:32:42,239 - 10 of 'em appear to tell us we've done everything. 564 00:32:42,239 --> 00:32:43,859 All right, thanks Bill. 565 00:32:43,859 --> 00:32:44,776 - Med care. 566 00:32:45,716 --> 00:32:47,626 Yes, this is her. 567 00:32:47,626 --> 00:32:49,999 - How you doing? - Oh good. 568 00:32:49,999 --> 00:32:51,450 - Tory? - No, this is Susanne. 569 00:32:51,450 --> 00:32:53,117 Mary's coming along. 570 00:33:02,809 --> 00:33:05,603 - Time for this situation here. 571 00:33:05,603 --> 00:33:08,139 - We're killing him I think. 572 00:33:08,139 --> 00:33:09,923 We're kidding ourselves if we think 573 00:33:09,923 --> 00:33:11,420 that these meds are helping him. 574 00:33:11,420 --> 00:33:13,249 The guy would be just the same if he wasn't on 'em. 575 00:33:13,249 --> 00:33:15,234 - He'd be just the same. 576 00:33:15,234 --> 00:33:17,202 But he's not getting better? - He really would, no. 577 00:33:17,202 --> 00:33:18,926 - No matter what. - I'm not seeing he is. 578 00:33:18,926 --> 00:33:20,860 - Kinda be better to get him out of the hospital. 579 00:33:20,860 --> 00:33:22,399 - Exactly. - Get him out-- 580 00:33:22,399 --> 00:33:24,236 - We are not doing one, I bet if we put 581 00:33:24,236 --> 00:33:26,143 a swan in and checked all his numbers, 582 00:33:26,143 --> 00:33:28,919 they'd be exactly the same as when they were-- 583 00:33:28,919 --> 00:33:30,745 - A week ago. - Without anything. 584 00:33:30,745 --> 00:33:32,078 - Yeah, I agree. 585 00:33:33,214 --> 00:33:35,118 - It's really funny, I haven't been here 586 00:33:35,118 --> 00:33:37,783 since we put the swan in Friday night and it's 587 00:33:37,783 --> 00:33:42,063 unbelievable because you have such an objective, 588 00:33:42,063 --> 00:33:45,149 you come here and you say what has been done? 589 00:33:45,149 --> 00:33:48,566 And we've come full circle with this guy. 590 00:33:49,406 --> 00:33:52,785 Like I mean when we put the swan in, 591 00:33:52,785 --> 00:33:54,975 it was because he had a fever and it's like 592 00:33:54,975 --> 00:33:58,727 nobody ever mentioned anything about the fever. 593 00:33:58,727 --> 00:34:00,473 What happened to that? 594 00:34:00,473 --> 00:34:02,687 - The fever's gone, not an issue. 595 00:34:02,687 --> 00:34:04,346 - No sepsis. 596 00:34:04,346 --> 00:34:06,220 - The thing is he's one of these guys with 597 00:34:06,220 --> 00:34:08,768 end-stage cardiomyopathy, you can't do anything. 598 00:34:08,768 --> 00:34:12,333 You might as well get him out of the ICU. 599 00:34:12,333 --> 00:34:13,605 Take him off all these drips 600 00:34:13,605 --> 00:34:15,096 before something's gonna happen. 601 00:34:15,096 --> 00:34:17,641 - I think we're being really mean. 602 00:34:17,641 --> 00:34:19,922 - Did he keep going into failure at home? 603 00:34:19,922 --> 00:34:21,670 - He had only been home for two weeks. 604 00:34:21,670 --> 00:34:24,492 He had been at the grade two rehab for 605 00:34:24,492 --> 00:34:28,039 most of the summer after all his heart surgery 606 00:34:28,039 --> 00:34:32,264 and so he had a little bit of dietary indiscretion at home. 607 00:34:32,264 --> 00:34:35,304 He had a field day with Kentucky Fried Chicken and pasta. 608 00:34:35,304 --> 00:34:38,246 - Oh gee, poor guy. - I know. 609 00:34:38,246 --> 00:34:39,746 He's very brittle. 610 00:34:42,650 --> 00:34:44,811 I bet he wishes he'd never done that. 611 00:34:44,811 --> 00:34:46,893 - Had the chicken. - Yeah. 612 00:34:53,170 --> 00:34:54,907 - [Scott] Can we listen to your heart and your lungs? 613 00:34:54,907 --> 00:34:56,157 - Go on. - Good. 614 00:34:58,159 --> 00:35:00,217 - [Scott] Just under this, we're gonna listen 615 00:35:00,217 --> 00:35:03,278 to your heart first and then we'll sit you up. 616 00:35:03,278 --> 00:35:05,716 - [Mr. Gavin] Scratch my back a little bit. 617 00:35:05,716 --> 00:35:06,891 - [Scott] You want us to scratch 618 00:35:06,891 --> 00:35:08,172 your back, where do you itch? 619 00:35:08,172 --> 00:35:11,529 - [Mr. Gavin] Just up top there and in between. 620 00:35:11,529 --> 00:35:14,213 In between, over a little more, that's it, yeah. 621 00:35:14,213 --> 00:35:16,380 - Good. - That's wonderful. 622 00:35:17,407 --> 00:35:18,936 Get the doctor to scratch my 623 00:35:18,936 --> 00:35:22,331 back the first thing in the morning. 624 00:35:22,331 --> 00:35:23,748 - What can I say? 625 00:35:26,028 --> 00:35:29,528 Let's just take a listen here. - All right. 626 00:35:39,129 --> 00:35:42,629 - [Doctor] What's the long term goal here? 627 00:35:43,961 --> 00:35:47,622 - Well I mean the long term goal is he might get better, 628 00:35:47,622 --> 00:35:49,861 he might get worse, he might stay the same. 629 00:35:49,861 --> 00:35:52,695 He sounds like he's slowly getting worse. 630 00:35:52,695 --> 00:35:54,981 - That seems to be. - Yeah. 631 00:35:54,981 --> 00:35:56,872 - [Doctor] It's my opinion too, I just wondered 632 00:35:56,872 --> 00:35:59,783 how long he's gonna stay on all these drips and everything. 633 00:35:59,783 --> 00:36:02,143 Because it seems like he has end-stage heart disease. 634 00:36:02,143 --> 00:36:02,976 - Yeah. 635 00:36:04,005 --> 00:36:05,467 What I'd do is I'd stop most of it 636 00:36:05,467 --> 00:36:08,077 and give him morphine at this point. 637 00:36:08,077 --> 00:36:11,502 - [Nurse] I don't think he would be any different. 638 00:36:11,502 --> 00:36:14,580 - I hate to say it but I don't think he would either. 639 00:36:14,580 --> 00:36:18,791 I don't think we can do anything for him. 640 00:36:18,791 --> 00:36:20,849 But I think he's dying, I think he's dying 641 00:36:20,849 --> 00:36:24,195 and I mean I don't know how long it's gonna take but, 642 00:36:24,195 --> 00:36:26,730 it could take two days or it could take two weeks but 643 00:36:26,730 --> 00:36:29,322 we have nothing to offer him. - I think at this point 644 00:36:29,322 --> 00:36:31,134 the best thing we can do is be as aggressive 645 00:36:31,134 --> 00:36:32,911 as we can be about getting him outta here 646 00:36:32,911 --> 00:36:34,683 because let's face it, the man was home 647 00:36:34,683 --> 00:36:37,009 for two weeks in the last six months. 648 00:36:37,009 --> 00:36:38,634 - [Scott] We're not gonna get him outta here. 649 00:36:38,634 --> 00:36:40,086 - [Nurse] Let's get him so that 650 00:36:40,086 --> 00:36:42,170 he's not hooked up to all this stuff. 651 00:36:42,170 --> 00:36:44,250 - I think what I probably would've done 652 00:36:44,250 --> 00:36:46,038 in the middle of the night last night with 653 00:36:46,038 --> 00:36:48,035 the chest pain is I just would've pushed 654 00:36:48,035 --> 00:36:49,778 the morphine until the pain went away. 655 00:36:49,778 --> 00:36:51,774 His pressure would have bottomed out and that 656 00:36:51,774 --> 00:36:54,183 would've been it but look, we've done everything 657 00:36:54,183 --> 00:36:55,801 humanly possible that you can do here. 658 00:36:55,801 --> 00:36:57,633 We've given him every kind of-- 659 00:36:57,633 --> 00:36:59,038 - [Nurse] Every drug known. 660 00:36:59,038 --> 00:37:00,621 - And we know that, 661 00:37:02,298 --> 00:37:04,633 I mean we take a step backwards every day. 662 00:37:04,633 --> 00:37:09,368 The guy hasn't had diuresis over the past week. 663 00:37:09,368 --> 00:37:13,409 So I mean I think we oughta talk to Bill Taylor 664 00:37:13,409 --> 00:37:17,228 and maybe talk to Mr. Gavin about some of this stuff and 665 00:37:17,228 --> 00:37:20,621 I mean I just, I really don't think things are gonna change. 666 00:37:20,621 --> 00:37:23,677 I think if we give him the morphine, 667 00:37:23,677 --> 00:37:25,918 and it may be that he wants us to keep going. 668 00:37:25,918 --> 00:37:27,450 It may be that he wants to sorta keep up 669 00:37:27,450 --> 00:37:28,990 with this because he certainly did before. 670 00:37:28,990 --> 00:37:30,406 He had this near-death experience in 671 00:37:30,406 --> 00:37:32,934 the sick queue where he was in there for two months 672 00:37:32,934 --> 00:37:36,972 and he finally got home for a week and a half. 673 00:37:36,972 --> 00:37:39,657 He may want to keep going. 674 00:37:39,657 --> 00:37:41,920 - When I talked to him in the past, he does. 675 00:37:41,920 --> 00:37:43,652 So I mean I have a hard time 676 00:37:43,652 --> 00:37:45,147 just stopping everything right now. 677 00:37:45,147 --> 00:37:46,919 What I would do is talk to him and the next time 678 00:37:46,919 --> 00:37:49,821 he has that amount of chest pain, just stop everything. 679 00:37:49,821 --> 00:37:52,770 Assuming that the dobutamine and amerno is making it worse. 680 00:37:52,770 --> 00:37:54,587 - [Scott] Just give him morphine for the pain. 681 00:37:54,587 --> 00:37:56,473 - [Doctor] Once you've talked to him about it first. 682 00:37:56,473 --> 00:37:58,229 - [Scott] Oh no, we gotta talk to him. 683 00:37:58,229 --> 00:37:59,471 - But it's also, 684 00:37:59,471 --> 00:38:01,049 there's a medical decision to be made. 685 00:38:01,049 --> 00:38:03,535 Someone can't live forever on amerno and dopamine, 686 00:38:03,535 --> 00:38:05,733 dobutamine, et cetera so you can sort of, 687 00:38:05,733 --> 00:38:07,961 even if he still wants everything done, 688 00:38:07,961 --> 00:38:11,198 you can't live forever on those drugs. 689 00:38:11,198 --> 00:38:13,388 You can sort of start withdrawing one 690 00:38:13,388 --> 00:38:15,123 and then another and then another 691 00:38:15,123 --> 00:38:16,996 and see what difference if any it makes. 692 00:38:16,996 --> 00:38:18,859 It probably is not gonna make that much difference. 693 00:38:18,859 --> 00:38:22,524 - That's the irony of it all is that 694 00:38:22,524 --> 00:38:24,393 you know, he's at the point where 695 00:38:24,393 --> 00:38:27,317 the extra fluid that we give him from these medicines, 696 00:38:27,317 --> 00:38:29,792 it counteracts the effects of any of the medicines. 697 00:38:29,792 --> 00:38:31,740 So you could make a medical argument that 698 00:38:31,740 --> 00:38:34,990 he's better off on none of 'em and just 699 00:38:36,118 --> 00:38:38,035 get a daily Lasix dose. 700 00:38:39,401 --> 00:38:40,808 Well I think we gotta talk to him 701 00:38:40,808 --> 00:38:43,058 and we gotta talk to Billy. 702 00:38:44,173 --> 00:38:49,173 He is DNR, so I think that there's any urgent issues here. 703 00:38:49,690 --> 00:38:51,210 I think he knows, you know, 704 00:38:51,210 --> 00:38:52,909 I don't know if you got a look at him when we walked 705 00:38:52,909 --> 00:38:55,987 in the room this morning but he looked cadaverous. 706 00:38:55,987 --> 00:38:58,516 - Mr. Gavin, what happened last night? 707 00:38:58,516 --> 00:38:59,349 - Well, 708 00:39:00,757 --> 00:39:03,090 I was watching the ball game 709 00:39:04,066 --> 00:39:04,899 and 710 00:39:05,933 --> 00:39:06,766 my 711 00:39:08,302 --> 00:39:11,219 chest started to give me some pains 712 00:39:12,142 --> 00:39:12,975 and 713 00:39:14,835 --> 00:39:15,835 they came in 714 00:39:17,246 --> 00:39:18,079 and 715 00:39:19,535 --> 00:39:23,535 I don't know, they gave me all kinds of medicine 716 00:39:25,476 --> 00:39:29,143 and finally about two o'clock, they left me. 717 00:39:30,615 --> 00:39:32,115 The pain had left. 718 00:39:33,492 --> 00:39:36,579 Now I don't know whether it was angina pain 719 00:39:36,579 --> 00:39:39,079 or what kind of a pain it was. 720 00:39:40,467 --> 00:39:43,204 - [Bill] Can you tell me a little about what it felt like? 721 00:39:43,204 --> 00:39:44,981 - Well it felt, 722 00:39:44,981 --> 00:39:48,082 it seemed to be centralized more 723 00:39:48,082 --> 00:39:50,165 right here in the center. 724 00:39:56,033 --> 00:39:57,700 It was quite severe. 725 00:40:02,312 --> 00:40:06,479 Matter of fact, there was about four doctors here. 726 00:40:09,766 --> 00:40:12,766 - [Bill] What was that like for you? 727 00:40:13,759 --> 00:40:18,509 - It was like the pain when I first came in the hospital. 728 00:40:20,849 --> 00:40:22,961 - [Bill] You mean when you came in a few months ago? 729 00:40:22,961 --> 00:40:25,128 - No. - You mean this time? 730 00:40:26,022 --> 00:40:26,855 - Last 731 00:40:28,232 --> 00:40:29,649 Tuesday. - Uh-huh. 732 00:40:31,500 --> 00:40:33,000 - It was just like 733 00:40:34,419 --> 00:40:36,086 last Tuesday's pain. 734 00:40:40,188 --> 00:40:41,021 So, 735 00:40:42,933 --> 00:40:45,854 they left about two o'clock 736 00:40:45,854 --> 00:40:46,687 and 737 00:40:47,824 --> 00:40:48,657 I 738 00:40:49,653 --> 00:40:52,775 never moved the rest of the night. 739 00:40:52,775 --> 00:40:56,192 I laid perfectly still, the nurse made me 740 00:40:57,214 --> 00:41:00,464 stay still the rest of the night and... 741 00:41:05,835 --> 00:41:07,826 It went away then. 742 00:41:07,826 --> 00:41:09,482 - [Bill] Are you having any of it now? 743 00:41:09,482 --> 00:41:10,315 - No. 744 00:41:12,484 --> 00:41:14,734 I'm pretty good now. - Good. 745 00:41:16,146 --> 00:41:17,229 - There's no, 746 00:41:18,269 --> 00:41:19,852 no pain whatsoever. 747 00:41:22,304 --> 00:41:26,471 - Mr. Gavin, what's your sense of what's going on? 748 00:41:28,621 --> 00:41:30,454 - I really don't know. 749 00:41:32,636 --> 00:41:35,824 Nobody tells you too much. - Uh-huh. 750 00:41:35,824 --> 00:41:38,102 - You know what I mean? - I sure do 751 00:41:38,102 --> 00:41:40,295 and there's a lot of action around here all the time. 752 00:41:40,295 --> 00:41:41,212 - Yes, yes. 753 00:41:43,401 --> 00:41:46,267 - I suspect you have your own sense of it though. 754 00:41:46,267 --> 00:41:50,376 Would you be comfortable letting me hear a little of that? 755 00:41:50,376 --> 00:41:51,876 - I wouldn't mind. 756 00:41:52,908 --> 00:41:54,487 I would like to hear-- 757 00:41:54,487 --> 00:41:56,318 - You'd like to hear from me. 758 00:41:56,318 --> 00:41:58,818 - From you or somebody. - Yeah. 759 00:42:00,604 --> 00:42:02,650 Do you have a sense of it yourself in terms 760 00:42:02,650 --> 00:42:06,198 of what your understanding is of what's happening? 761 00:42:06,198 --> 00:42:07,031 - Well, 762 00:42:09,956 --> 00:42:12,373 from what the doctors tell me 763 00:42:14,148 --> 00:42:15,231 now and then, 764 00:42:16,519 --> 00:42:18,352 I'm on the borderline. 765 00:42:20,463 --> 00:42:23,546 I could pass away or I could survive. 766 00:42:27,070 --> 00:42:30,987 They never told me directly one way or another. 767 00:42:32,139 --> 00:42:35,583 - Well part of that I think is 'cause we don't know. 768 00:42:35,583 --> 00:42:38,489 - Well it could be, that's right. 769 00:42:38,489 --> 00:42:40,383 - We have all these sophisticated 770 00:42:40,383 --> 00:42:42,956 machines and equipment and everything 771 00:42:42,956 --> 00:42:45,433 and we can make our educated guesses but 772 00:42:45,433 --> 00:42:48,100 ultimately we don't know. - Yeah. 773 00:42:49,071 --> 00:42:51,852 - One thing we do know over the last few months 774 00:42:51,852 --> 00:42:53,969 with what you've been through with the heart 775 00:42:53,969 --> 00:42:56,468 attacks that you've had and the damage 776 00:42:56,468 --> 00:42:59,085 that your heart has suffered with the surgery 777 00:42:59,085 --> 00:43:02,731 that you had and the complications after that, 778 00:43:02,731 --> 00:43:05,627 that the result of all that is to put you on this, 779 00:43:05,627 --> 00:43:08,087 what you described as the borderline 780 00:43:08,087 --> 00:43:10,830 and with episodes like the one that brought you into 781 00:43:10,830 --> 00:43:15,208 the hospital and ones like the one that happened last night, 782 00:43:15,208 --> 00:43:20,208 it makes us concerned about the possibilities for recovery 783 00:43:20,469 --> 00:43:25,249 and we're not sure, as you said, how it's gonna go. 784 00:43:25,249 --> 00:43:26,573 - Yeah. 785 00:43:26,573 --> 00:43:28,317 - You've given us some directions 786 00:43:28,317 --> 00:43:30,653 about how you want things handled. 787 00:43:30,653 --> 00:43:33,929 Initially when we spoke in the emergency room, 788 00:43:33,929 --> 00:43:36,940 you told me as you had before that you wanted 789 00:43:36,940 --> 00:43:39,599 everything done that possibly could be 790 00:43:39,599 --> 00:43:42,162 and then when we spoke a few days later, 791 00:43:42,162 --> 00:43:44,490 you reconsidered that and spoke with 792 00:43:44,490 --> 00:43:47,407 your wife and your family and so on 793 00:43:48,569 --> 00:43:50,533 and you gave me a different set of directions, 794 00:43:50,533 --> 00:43:53,426 that you didn't want us to do certain things. 795 00:43:53,426 --> 00:43:55,635 You didn't want the tube put back in your throat. 796 00:43:55,635 --> 00:43:58,123 You didn't want to be put back on those 797 00:43:58,123 --> 00:44:00,818 life-supporting machines that you had been on in the past. 798 00:44:00,818 --> 00:44:02,901 - That's right, yes, yes. 799 00:44:03,995 --> 00:44:08,995 I've already signed an agreement with a lawyer on that. 800 00:44:09,091 --> 00:44:11,741 - [Bill] I heard, the so-called living will. 801 00:44:11,741 --> 00:44:13,276 - Yes. - Yeah. 802 00:44:13,276 --> 00:44:16,932 Well you told me about that and your wife did too. 803 00:44:16,932 --> 00:44:20,299 - I think my wife is on the same things as me. 804 00:44:20,299 --> 00:44:23,578 We both went to this lawyer and 805 00:44:23,578 --> 00:44:27,550 that was one of the questions he asked us 806 00:44:27,550 --> 00:44:28,383 about 807 00:44:30,321 --> 00:44:32,141 what do you call it, living? 808 00:44:32,141 --> 00:44:33,782 - [Bill] I've heard it called a living will. 809 00:44:33,782 --> 00:44:35,184 - Living will, yeah. 810 00:44:35,184 --> 00:44:37,090 - That's important but people 811 00:44:37,090 --> 00:44:38,832 are entitled to change their mind. 812 00:44:38,832 --> 00:44:40,900 So the most important thing to hear 813 00:44:40,900 --> 00:44:42,683 is the instructions that you give now. 814 00:44:42,683 --> 00:44:43,988 - [Mr. Gavin] Yes. 815 00:44:43,988 --> 00:44:48,437 He told me at that time that I could change my mind. 816 00:44:48,437 --> 00:44:49,270 - Right. 817 00:44:50,224 --> 00:44:52,180 - So it is possible. - Yeah. 818 00:44:52,180 --> 00:44:54,043 Well you know there are very few people 819 00:44:54,043 --> 00:44:56,804 who could make as informed a judgment as 820 00:44:56,804 --> 00:44:59,899 you can with everything that you've been through. 821 00:44:59,899 --> 00:45:03,208 You know firsthand all the things that happened. 822 00:45:03,208 --> 00:45:05,103 - [Mr. Gavin] That's right. 823 00:45:05,103 --> 00:45:06,583 - So there isn't much question that 824 00:45:06,583 --> 00:45:08,658 when you make a judgment about what to do, 825 00:45:08,658 --> 00:45:12,991 that it's an informed one because you've been there. 826 00:45:16,983 --> 00:45:19,292 It seems, Mr. Gavin, that we're reaching another 827 00:45:19,292 --> 00:45:22,169 point of decision now, particularly with what 828 00:45:22,169 --> 00:45:24,490 you went through last night and with what you're 829 00:45:24,490 --> 00:45:27,476 going through with all these different medications 830 00:45:27,476 --> 00:45:29,896 because it looks like the medications 831 00:45:29,896 --> 00:45:32,694 don't seem to be contributing a great deal 832 00:45:32,694 --> 00:45:35,720 to be helping your heart to function more efficiently. 833 00:45:35,720 --> 00:45:37,033 - [Mr. Gavin] Yeah. 834 00:45:37,033 --> 00:45:39,216 - It's also clear that you can't stay on 835 00:45:39,216 --> 00:45:41,611 medications like this and in this Intensive 836 00:45:41,611 --> 00:45:45,923 Care Unit for an indefinite period of time. 837 00:45:45,923 --> 00:45:48,535 The clear hope and the plan would be that 838 00:45:48,535 --> 00:45:51,441 if we could withdraw some of these, we could see 839 00:45:51,441 --> 00:45:53,771 if you're capable of moving from the Intensive 840 00:45:53,771 --> 00:45:56,039 Care Unit and doing okay in a regular part 841 00:45:56,039 --> 00:45:59,554 of the hospital with a hope toward moving 842 00:45:59,554 --> 00:46:01,837 toward a discharge-- 843 00:46:01,837 --> 00:46:05,716 - [Mr. Gavin] Experiment a little bit with the medicine. 844 00:46:05,716 --> 00:46:07,958 - We shy away from the word experiment because 845 00:46:07,958 --> 00:46:11,444 it sounds like we're treating you like a guinea pig. 846 00:46:11,444 --> 00:46:14,027 But I think that we need to see 847 00:46:15,162 --> 00:46:17,901 how you could do without having some of these 848 00:46:17,901 --> 00:46:21,793 powerful medications running into you all the time 849 00:46:21,793 --> 00:46:23,618 and one of the things to consider is 850 00:46:23,618 --> 00:46:25,882 whether the goal is to give you all 851 00:46:25,882 --> 00:46:28,047 the medications and see what that can do 852 00:46:28,047 --> 00:46:30,577 for the heart or to look at the whole picture 853 00:46:30,577 --> 00:46:33,935 and try to think toward what happens. 854 00:46:33,935 --> 00:46:35,974 Can you leave this part of the hospital, 855 00:46:35,974 --> 00:46:37,707 the Intensive Care Unit? 856 00:46:37,707 --> 00:46:39,491 Can we safely move you to another part 857 00:46:39,491 --> 00:46:41,767 of the hospital in the next few days 858 00:46:41,767 --> 00:46:43,829 and can we think about eventually having 859 00:46:43,829 --> 00:46:46,668 you leave the hospital if things go well? 860 00:46:46,668 --> 00:46:49,813 What are the goals for your treatment? 861 00:46:49,813 --> 00:46:51,713 And we have to face the possibility that 862 00:46:51,713 --> 00:46:54,275 you brought up about being on the borderline. 863 00:46:54,275 --> 00:46:56,381 We would hope that things would go well 864 00:46:56,381 --> 00:46:58,041 and that you could be able to leave this 865 00:46:58,041 --> 00:46:59,919 part of the hospital and hopefully that you 866 00:46:59,919 --> 00:47:02,387 could eventually go home, as you were for 867 00:47:02,387 --> 00:47:05,245 a few days before you came back in this time. 868 00:47:05,245 --> 00:47:07,368 But we don't know. 869 00:47:07,368 --> 00:47:09,149 And in the midst of dealing with all that, 870 00:47:09,149 --> 00:47:11,488 we have to have some idea of what 871 00:47:11,488 --> 00:47:14,060 the ultimate goal is for what we're doing 872 00:47:14,060 --> 00:47:16,522 and what I heard from you and your wife 873 00:47:16,522 --> 00:47:19,673 when we spoke the other day was that your goal 874 00:47:19,673 --> 00:47:23,978 was not to necessarily have every available 875 00:47:23,978 --> 00:47:27,579 test, medication and machine but that we needed to 876 00:47:27,579 --> 00:47:30,109 maybe get a little more reasonable about that. 877 00:47:30,109 --> 00:47:33,629 Devote our attention to something maybe more realistic. 878 00:47:33,629 --> 00:47:36,387 One thing that is realistic is your comfort. 879 00:47:36,387 --> 00:47:39,417 We can always keep you comfortable 880 00:47:39,417 --> 00:47:42,188 and we're never gonna forget about that. 881 00:47:42,188 --> 00:47:44,932 Last night in the midst of your pain, 882 00:47:44,932 --> 00:47:47,527 they were walking a tightrope with balancing 883 00:47:47,527 --> 00:47:50,843 the different medications and trying to get rid of the pain. 884 00:47:50,843 --> 00:47:53,721 We do have medications to get rid of pain though 885 00:47:53,721 --> 00:47:55,501 and one of the ways that we could decide 886 00:47:55,501 --> 00:47:57,973 to go depending on how it sounds to you 887 00:47:57,973 --> 00:48:01,460 is to make your comfort our number one priority 888 00:48:01,460 --> 00:48:03,522 and to do things for your comfort, 889 00:48:03,522 --> 00:48:06,133 even if it may mean withholding some of 890 00:48:06,133 --> 00:48:08,449 the medications that we're currently giving you 891 00:48:08,449 --> 00:48:11,787 with all these intravenous drips and so on 892 00:48:11,787 --> 00:48:15,250 that can only be given here in the Intensive Care Unit. 893 00:48:15,250 --> 00:48:18,022 How you feel about that is really key. 894 00:48:18,022 --> 00:48:21,093 - It's kind of expensive too, isn't it? 895 00:48:21,093 --> 00:48:23,534 - Yeah but fortunately we're in a situation where 896 00:48:23,534 --> 00:48:25,930 that's not really something that we have to deal with. 897 00:48:25,930 --> 00:48:27,253 - Yeah. 898 00:48:27,253 --> 00:48:29,665 Is that right, you don't have to deal with that? 899 00:48:29,665 --> 00:48:30,999 - No. 900 00:48:30,999 --> 00:48:34,523 That doesn't enter into the decision-making at all. 901 00:48:34,523 --> 00:48:35,356 - Yeah. 902 00:48:37,723 --> 00:48:40,212 - Is that something that's of concern to you? 903 00:48:40,212 --> 00:48:43,576 - Well naturally it would be, sure. 904 00:48:43,576 --> 00:48:44,905 - Your situation with your-- 905 00:48:44,905 --> 00:48:48,306 - This thing ain't gonna go on forever you know what I mean? 906 00:48:48,306 --> 00:48:50,166 - What do you mean by that, Mr. Gavin? 907 00:48:50,166 --> 00:48:54,083 - I don't mean forever, I mean you know for any 908 00:48:55,270 --> 00:48:59,194 real length of time and I'm fortunate enough 909 00:48:59,194 --> 00:49:03,651 as it is now to have the Blue Cross and Blue Shield 910 00:49:03,651 --> 00:49:08,532 taking care of these bills, otherwise I'd be cleaned out. 911 00:49:08,532 --> 00:49:10,312 - Yeah, anybody would be cleaned out 912 00:49:10,312 --> 00:49:13,145 with the bill that gets generated. 913 00:49:14,847 --> 00:49:16,747 But I think fortunately that's something 914 00:49:16,747 --> 00:49:18,612 that we don't have to take into account 915 00:49:18,612 --> 00:49:21,529 right here in making this decision. 916 00:49:23,002 --> 00:49:25,002 - Well that's good then. 917 00:49:26,240 --> 00:49:27,650 - Could you share with me what 918 00:49:27,650 --> 00:49:28,946 thoughts you're having about all this? 919 00:49:28,946 --> 00:49:29,779 - Hmm? 920 00:49:29,779 --> 00:49:31,469 - I said could you share with me what thoughts 921 00:49:31,469 --> 00:49:33,382 you're having about all this as we talk? 922 00:49:33,382 --> 00:49:36,549 - There's different cases in the paper 923 00:49:38,123 --> 00:49:38,956 locally 924 00:49:40,564 --> 00:49:41,397 and 925 00:49:43,206 --> 00:49:46,373 the people are nothing but vegetables, 926 00:49:47,798 --> 00:49:49,849 if you follow what I mean, you know? 927 00:49:49,849 --> 00:49:51,580 They're just 928 00:49:51,580 --> 00:49:52,413 kept 929 00:49:53,438 --> 00:49:55,605 alive through machines and 930 00:49:57,265 --> 00:49:58,098 so forth. 931 00:49:59,821 --> 00:50:02,930 I wouldn't want to be like that. 932 00:50:02,930 --> 00:50:05,903 In other words, I wouldn't want to 933 00:50:05,903 --> 00:50:09,320 not recognize you or my wife or my family 934 00:50:12,287 --> 00:50:13,120 and 935 00:50:14,813 --> 00:50:16,470 that's about, 936 00:50:16,470 --> 00:50:19,270 that's what I consider a vegetable. 937 00:50:19,270 --> 00:50:21,216 - Well the decision that you and your wife 938 00:50:21,216 --> 00:50:23,712 gave me a few days ago, that you didn't want 939 00:50:23,712 --> 00:50:26,406 the machines and tubes and so on is a way 940 00:50:26,406 --> 00:50:28,836 that we can promise you that we can 941 00:50:28,836 --> 00:50:31,866 do everything we can to avoid that. 942 00:50:31,866 --> 00:50:34,778 But that situation usually happens when we use 943 00:50:34,778 --> 00:50:38,309 all those machines for artificial life support. 944 00:50:38,309 --> 00:50:40,976 - Some people, what was it that, 945 00:50:43,064 --> 00:50:45,231 that woman that was on the 946 00:50:49,439 --> 00:50:51,772 diabetes there, her husband. 947 00:50:53,711 --> 00:50:56,278 The case just a couple of years ago. 948 00:50:56,278 --> 00:50:58,564 - [Bill] I know who you mean. 949 00:50:58,564 --> 00:51:00,504 - I forgot what their name-- - Von Bulow. 950 00:51:00,504 --> 00:51:01,669 - What? - Von Bulow. 951 00:51:01,669 --> 00:51:03,451 - Bulow, yeah. 952 00:51:03,451 --> 00:51:06,272 You wouldn't want to be like that, you know? 953 00:51:06,272 --> 00:51:07,391 - [Bill] Yeah. 954 00:51:07,391 --> 00:51:10,224 - And that's what I'm considering. 955 00:51:13,285 --> 00:51:16,938 Because you always pick the worst case first. 956 00:51:16,938 --> 00:51:18,800 - [Bill] Yeah, I understand. 957 00:51:18,800 --> 00:51:22,420 And fortunately those worst cases are pretty unusual. 958 00:51:22,420 --> 00:51:23,284 - Yeah. 959 00:51:23,284 --> 00:51:24,766 - But it's not that unusual in 960 00:51:24,766 --> 00:51:26,620 a hospital like this to have some cases 961 00:51:26,620 --> 00:51:28,562 that may not be that extreme but that are 962 00:51:28,562 --> 00:51:30,998 also very difficult and situations that 963 00:51:30,998 --> 00:51:33,230 I think some people wish they hadn't 964 00:51:33,230 --> 00:51:35,261 gotten into by the time they were in it. 965 00:51:35,261 --> 00:51:37,649 Not only the people but their families and so on. 966 00:51:37,649 --> 00:51:38,514 - Yeah. 967 00:51:38,514 --> 00:51:41,298 - So that I think although it may be difficult, 968 00:51:41,298 --> 00:51:43,761 having this kind of conversation ahead of time 969 00:51:43,761 --> 00:51:46,080 when you're capable of having it will help 970 00:51:46,080 --> 00:51:49,264 do everything you can to prevent that kind of situation. 971 00:51:49,264 --> 00:51:52,988 - Well in a case like that, Doctor, 972 00:51:52,988 --> 00:51:56,321 it would depend upon the case, you know? 973 00:51:59,482 --> 00:52:00,982 Maybe we were too, 974 00:52:02,252 --> 00:52:03,085 too... 975 00:52:08,125 --> 00:52:11,958 Too quick in making a decision on that, 976 00:52:11,958 --> 00:52:15,079 on something like that, you know? 977 00:52:15,079 --> 00:52:17,780 Because we made it down in Florida. 978 00:52:17,780 --> 00:52:20,732 We drew the will up down in Florida. 979 00:52:20,732 --> 00:52:23,220 - Well one of the things that I mentioned to you 980 00:52:23,220 --> 00:52:25,326 a couple days ago when you gave me your decision 981 00:52:25,326 --> 00:52:28,010 then is that these things can always be changed. 982 00:52:28,010 --> 00:52:29,327 - Oh, I know that. 983 00:52:29,327 --> 00:52:30,691 - So you think about it as you 984 00:52:30,691 --> 00:52:32,798 talk to your wife and your kids. 985 00:52:32,798 --> 00:52:34,415 What you said a couple days ago 986 00:52:34,415 --> 00:52:36,841 doesn't have to be what you say today 987 00:52:36,841 --> 00:52:38,736 and whatever instructions you give to me 988 00:52:38,736 --> 00:52:41,860 and the rest of us here are the ones we'll follow. 989 00:52:41,860 --> 00:52:42,693 - Yeah. 990 00:52:46,696 --> 00:52:50,415 In other words, do I have to give you a decision today? 991 00:52:50,415 --> 00:52:52,646 - Not necessarily but I think that we need 992 00:52:52,646 --> 00:52:55,138 to continue this conversation because the current 993 00:52:55,138 --> 00:52:58,307 situation with all these powerful medications 994 00:52:58,307 --> 00:53:01,169 that can only be given here in the Intensive Care Unit 995 00:53:01,169 --> 00:53:04,121 is not something that can go on and on and on. 996 00:53:04,121 --> 00:53:06,836 I think one of the decisions that we're facing 997 00:53:06,836 --> 00:53:10,904 is do we see how you would do on fewer of these medications? 998 00:53:10,904 --> 00:53:11,737 - Sure. 999 00:53:11,737 --> 00:53:13,897 - And to do that might mean really making 1000 00:53:13,897 --> 00:53:17,621 a new goal for your treatment and the goal might be 1001 00:53:17,621 --> 00:53:19,401 that we're gonna try to have you on as few 1002 00:53:19,401 --> 00:53:22,061 medications as possible so that we can think 1003 00:53:22,061 --> 00:53:25,049 toward getting you out of the Intensive Care Unit 1004 00:53:25,049 --> 00:53:29,226 and we're gonna maximize your comfort above all else 1005 00:53:29,226 --> 00:53:32,006 and if we do that, we have to understand that we're 1006 00:53:32,006 --> 00:53:34,743 taking a risk because it's possible that some of 1007 00:53:34,743 --> 00:53:37,383 these medications may be doing something to improve 1008 00:53:37,383 --> 00:53:40,113 the functioning of your heart and that without them, 1009 00:53:40,113 --> 00:53:41,851 it may be more dangerous. 1010 00:53:41,851 --> 00:53:44,290 You talked about being in that borderline situation 1011 00:53:44,290 --> 00:53:47,194 where we weren't sure whether you were gonna survive or not. 1012 00:53:47,194 --> 00:53:49,091 It's possible that withdrawing some of 1013 00:53:49,091 --> 00:53:53,552 the medications could jeopardize your survival. 1014 00:53:53,552 --> 00:53:55,449 It's not something, 1015 00:53:55,449 --> 00:53:58,699 it's not a step to think about lightly. 1016 00:54:06,579 --> 00:54:09,185 - I really don't know what to 1017 00:54:09,185 --> 00:54:11,736 tell you right here, not here and now. 1018 00:54:11,736 --> 00:54:14,998 - In the past when we've talked about things like this, 1019 00:54:14,998 --> 00:54:17,176 you've wanted to talk it over with 1020 00:54:17,176 --> 00:54:19,072 your wife and have us talk together. 1021 00:54:19,072 --> 00:54:22,972 - Oh yeah because it's a big decision to make. 1022 00:54:22,972 --> 00:54:25,462 - She's gonna be in a little bit later. 1023 00:54:25,462 --> 00:54:27,082 Would you prefer to have me come back 1024 00:54:27,082 --> 00:54:28,759 and we can talk when she's here? 1025 00:54:28,759 --> 00:54:29,636 - Beautiful. 1026 00:54:29,636 --> 00:54:31,249 - All righty, let's do that. 1027 00:54:31,249 --> 00:54:33,947 - Because maybe what she can't think of, I can. 1028 00:54:33,947 --> 00:54:34,780 - Yeah. 1029 00:54:34,780 --> 00:54:37,215 - Or I can't think of, she can. 1030 00:54:37,215 --> 00:54:39,286 Which is mostly that. 1031 00:54:39,286 --> 00:54:42,569 - I think it works both ways, Mr. Gavin. 1032 00:54:42,569 --> 00:54:44,799 All right, well I asked her to give me a call when she 1033 00:54:44,799 --> 00:54:47,908 comes in, so I'll come back and we'll all talk together. 1034 00:54:47,908 --> 00:54:49,388 - Okay. - All righty. 1035 00:54:49,388 --> 00:54:51,126 It's good to see you. - Fair enough. 1036 00:54:51,126 --> 00:54:53,248 - [Bill] I'll be back later to see you. 1037 00:54:53,248 --> 00:54:55,523 - [Mr. Gavin] Okay. 1038 00:54:55,523 --> 00:54:57,261 - The issue is how intensively should 1039 00:54:57,261 --> 00:54:59,967 he be involved in the decision-making 1040 00:54:59,967 --> 00:55:02,468 and if something's a medical issue like he's not 1041 00:55:02,468 --> 00:55:06,550 responding well to anatropic meds that he's on, 1042 00:55:06,550 --> 00:55:10,109 isn't it a medical judgment that they're not working well? 1043 00:55:10,109 --> 00:55:12,364 - And should it be presented to him that way? 1044 00:55:12,364 --> 00:55:13,853 This is what's happened, you've been 1045 00:55:13,853 --> 00:55:15,553 on these meds for such-and-such number 1046 00:55:15,553 --> 00:55:18,345 of days and they're not working and I think 1047 00:55:18,345 --> 00:55:21,359 we need to talk about, I mean I don't 1048 00:55:21,359 --> 00:55:23,333 need to tell you how to present it to him. 1049 00:55:23,333 --> 00:55:25,750 But there's a fine line about 1050 00:55:27,945 --> 00:55:31,794 where his responsibility ends. - Yeah, absolutely. 1051 00:55:31,794 --> 00:55:34,535 - And our responsibility becomes more. 1052 00:55:34,535 --> 00:55:38,647 - And even in this case, it's gonna be more us. 1053 00:55:38,647 --> 00:55:40,127 - It certainly is. - Yeah. 1054 00:55:40,127 --> 00:55:43,352 - The angina is gonna worsen his heart function 1055 00:55:43,352 --> 00:55:45,925 and cause him pain, worsen his heart function 1056 00:55:45,925 --> 00:55:48,439 and make him have more pulmonary edema. 1057 00:55:48,439 --> 00:55:50,175 - I think just by virtue of the fact of 1058 00:55:50,175 --> 00:55:52,085 the amount of IV fluid that he's getting 1059 00:55:52,085 --> 00:55:55,253 with all these different drugs is making him worse. 1060 00:55:55,253 --> 00:55:58,633 I mean if he weren't getting all of this IV fluid, 1061 00:55:58,633 --> 00:56:00,528 I think that we would be able to stay on top 1062 00:56:00,528 --> 00:56:02,860 of his diuresis a little bit better than we are. 1063 00:56:02,860 --> 00:56:04,478 - I don't think there's any question. 1064 00:56:04,478 --> 00:56:06,436 He doesn't have to participate in the medical 1065 00:56:06,436 --> 00:56:08,817 judgment about how we're gonna minimize 1066 00:56:08,817 --> 00:56:11,675 his angina and maximize his cardiac output. 1067 00:56:11,675 --> 00:56:13,587 But it is a fundamental reorganization 1068 00:56:13,587 --> 00:56:16,846 or reorientation of what we're doing if we say that 1069 00:56:16,846 --> 00:56:19,135 comfort above all else is the criteria by which 1070 00:56:19,135 --> 00:56:22,324 we judge everything and I think it would be 1071 00:56:22,324 --> 00:56:25,779 fair to have him and his wife involved in that. 1072 00:56:25,779 --> 00:56:27,473 But he would've been treated differently 1073 00:56:27,473 --> 00:56:30,289 last night if that had been the goal. 1074 00:56:30,289 --> 00:56:33,013 He could conceivably be treated differently today 1075 00:56:33,013 --> 00:56:36,680 if that's the change that were made I think. 1076 00:56:38,206 --> 00:56:41,934 - [Doctor] So where is he at this point? 1077 00:56:41,934 --> 00:56:44,453 - He wants to mull over what we just talked about 1078 00:56:44,453 --> 00:56:46,727 which is this sorta stuff and he wants to wait 'til his 1079 00:56:46,727 --> 00:56:49,462 wife comes in and we'll talk some more a little later. 1080 00:56:49,462 --> 00:56:51,501 I actually spoke to her a few minutes ago 1081 00:56:51,501 --> 00:56:54,870 and she said she's coming in soon. 1082 00:56:54,870 --> 00:56:56,620 We'll pursue it then. 1083 00:56:57,483 --> 00:57:00,300 - So as it stand now, we'll just continue everything? 1084 00:57:00,300 --> 00:57:01,165 Okay. 1085 00:57:01,165 --> 00:57:03,107 - Well, not necessarily. 1086 00:57:03,107 --> 00:57:04,916 - [Doctor] Start taking off some off the inotropes? 1087 00:57:04,916 --> 00:57:06,418 - Yeah, I think that you know-- 1088 00:57:06,418 --> 00:57:07,822 - You think that's reasonable to do? 1089 00:57:07,822 --> 00:57:09,684 - If it's clear to everybody that they're not 1090 00:57:09,684 --> 00:57:11,481 doing any good, that they're potential harmful, 1091 00:57:11,481 --> 00:57:13,300 then we oughta move, I don't think, 1092 00:57:13,300 --> 00:57:15,539 as you said, he doesn't need to make that medical call. 1093 00:57:15,539 --> 00:57:17,898 But in the meantime we'll treat him, 1094 00:57:17,898 --> 00:57:20,392 focused on his cardiac output and his ischemia. 1095 00:57:20,392 --> 00:57:22,208 - [Female Doctor] Until maybe he comes to terms 1096 00:57:22,208 --> 00:57:24,082 with the fact that comfort is the way to go, 1097 00:57:24,082 --> 00:57:26,240 I guess we could put him to back where he was. 1098 00:57:26,240 --> 00:57:27,893 - [Doctor] Yeah, I think so. 1099 00:57:27,893 --> 00:57:30,430 - I wouldn't go above this. - No, absolutely. 1100 00:57:30,430 --> 00:57:32,336 And he's said that, he doesn't want to be intubated, 1101 00:57:32,336 --> 00:57:33,902 he doesn't want to be back on a respirator. 1102 00:57:33,902 --> 00:57:36,309 He doesn't want to be reconsidered for surgery. 1103 00:57:36,309 --> 00:57:40,124 So all that helps in terms of the degree of 1104 00:57:40,124 --> 00:57:44,706 invasiveness that we're gonna subject him to. 1105 00:57:44,706 --> 00:57:46,813 - Okay. - All righty. 1106 00:57:46,813 --> 00:57:48,146 To be continued. 1107 00:57:59,610 --> 00:58:01,652 - Dr. Morgan, answer page on line five. 1108 00:58:01,652 --> 00:58:03,652 Dr. Morgan on line five. 1109 00:58:09,592 --> 00:58:12,009 (chattering) 1110 00:58:15,104 --> 00:58:17,437 - [Nurse] X-ray, room seven. 1111 00:58:25,949 --> 00:58:27,764 - [Nurse] Gonna give you a little more John, okay? 1112 00:58:27,764 --> 00:58:28,764 - All right. 1113 00:58:30,040 --> 00:58:32,270 - Give you some, we'll wait a few minutes 1114 00:58:32,270 --> 00:58:35,447 and then I'll give you some more 1115 00:58:35,447 --> 00:58:38,183 until you're feeling a little better, okay? 1116 00:58:38,183 --> 00:58:39,266 A lot better. 1117 00:59:19,413 --> 00:59:22,064 - Mr. Gavin, it's gonna be a few minutes for that medication 1118 00:59:22,064 --> 00:59:25,628 to take effect and for you to feel some of the pain relief. 1119 00:59:25,628 --> 00:59:27,163 I'm gonna step out and talk to your wife 1120 00:59:27,163 --> 00:59:28,858 for a couple of minutes and then come back in. 1121 00:59:28,858 --> 00:59:29,691 - All right. 1122 00:59:29,691 --> 00:59:31,381 - Hopefully you'll be feeling better soon. 1123 00:59:31,381 --> 00:59:32,214 - Okay. 1124 00:59:38,242 --> 00:59:42,663 - None of this is good news with all that's going on. 1125 00:59:42,663 --> 00:59:45,366 Last night was more bad news with 1126 00:59:45,366 --> 00:59:48,449 the long episode of pain he had then. 1127 00:59:50,131 --> 00:59:52,727 It looks like all the medication that he's 1128 00:59:52,727 --> 00:59:57,227 getting is really doing very little to improve things. 1129 00:59:58,439 --> 01:00:00,093 - He's got that shot of morphine, 1130 01:00:00,093 --> 01:00:01,539 you don't wanna fall asleep. 1131 01:00:01,539 --> 01:00:04,086 - Yeah. - He seems to be fighting. 1132 01:00:04,086 --> 01:00:05,753 - Well also I think, 1133 01:00:06,789 --> 01:00:09,518 what's your sense of things? 1134 01:00:09,518 --> 01:00:11,101 - Oh, I don't know. 1135 01:00:12,284 --> 01:00:16,223 I've been just hoping that something would break and 1136 01:00:16,223 --> 01:00:20,791 everything would be fine, it don't seem to be today. 1137 01:00:20,791 --> 01:00:22,067 - [Bill] No, it doesn't seem to be. 1138 01:00:22,067 --> 01:00:25,090 - Yesterday I thought I had a little hope. 1139 01:00:25,090 --> 01:00:29,473 But today again, it don't seem to be any better. 1140 01:00:29,473 --> 01:00:32,163 - I share some of that, it is discouraging. 1141 01:00:32,163 --> 01:00:33,665 There's always reason to hope. 1142 01:00:33,665 --> 01:00:36,647 We never can predict the future for sure but 1143 01:00:36,647 --> 01:00:41,397 it's looking worse and worse as more of this is going on. 1144 01:00:42,255 --> 01:00:44,456 I'm coming to the opinion and I think the doctors 1145 01:00:44,456 --> 01:00:47,461 here are sharing it with me that a lot of the medications 1146 01:00:47,461 --> 01:00:50,515 we're giving him are really not accomplishing much 1147 01:00:50,515 --> 01:00:54,559 in terms of improving the functioning of his heart 1148 01:00:54,559 --> 01:00:57,458 and I think that if he is gonna be able to manage, 1149 01:00:57,458 --> 01:01:00,024 he's gonna have to manage without those medications since 1150 01:01:00,024 --> 01:01:03,474 those can only be given here in the Intensive Care Unit. 1151 01:01:03,474 --> 01:01:06,118 My sense and the sense of the other doctors here 1152 01:01:06,118 --> 01:01:08,777 I think is that the thing that makes sense is 1153 01:01:08,777 --> 01:01:11,725 for us to withdraw some of those medications 1154 01:01:11,725 --> 01:01:14,728 and do everything we can for him, 1155 01:01:14,728 --> 01:01:17,561 especially devoted to his comfort. 1156 01:01:18,495 --> 01:01:22,352 - [Mrs. Gavin] You don't think that he will come around? 1157 01:01:22,352 --> 01:01:24,554 - I don't know, I think that-- 1158 01:01:24,554 --> 01:01:26,982 - [Mrs. Gavin] You're just hoping, we're all hoping. 1159 01:01:26,982 --> 01:01:28,922 - We're hoping and we'll see. 1160 01:01:28,922 --> 01:01:30,170 I mean he's got a lot of strength, 1161 01:01:30,170 --> 01:01:31,530 he's fooled us in the past. 1162 01:01:31,530 --> 01:01:33,757 He's come through things that we never thought he would. 1163 01:01:33,757 --> 01:01:34,590 - Yes. 1164 01:01:34,590 --> 01:01:36,526 - But I think more and more of these episodes 1165 01:01:36,526 --> 01:01:40,124 make it less and less likely that that's gonna happen. 1166 01:01:40,124 --> 01:01:41,451 But I think it's important to 1167 01:01:41,451 --> 01:01:44,227 realize we don't know for sure. 1168 01:01:44,227 --> 01:01:47,948 - You think now he's going downhill? 1169 01:01:47,948 --> 01:01:50,281 - That's what it looks like. 1170 01:01:51,212 --> 01:01:54,129 - It's sad because he has his mind. 1171 01:01:59,394 --> 01:02:02,506 I don't know what'll save him. 1172 01:02:02,506 --> 01:02:03,339 Just hope. 1173 01:02:04,294 --> 01:02:06,202 - We'll do that together. 1174 01:02:06,202 --> 01:02:07,202 - All right. 1175 01:02:11,297 --> 01:02:15,137 - When he's feeling a little more comfortable, 1176 01:02:15,137 --> 01:02:18,486 we'll talk with him about this. 1177 01:02:18,486 --> 01:02:22,569 Are you going this way? - No, I'll just stay here. 1178 01:02:23,908 --> 01:02:26,908 I feel terrible. - I understand that. 1179 01:02:27,805 --> 01:02:29,472 - Because this last, 1180 01:02:30,340 --> 01:02:33,537 well he's been, it was good the cardiologist was 1181 01:02:33,537 --> 01:02:37,395 right here on the floor when he had that other attack. 1182 01:02:37,395 --> 01:02:41,355 It was kind of, you know, they came right in. 1183 01:02:41,355 --> 01:02:44,550 I know they're doing everything they can but 1184 01:02:44,550 --> 01:02:47,883 it just don't seem to be enough for him. 1185 01:02:49,479 --> 01:02:50,312 Well, 1186 01:02:51,550 --> 01:02:56,286 do you think he'll go to sleep or shall I stay here? 1187 01:02:56,286 --> 01:02:59,505 - I think it's good for him to have you nearby. 1188 01:02:59,505 --> 01:03:01,032 What do you think? 1189 01:03:01,032 --> 01:03:05,124 - The boys are here too, they're downstairs. 1190 01:03:05,124 --> 01:03:07,979 - When they come back up, maybe we could talk as well. 1191 01:03:07,979 --> 01:03:12,812 - All right, I'd like you to talk to them, I really would. 1192 01:03:14,611 --> 01:03:17,098 I don't know what else to do. 1193 01:03:17,098 --> 01:03:20,663 Just hope and say a prayer for him. 1194 01:03:20,663 --> 01:03:22,733 He's gone through 1195 01:03:22,733 --> 01:03:24,983 an awful lot. - He sure has. 1196 01:03:27,827 --> 01:03:31,160 - It's gonna come to an end I think now. 1197 01:03:36,298 --> 01:03:39,298 - Have you and he talked about that? 1198 01:03:40,214 --> 01:03:41,706 - [Mrs. Gavin] No, he didn't say 1199 01:03:41,706 --> 01:03:43,728 anything today when I came in. 1200 01:03:43,728 --> 01:03:44,886 I said "Did you talk?" 1201 01:03:44,886 --> 01:03:47,398 And he says "Yeah, I was talking about, 1202 01:03:47,398 --> 01:03:50,014 "Dr. Taylor was talking about keeping 1203 01:03:50,014 --> 01:03:52,681 "me alive on machines," he said. 1204 01:03:54,183 --> 01:03:55,837 - How do you think it would be for him 1205 01:03:55,837 --> 01:03:58,538 if you and he talked about the possibilities, 1206 01:03:58,538 --> 01:04:02,569 including the possibility that he might not make it? 1207 01:04:02,569 --> 01:04:06,486 - I always feel that he is going to, up to now. 1208 01:04:08,671 --> 01:04:10,079 What do you think? 1209 01:04:10,079 --> 01:04:11,823 - Well I have the sense that it's on 1210 01:04:11,823 --> 01:04:13,587 both of your minds and that it might be better 1211 01:04:13,587 --> 01:04:15,856 for both of you if you could share that, 1212 01:04:15,856 --> 01:04:18,588 but it depends on what you're comfortable with. 1213 01:04:18,588 --> 01:04:23,305 - Yeah, I don't want to talk about it, I really don't. 1214 01:04:23,305 --> 01:04:25,290 - Would it be something-- - I don't know when, 1215 01:04:25,290 --> 01:04:27,248 he wouldn't either. 1216 01:04:27,248 --> 01:04:29,166 - Would you want me to bring it up when you're there 1217 01:04:29,166 --> 01:04:30,907 and see if he wants to talk about it with us all together? 1218 01:04:30,907 --> 01:04:31,740 - Sure. 1219 01:04:32,646 --> 01:04:35,313 But I don't want to bring it up. 1220 01:04:36,249 --> 01:04:39,143 You know, it's a touchy subject too. 1221 01:04:39,143 --> 01:04:41,964 - It sure is. - It's a touchy one. 1222 01:04:41,964 --> 01:04:44,413 When the boys come up, maybe we can talk. 1223 01:04:44,413 --> 01:04:48,676 - Okay, let's see if he gets a little more comfortable. 1224 01:04:48,676 --> 01:04:51,084 - Would he be asleep with that morphine? 1225 01:04:51,084 --> 01:04:52,861 - We don't know. - You don't know. 1226 01:04:52,861 --> 01:04:53,694 All right. 1227 01:04:56,848 --> 01:05:01,321 I don't know what else you can do, it's up to you. 1228 01:05:01,321 --> 01:05:04,888 - You know you're doing a lot too by being there with him. 1229 01:05:04,888 --> 01:05:07,805 I'm gonna go help them. - All right. 1230 01:05:13,746 --> 01:05:16,185 - [Bill] The Coordinator will call you when 1231 01:05:16,185 --> 01:05:19,081 your sons come back and I'll come back and we'll talk. 1232 01:05:19,081 --> 01:05:21,699 - Okay, they're only gone down for coffee. 1233 01:05:21,699 --> 01:05:25,121 - You let me know when and I'll be back. 1234 01:05:25,121 --> 01:05:26,954 - I'll be here. - Good. 1235 01:05:29,646 --> 01:05:31,063 - Bye guys. - Bye. 1236 01:05:47,135 --> 01:05:49,968 (electronic beep) 1237 01:06:02,663 --> 01:06:04,277 - All the medications that we've been giving 1238 01:06:04,277 --> 01:06:07,008 in this Intensive Care Unit, kinda doses 1239 01:06:07,008 --> 01:06:11,425 have not been improving the functioning of his heart. 1240 01:06:12,491 --> 01:06:14,968 So that I think, you know we never can predict 1241 01:06:14,968 --> 01:06:18,238 the future for sure but he said it to me this morning, 1242 01:06:18,238 --> 01:06:22,016 he said he's on the borderline between surviving and not 1243 01:06:22,016 --> 01:06:25,327 and each one of these episodes that he has I think 1244 01:06:25,327 --> 01:06:29,827 makes it a little less likely that he's gonna survive. 1245 01:06:32,721 --> 01:06:34,973 He's a very strong man though. 1246 01:06:34,973 --> 01:06:37,579 - He's been through a lot, he's been through a lot. 1247 01:06:37,579 --> 01:06:39,699 - And he's fooled us in the past too 1248 01:06:39,699 --> 01:06:41,854 when we didn't think he was gonna make it. 1249 01:06:41,854 --> 01:06:44,819 So I think we have to be humble about our ability to 1250 01:06:44,819 --> 01:06:46,402 predict the future. 1251 01:06:47,830 --> 01:06:49,727 But one of the things that I wondered and I 1252 01:06:49,727 --> 01:06:53,208 spoke with Mrs. Gavin about it a few minutes ago is that 1253 01:06:53,208 --> 01:06:56,576 sometimes when everybody's aware of the issues about 1254 01:06:56,576 --> 01:06:59,788 is he gonna survive, isn't he, 1255 01:06:59,788 --> 01:07:04,788 that it might help to take away some of the barriers between 1256 01:07:06,482 --> 01:07:09,778 you folks if that's talked about in the open. 1257 01:07:09,778 --> 01:07:10,984 Different people are different. 1258 01:07:10,984 --> 01:07:12,435 Some people would rather not do that, 1259 01:07:12,435 --> 01:07:14,794 some people would see it as throwing in 1260 01:07:14,794 --> 01:07:17,163 the towel and giving up, which we're not doing. 1261 01:07:17,163 --> 01:07:18,774 We don't want to give him the wrong message. 1262 01:07:18,774 --> 01:07:21,388 But on the other hand, it's on your minds, it's on 1263 01:07:21,388 --> 01:07:26,221 his mind and if it would allow you folks to talk about it, 1264 01:07:27,100 --> 01:07:29,001 I think it would probably be good for people 1265 01:07:29,001 --> 01:07:31,791 to be able to share their concerns because 1266 01:07:31,791 --> 01:07:35,230 I think he might feel that support. 1267 01:07:35,230 --> 01:07:37,520 If he knows you're thinking about it and he is, 1268 01:07:37,520 --> 01:07:39,476 maybe to be able to talk about it together 1269 01:07:39,476 --> 01:07:43,226 would be something that he'd feel good about. 1270 01:07:45,311 --> 01:07:48,095 If he's more comfortable after the effects of the morphine. 1271 01:07:48,095 --> 01:07:49,632 - Yeah. 1272 01:07:49,632 --> 01:07:51,632 - [Bill] Take your time. 1273 01:07:53,710 --> 01:07:54,543 - Gosh. 1274 01:07:55,997 --> 01:07:58,576 I don't know what we will do. 1275 01:07:58,576 --> 01:08:00,051 - [Son] The life support. 1276 01:08:00,051 --> 01:08:02,948 - Would it go as far as that? - A life-support system? 1277 01:08:02,948 --> 01:08:05,942 - He's already given us very clear instructions about that, 1278 01:08:05,942 --> 01:08:08,636 that he didn't want life-support systems 1279 01:08:08,636 --> 01:08:11,213 in terms of tubes and machines and so on. 1280 01:08:11,213 --> 01:08:13,716 He doesn't want his heart restarted if it stops. 1281 01:08:13,716 --> 01:08:16,910 He doesn't want a tube put in to breathe for him 1282 01:08:16,910 --> 01:08:19,910 if he's unable to breathe on his own 1283 01:08:21,519 --> 01:08:24,234 and I think frankly that that's a wise decision 1284 01:08:24,234 --> 01:08:26,688 because if it reaches that point where his heart does 1285 01:08:26,688 --> 01:08:30,448 stop as it has in the past or if he's unable to breathe, 1286 01:08:30,448 --> 01:08:32,794 I think the likelihood of him being able to have 1287 01:08:32,794 --> 01:08:35,907 a meaningful recovery after that is so small-- 1288 01:08:35,907 --> 01:08:38,749 - Next to nothing. - Yeah and it really would be. 1289 01:08:38,749 --> 01:08:40,943 - What are you doing now Doctor as far as reviving 1290 01:08:40,943 --> 01:08:45,404 when he's having these pains and everything else? 1291 01:08:45,404 --> 01:08:47,094 - [Son] Do you just stimulate him enough 1292 01:08:47,094 --> 01:08:48,591 to get him going again? 1293 01:08:48,591 --> 01:08:50,084 - We're actually not stimulating. 1294 01:08:50,084 --> 01:08:51,906 We're giving him morphine. 1295 01:08:51,906 --> 01:08:54,761 The primary action of that is to relieve his pain. 1296 01:08:54,761 --> 01:08:56,466 But there is some reason to think that it 1297 01:08:56,466 --> 01:08:58,957 also helps his heart to function more effectively. 1298 01:08:58,957 --> 01:09:00,857 So if we can get some more effect that way, 1299 01:09:00,857 --> 01:09:02,684 we're delighted to have it but we're 1300 01:09:02,684 --> 01:09:05,145 focusing our attention on his comfort. 1301 01:09:05,145 --> 01:09:08,952 One thing we can do is prevent him from being uncomfortable 1302 01:09:08,952 --> 01:09:11,332 and the morphine is the best way when he's 1303 01:09:11,332 --> 01:09:13,868 having the pain that we can accomplish that 1304 01:09:13,868 --> 01:09:16,938 and if it has other benefits, so much the better. 1305 01:09:16,938 --> 01:09:20,082 But I think our primary goal at this point is to 1306 01:09:20,082 --> 01:09:23,832 do everything we can to keep him comfortable. 1307 01:09:26,527 --> 01:09:28,776 - But he did say he didn't want to be on anything. 1308 01:09:28,776 --> 01:09:32,172 - He's been pretty specific. - On several occasions, 1309 01:09:32,172 --> 01:09:33,532 he has said this in the past. 1310 01:09:33,532 --> 01:09:36,879 - [Son] And there really wouldn't be much point to it, 1311 01:09:36,879 --> 01:09:39,796 his condition the way it is. - That's right. 1312 01:09:39,796 --> 01:09:42,366 - He's made it pretty clear, he doesn't-- 1313 01:09:42,366 --> 01:09:44,486 - We all feel pretty much the same way really. 1314 01:09:44,486 --> 01:09:46,926 - And he hasn't walked for over a year and he said 1315 01:09:46,926 --> 01:09:49,813 "I don't think I'm gonna be able to walk anymore." 1316 01:09:49,813 --> 01:09:52,362 He says "With this heart condition the way it is," 1317 01:09:52,362 --> 01:09:56,862 he says "I'm just gonna be in a chair and that is it." 1318 01:09:58,066 --> 01:10:00,115 I said "Oh, don't feel like that." 1319 01:10:00,115 --> 01:10:02,317 I says "You're liable to 1320 01:10:02,317 --> 01:10:06,108 "come around and start walking, you never know. 1321 01:10:06,108 --> 01:10:07,525 I don't know, so. 1322 01:10:09,452 --> 01:10:12,314 He's got to the point where he feels 1323 01:10:12,314 --> 01:10:15,725 that he isn't gonna get up again. 1324 01:10:15,725 --> 01:10:17,620 - [Son] He knows his condition. 1325 01:10:17,620 --> 01:10:21,370 - That's why I wanted to boys to talk to you. 1326 01:10:23,118 --> 01:10:24,903 - When he is more comfortable, do you want to speak 1327 01:10:24,903 --> 01:10:27,856 with him alone or would you like me to go in with you? 1328 01:10:27,856 --> 01:10:28,689 - Yeah. 1329 01:10:30,507 --> 01:10:33,228 He'll be asleep awhile now but they can page you. 1330 01:10:33,228 --> 01:10:34,514 - [Son] Would you like to wait? 1331 01:10:34,514 --> 01:10:35,865 How long you gonna be here, Doctor? 1332 01:10:35,865 --> 01:10:37,094 - I'll be around for a little bit. 1333 01:10:37,094 --> 01:10:39,834 - [Son] Would you want to wait until Jack comes in? 1334 01:10:39,834 --> 01:10:41,834 - Yeah, I think-- - Yeah. 1335 01:10:43,174 --> 01:10:45,179 - Why don't we do that? - Yeah. 1336 01:10:45,179 --> 01:10:48,159 About what time will you be here 'til? 1337 01:10:48,159 --> 01:10:50,779 - Until about six. - Oh, he'll be here. 1338 01:10:50,779 --> 01:10:54,243 - He'll be here probably 4:30, five o'clock. 1339 01:10:54,243 --> 01:10:56,381 - [Mrs. Gavin] So we'll wait around and we'll talk to you. 1340 01:10:56,381 --> 01:10:57,918 - We'll let dad sleep for a little while. 1341 01:10:57,918 --> 01:10:58,751 - Okay. - All right? 1342 01:10:58,751 --> 01:10:59,770 - [Mrs. Gavin] All right. 1343 01:10:59,770 --> 01:11:02,628 - And we'll wait for Jack to come in and then we can talk. 1344 01:11:02,628 --> 01:11:05,318 - When he comes, would you like us to page you? 1345 01:11:05,318 --> 01:11:07,318 - It's up to you. - Sure. 1346 01:11:08,448 --> 01:11:11,492 I'd prefer to have you talk to him also. 1347 01:11:11,492 --> 01:11:14,976 - He knows the ramifications, he knows everything-- 1348 01:11:14,976 --> 01:11:16,606 - He knows everything firsthand. 1349 01:11:16,606 --> 01:11:17,639 - [Bill] I misunderstood, 1350 01:11:17,639 --> 01:11:19,046 I would like to get to talk with him. 1351 01:11:19,046 --> 01:11:20,647 Whether you want me to be in the room when you 1352 01:11:20,647 --> 01:11:22,728 speak with your dad or not would be up to you. 1353 01:11:22,728 --> 01:11:25,215 - Sure, that's fine. - That's fine. 1354 01:11:25,215 --> 01:11:26,619 - [Bill] All righty, so I'll be around 1355 01:11:26,619 --> 01:11:28,107 and you give me a buzz when he arrives. 1356 01:11:28,107 --> 01:11:30,103 - [Son] All right. 1357 01:11:30,103 --> 01:11:34,020 - All right, thanks Doctor. - Thank you, Doctor. 1358 01:11:43,568 --> 01:11:45,889 - [Doctor] The problem is if they lose bowels, 1359 01:11:45,889 --> 01:11:49,722 the main bladder, they lose function all over. 1360 01:11:57,799 --> 01:11:59,049 - [Nurse] Okay. 1361 01:12:05,519 --> 01:12:08,976 - Well that's probably what it is. 1362 01:12:08,976 --> 01:12:10,226 She told me to, 1363 01:12:12,238 --> 01:12:15,206 I don't know, it seems like 1364 01:12:15,206 --> 01:12:18,163 when I talk a little too much, you know? 1365 01:12:18,163 --> 01:12:20,936 - Yeah, even the exertion from that probably is a lot. 1366 01:12:20,936 --> 01:12:21,769 - Yeah. 1367 01:12:25,001 --> 01:12:26,999 - He says "Am I talking too much, 1368 01:12:26,999 --> 01:12:30,257 "that's causing all this exertion?" 1369 01:12:30,257 --> 01:12:31,674 But I don't know. 1370 01:12:34,829 --> 01:12:35,662 - Well, 1371 01:12:38,006 --> 01:12:39,089 looks like an 1372 01:12:40,309 --> 01:12:41,226 experiment. 1373 01:12:43,793 --> 01:12:46,876 When my boy Jackie was in last night, 1374 01:12:48,431 --> 01:12:49,598 after he left, 1375 01:12:51,113 --> 01:12:52,863 that's when I had the 1376 01:12:55,115 --> 01:12:57,532 little attack again. - Uh-huh. 1377 01:12:58,786 --> 01:12:59,619 - And 1378 01:13:01,524 --> 01:13:02,607 it seems that 1379 01:13:04,373 --> 01:13:07,075 that's what it was I think. 1380 01:13:07,075 --> 01:13:08,658 I believe that was, 1381 01:13:10,738 --> 01:13:12,238 He left about 7:30 1382 01:13:14,775 --> 01:13:15,608 or eight. 1383 01:13:17,512 --> 01:13:18,345 You know? 1384 01:13:20,657 --> 01:13:23,180 - Would that exertion do it? 1385 01:13:23,180 --> 01:13:26,029 - [Bill] Well it's hard to say. 1386 01:13:26,029 --> 01:13:30,279 We'd have to wonder if, but it seems to be related. 1387 01:13:32,773 --> 01:13:35,308 I think it's possible that it's not related though. 1388 01:13:35,308 --> 01:13:39,994 It may be that these things just happen and we look for-- 1389 01:13:39,994 --> 01:13:41,077 - I know. - Reasons to try to figure 1390 01:13:41,077 --> 01:13:43,691 it out and sometimes we hit on them 1391 01:13:43,691 --> 01:13:46,426 and sometimes it's just a coincidence. 1392 01:13:46,426 --> 01:13:49,017 We don't really know, I guess that's 1393 01:13:49,017 --> 01:13:52,765 one of the main messages is how little we end up knowing. 1394 01:13:52,765 --> 01:13:53,598 - Yeah. 1395 01:13:57,198 --> 01:13:58,031 Because 1396 01:14:02,309 --> 01:14:03,142 you see, 1397 01:14:06,473 --> 01:14:11,106 well you and Tommy were in the room around when, 1398 01:14:11,106 --> 01:14:14,622 around noontime wasn't it? - Just about noontime, yeah. 1399 01:14:14,622 --> 01:14:15,789 - Yeah. - Yeah. 1400 01:14:17,130 --> 01:14:18,946 - It seems that-- 1401 01:14:18,946 --> 01:14:20,735 - [Son] Shortly after that you had another one? 1402 01:14:20,735 --> 01:14:22,985 - Shortly after that, yeah. 1403 01:14:24,338 --> 01:14:25,671 So I don't know. 1404 01:14:27,137 --> 01:14:30,472 - [Mrs. Gavin] I don't think they talk that much. 1405 01:14:30,472 --> 01:14:34,278 - It's hard to pin it down. - Yeah, it is. 1406 01:14:34,278 --> 01:14:35,776 I suspect that some of the talking 1407 01:14:35,776 --> 01:14:38,276 is probably very good for you. 1408 01:14:41,366 --> 01:14:44,147 - Stretch those vocal chords. 1409 01:14:44,147 --> 01:14:46,291 - [Son] Do some yelling. 1410 01:14:46,291 --> 01:14:47,541 - There was awhile there you 1411 01:14:47,541 --> 01:14:50,124 couldn't talk at all, remember? 1412 01:14:52,140 --> 01:14:54,014 - Also to get some of the positive stuff 1413 01:14:54,014 --> 01:14:58,097 that comes from having your family here with you. 1414 01:15:02,665 --> 01:15:05,373 - So you were gonna ask him 1415 01:15:05,373 --> 01:15:07,605 about the machines and everything. 1416 01:15:07,605 --> 01:15:09,384 - Yeah, I think we've been through that. 1417 01:15:09,384 --> 01:15:11,497 I understand pretty well I think, Mr. Gavin, 1418 01:15:11,497 --> 01:15:14,587 your instructions about what you wish 1419 01:15:14,587 --> 01:15:17,247 for us to do if things are to get worse. 1420 01:15:17,247 --> 01:15:19,627 If your heart should stop, if your breathing should stop, 1421 01:15:19,627 --> 01:15:23,312 you've given pretty clear instructions that you don't want 1422 01:15:23,312 --> 01:15:26,591 tubes and machines and all the things that you went 1423 01:15:26,591 --> 01:15:31,424 through a few months ago when you experienced all of that. 1424 01:15:32,496 --> 01:15:33,329 - Yeah. 1425 01:15:34,266 --> 01:15:37,001 - I don't know that we need to bring it up again 1426 01:15:37,001 --> 01:15:39,521 beyond that unless you feel that there's something 1427 01:15:39,521 --> 01:15:42,263 different or that you've changed your mind about things 1428 01:15:42,263 --> 01:15:45,272 and if you ever do-- - Oh no, it's just that 1429 01:15:45,272 --> 01:15:47,022 I thought once it was 1430 01:15:51,652 --> 01:15:54,478 pinned down, this thing, you know 1431 01:15:54,478 --> 01:15:56,145 with the lawyer that 1432 01:15:57,135 --> 01:16:00,004 that means I have to go along with it. 1433 01:16:00,004 --> 01:16:01,777 - That's not true. 1434 01:16:01,777 --> 01:16:03,635 - Well you've, 1435 01:16:03,635 --> 01:16:06,779 you've changed my mind on that then. 1436 01:16:06,779 --> 01:16:10,409 - You can always change your mind. 1437 01:16:10,409 --> 01:16:13,559 We'll go by whatever you tell us, even if it's 1438 01:16:13,559 --> 01:16:16,873 something different today from what it was yesterday. 1439 01:16:16,873 --> 01:16:19,249 Even if it's different from what you thought 1440 01:16:19,249 --> 01:16:23,943 when you signed that living will with the lawyer. 1441 01:16:23,943 --> 01:16:26,326 Whatever you tell us is what we'll go by 1442 01:16:26,326 --> 01:16:28,897 and you're entitled to change your opinion, 1443 01:16:28,897 --> 01:16:31,241 change your instructions to us and whatever you tell us, 1444 01:16:31,241 --> 01:16:35,408 we'll listen to that and follow your instructions. 1445 01:16:39,713 --> 01:16:41,447 Have you thought about changing your mind, Mr. Gavin? 1446 01:16:41,447 --> 01:16:44,397 - Have you thought of anything? 1447 01:16:44,397 --> 01:16:46,394 - Have I thought of anything? 1448 01:16:46,394 --> 01:16:48,881 - Have you thought about changing your mind? 1449 01:16:48,881 --> 01:16:50,622 You just said you want Dr. Taylor 1450 01:16:50,622 --> 01:16:52,877 to do whatever he thinks is best. 1451 01:16:52,877 --> 01:16:57,294 - Well no, the way I was explaining it to Dr. Taylor, 1452 01:16:58,223 --> 01:16:59,390 because I took 1453 01:17:00,919 --> 01:17:02,752 the most severe cases. 1454 01:17:04,246 --> 01:17:05,329 You know, the 1455 01:17:06,411 --> 01:17:07,744 Von Bulow and... 1456 01:17:10,478 --> 01:17:11,311 And 1457 01:17:12,887 --> 01:17:16,387 well there was a couple more too that were 1458 01:17:17,897 --> 01:17:19,314 not quite so big. 1459 01:17:21,415 --> 01:17:22,248 But 1460 01:17:26,863 --> 01:17:29,280 I just assumed all along that 1461 01:17:32,260 --> 01:17:35,260 because the other ones, they were... 1462 01:17:36,359 --> 01:17:37,192 But 1463 01:17:39,298 --> 01:17:40,715 we don't have to, 1464 01:17:43,749 --> 01:17:45,717 don't have to take the severest ones. 1465 01:17:45,717 --> 01:17:46,550 - No. 1466 01:17:48,704 --> 01:17:50,434 You feel like you want Dr. Taylor 1467 01:17:50,434 --> 01:17:52,978 to do what he thinks is best for you. 1468 01:17:52,978 --> 01:17:55,645 - What you think is best for me, 1469 01:17:56,624 --> 01:17:59,124 I'll go along with you Doctor. 1470 01:18:01,123 --> 01:18:02,916 - Well I think at this point Mr. Gavin, 1471 01:18:02,916 --> 01:18:05,331 given all that you've been through, 1472 01:18:05,331 --> 01:18:07,727 given the episodes of pain that you had last night 1473 01:18:07,727 --> 01:18:12,196 and today and given the failure of the medications that 1474 01:18:12,196 --> 01:18:16,789 we've used to try to improve the functioning of your heart, 1475 01:18:16,789 --> 01:18:19,122 that what's best is probably 1476 01:18:20,204 --> 01:18:21,287 to try to see 1477 01:18:22,509 --> 01:18:25,591 how you will do without some of these powerful medications 1478 01:18:25,591 --> 01:18:29,496 that are making some of their own complications 1479 01:18:29,496 --> 01:18:32,183 and in the midst of the changes as we 1480 01:18:32,183 --> 01:18:34,775 try to see if we can turn down or even 1481 01:18:34,775 --> 01:18:37,902 turn off some of these powerful medications, 1482 01:18:37,902 --> 01:18:40,581 to do everything we can above all else 1483 01:18:40,581 --> 01:18:43,947 to make sure that we keep you comfortable. 1484 01:18:43,947 --> 01:18:45,893 - Well that's the main thing. 1485 01:18:45,893 --> 01:18:49,057 - We don't mean to be puttin' it all in your hands. 1486 01:18:49,057 --> 01:18:52,029 - [Bill] It's fair for us to share it, I think. 1487 01:18:52,029 --> 01:18:53,029 - All right. 1488 01:19:01,401 --> 01:19:05,503 But you know Dr. Taylor will do what he can for you. 1489 01:19:05,503 --> 01:19:09,271 You know Dr. Taylor will do what he can for you. 1490 01:19:09,271 --> 01:19:12,548 - [Mr. Gavin] Oh, I know that. 1491 01:19:12,548 --> 01:19:16,648 Definitely. - That's a vote of confidence. 1492 01:19:16,648 --> 01:19:19,800 - [Bill] We've been through a lot together, Mr. Gavin. 1493 01:19:19,800 --> 01:19:20,707 - Yeah. 1494 01:19:20,707 --> 01:19:24,374 - [Bill] It's been a very long haul for you. 1495 01:19:25,843 --> 01:19:27,753 - [Mrs. Gavin] Well you never know, 1496 01:19:27,753 --> 01:19:30,543 he might be up and around before you know it. 1497 01:19:30,543 --> 01:19:32,492 - [Bill] We don't know how to predict the future. 1498 01:19:32,492 --> 01:19:33,992 - [Mrs. Gavin] No. 1499 01:19:35,339 --> 01:19:36,747 - [Bill] And we've been, 1500 01:19:36,747 --> 01:19:38,778 we talked about that earlier, I talked about that 1501 01:19:38,778 --> 01:19:41,055 with your family, we've been surprised before. 1502 01:19:41,055 --> 01:19:42,672 You've come back from situations that 1503 01:19:42,672 --> 01:19:44,372 nobody ever thought that you could. 1504 01:19:44,372 --> 01:19:47,026 So we have to be humble about predicting the future, 1505 01:19:47,026 --> 01:19:50,022 as we talked about before. 1506 01:19:50,022 --> 01:19:52,726 But as you said to me this morning, 1507 01:19:52,726 --> 01:19:56,040 you're sort of in a borderline situation now 1508 01:19:56,040 --> 01:19:59,155 between surviving and not surviving 1509 01:19:59,155 --> 01:20:01,523 and I think that your bringing that up 1510 01:20:01,523 --> 01:20:04,062 is something that we shouldn't run away from. 1511 01:20:04,062 --> 01:20:06,897 At the same time that we acknowledge that 1512 01:20:06,897 --> 01:20:10,030 we don't know what's gonna happen and that we 1513 01:20:10,030 --> 01:20:12,471 point out that you're a man of great strength 1514 01:20:12,471 --> 01:20:14,709 and that you've fooled us before in terms of 1515 01:20:14,709 --> 01:20:17,273 your ability to come back from situations 1516 01:20:17,273 --> 01:20:20,885 that we didn't think it was possible. 1517 01:20:20,885 --> 01:20:23,671 I think it's important that we acknowledge 1518 01:20:23,671 --> 01:20:25,638 what all of us are afraid of too 1519 01:20:25,638 --> 01:20:28,875 and what we're all thinking of as a possibility. 1520 01:20:28,875 --> 01:20:30,939 Because sometimes if we don't acknowledge 1521 01:20:30,939 --> 01:20:33,568 the possibility that you mentioned this morning, 1522 01:20:33,568 --> 01:20:36,006 not only the one that you might survive and be up 1523 01:20:36,006 --> 01:20:40,483 and around but also the possibility that you might not, 1524 01:20:40,483 --> 01:20:43,628 sometimes that can be a barrier between people. 1525 01:20:43,628 --> 01:20:46,074 Even between people who love each other a lot. 1526 01:20:46,074 --> 01:20:47,928 If you're having a thought about what might happen 1527 01:20:47,928 --> 01:20:51,126 if you don't make it and your wife's having that thought, 1528 01:20:51,126 --> 01:20:52,696 sometimes it's too bad if people 1529 01:20:52,696 --> 01:20:54,517 can't talk to each other about it. 1530 01:20:54,517 --> 01:20:56,100 - Well that's true. 1531 01:20:57,262 --> 01:20:58,262 That's true. 1532 01:21:03,927 --> 01:21:06,344 Of course you know as you say 1533 01:21:07,343 --> 01:21:08,343 Doctor, this 1534 01:21:09,865 --> 01:21:12,698 living will fools a lot of people. 1535 01:21:14,812 --> 01:21:16,851 - How so? - Especially 1536 01:21:16,851 --> 01:21:17,851 people that, 1537 01:21:19,119 --> 01:21:21,536 in a category like us, I mean 1538 01:21:22,603 --> 01:21:25,762 we don't know too much about it really. 1539 01:21:25,762 --> 01:21:27,512 I don't, I know that. 1540 01:21:28,477 --> 01:21:30,249 - Well it's interesting for you to say that, 1541 01:21:30,249 --> 01:21:32,157 Mr. Gavin because I don't know many people who know 1542 01:21:32,157 --> 01:21:34,388 more about it than you do with what you've been through. 1543 01:21:34,388 --> 01:21:36,193 You know firsthand what-- - That's true, yeah. 1544 01:21:36,193 --> 01:21:40,062 - All those things are like in a way that most of us never 1545 01:21:40,062 --> 01:21:42,954 experience until we're in the midst of it. 1546 01:21:42,954 --> 01:21:45,046 You've already been there. - Yeah. 1547 01:21:45,046 --> 01:21:49,713 - So you know very much what those different things are. 1548 01:21:52,862 --> 01:21:56,695 - Just hope and pray everything shall be fine. 1549 01:21:58,208 --> 01:22:01,862 We won't have to worry about those things maybe. 1550 01:22:01,862 --> 01:22:04,279 - Well that's just one of the 1551 01:22:07,613 --> 01:22:11,280 things that might run in a way I don't want. 1552 01:22:12,262 --> 01:22:13,679 - I hope I don't. 1553 01:22:15,212 --> 01:22:17,531 - [Bill] I hope you don't too but I have a sense 1554 01:22:17,531 --> 01:22:20,009 that the two of you and actually maybe all of you 1555 01:22:20,009 --> 01:22:23,169 have some things to talk about that if you wish to. 1556 01:22:23,169 --> 01:22:25,336 - Yeah. - That's up to you. 1557 01:22:26,971 --> 01:22:28,968 Because I have a sense that there are some things 1558 01:22:28,968 --> 01:22:31,868 on your mind not only about the hopeful things 1559 01:22:31,868 --> 01:22:35,023 because we all have hope but also some of the concerns 1560 01:22:35,023 --> 01:22:38,941 we have if what we're hoping for doesn't happen 1561 01:22:40,749 --> 01:22:42,823 and one of my hopes is that you folks 1562 01:22:42,823 --> 01:22:46,929 get a chance to talk about that with each other. 1563 01:22:46,929 --> 01:22:49,032 - [Mrs. Gavin] Okay, we will. 1564 01:22:49,032 --> 01:22:51,115 - You'll do what's right. 1565 01:22:53,059 --> 01:22:55,126 Mr. Gavin, I'm gonna go now and leave you with 1566 01:22:55,126 --> 01:22:57,936 your family together but I'm gonna be back in the morning 1567 01:22:57,936 --> 01:23:00,610 and in the meantime folks here know how to reach me. 1568 01:23:00,610 --> 01:23:02,777 - Yes. - All right, Doctor. 1569 01:23:03,806 --> 01:23:06,306 Bye bye now. - Good to see you. 1570 01:23:11,540 --> 01:23:14,030 - [Nurse] Do you need anything? 1571 01:23:14,030 --> 01:23:16,863 I'll be outside, okay? - All right. 1572 01:23:18,523 --> 01:23:20,940 (chattering) 1573 01:23:25,794 --> 01:23:30,022 - [Scott] Anyway he's, he's looking good. 1574 01:23:30,022 --> 01:23:32,105 - So there's, this is it. 1575 01:23:33,347 --> 01:23:35,138 - Oh yeah. - Yeah I mean, we're not-- 1576 01:23:35,138 --> 01:23:39,599 - He's DNR, I mean he understands what the situation is. 1577 01:23:39,599 --> 01:23:41,250 Why don't you just come right out and say it? 1578 01:23:41,250 --> 01:23:42,215 - No, I just assumed. 1579 01:23:42,215 --> 01:23:44,415 - He's talked to him about it and Bill's talked to him 1580 01:23:44,415 --> 01:23:48,082 and he's pretty, I think he understands that 1581 01:23:49,380 --> 01:23:50,511 everything has been done. 1582 01:23:50,511 --> 01:23:51,921 I think the goal is to see if we can get 1583 01:23:51,921 --> 01:23:54,857 him out of here and maybe get him home for, 1584 01:23:54,857 --> 01:23:57,023 I mean he's been home for, 1585 01:23:58,201 --> 01:23:59,934 what did he get, two weeks? 1586 01:23:59,934 --> 01:24:01,260 I guess he didn't even get two weeks. 1587 01:24:01,260 --> 01:24:03,338 Two weeks out of the hospital in a rehab hospital. 1588 01:24:03,338 --> 01:24:05,959 He's never been home since he had to operation. 1589 01:24:05,959 --> 01:24:08,700 If we could get him home at all, it would be a victory. 1590 01:24:08,700 --> 01:24:10,227 - Is he, 1591 01:24:10,227 --> 01:24:13,836 he's on procaine, can he use IV antiarrythmics or 1592 01:24:13,836 --> 01:24:15,770 how DNR is DNR? 1593 01:24:15,770 --> 01:24:17,675 - Well yeah, no I mean anything 1594 01:24:17,675 --> 01:24:21,537 pharmacologically you wanna play around with is fine. 1595 01:24:21,537 --> 01:24:22,370 - Okay. 1596 01:24:22,370 --> 01:24:23,772 - But I mean I don't think, 1597 01:24:23,772 --> 01:24:26,209 his activity has not been a problem. 1598 01:24:26,209 --> 01:24:27,943 - [Doctor] No. 1599 01:24:27,943 --> 01:24:29,394 - Power failure. - Power failure. 1600 01:24:29,394 --> 01:24:32,295 - Power failure has been the problem. 1601 01:24:32,295 --> 01:24:34,068 - And chest pain. - And chest pain. 1602 01:24:34,068 --> 01:24:35,485 But he, you know, 1603 01:24:36,592 --> 01:24:39,032 I think basically what we've decided to do is respond 1604 01:24:39,032 --> 01:24:43,532 to the chest pain with morphine and nitro rather than, 1605 01:24:45,743 --> 01:24:48,245 and at this point I wouldn't put him back on IV nitro. 1606 01:24:48,245 --> 01:24:51,995 I would just give him morphine and the paste. 1607 01:24:53,541 --> 01:24:57,350 We're not gonna escalate this thing again. 1608 01:24:57,350 --> 01:25:00,639 The guy's been through enough. 1609 01:25:00,639 --> 01:25:03,825 But that's not gonna be an issue today, he's looking good. 1610 01:25:03,825 --> 01:25:06,299 We may get him to the floor. 1611 01:25:06,299 --> 01:25:08,913 - [Nurse] I'll come back and get all that stuff. 1612 01:25:08,913 --> 01:25:11,325 - My glasses are over there anyways. 1613 01:25:11,325 --> 01:25:14,046 - [Nurse] Yeah, do you want them to come with you now, or? 1614 01:25:14,046 --> 01:25:17,282 - [Mr. Gavin] No, I should have them with me 1615 01:25:17,282 --> 01:25:22,093 at all times because I'm as blind as a bat without them. 1616 01:25:22,093 --> 01:25:25,652 - [Mrs. Gavin] Do you wanna take your applesauce with ya? 1617 01:25:25,652 --> 01:25:29,786 - I do not want that stuff. - No applesauce. 1618 01:25:29,786 --> 01:25:31,440 - [Nurse] Absolutely not. 1619 01:25:31,440 --> 01:25:34,112 - [Mr. Gavin] I did not order the applesauce 1620 01:25:34,112 --> 01:25:38,695 and whoever took my dinner did not want the applesauce. 1621 01:25:39,975 --> 01:25:42,915 - I did. - You took my dinner? 1622 01:25:42,915 --> 01:25:44,951 - [Nurse] No, she wants your applesauce. 1623 01:25:44,951 --> 01:25:47,201 - I ordered the applesauce. 1624 01:25:48,190 --> 01:25:51,266 - [Nurse] Why don't you take the applesauce? 1625 01:25:51,266 --> 01:25:53,177 - I don't want it. (laughs) 1626 01:25:53,177 --> 01:25:57,010 No way, I just thought maybe he would have it. 1627 01:25:58,032 --> 01:26:00,562 - I'd love you to have it. - I bet when we get down there 1628 01:26:00,562 --> 01:26:02,291 he's gonna be calling me up on 1629 01:26:02,291 --> 01:26:04,996 the phone looking for his applesauce. 1630 01:26:04,996 --> 01:26:06,359 Okay? 1631 01:26:06,359 --> 01:26:07,746 - Yep. 1632 01:26:07,746 --> 01:26:10,526 We're all set, gimme that too. 1633 01:26:10,526 --> 01:26:12,402 - Can you hold your chart for me? 1634 01:26:12,402 --> 01:26:15,818 - Yes, put it right in there. - All right. 1635 01:26:16,809 --> 01:26:17,842 - How's that? 1636 01:26:17,842 --> 01:26:20,297 - Is my handkerchief around here? 1637 01:26:20,297 --> 01:26:22,036 - Yeah, I threw it in your bag 1638 01:26:22,036 --> 01:26:25,119 because it kept landing on the floor. 1639 01:26:31,040 --> 01:26:31,873 That's it. 1640 01:26:34,943 --> 01:26:36,943 - [Nurse] See you later. 1641 01:26:40,808 --> 01:26:43,891 (electronic beeping) 1642 01:26:48,398 --> 01:26:50,054 - The same problem that we had with 1643 01:26:50,054 --> 01:26:53,335 the Wong family and this person was brain dead. 1644 01:26:53,335 --> 01:26:55,541 - He's not brain dead though. - I know he isn't but-- 1645 01:26:55,541 --> 01:26:56,705 - [Nurse] If he's legally brain dead, 1646 01:26:56,705 --> 01:26:57,940 the tube comes out and that's it. 1647 01:26:57,940 --> 01:26:59,517 - Well that wasn't with the Wong family. 1648 01:26:59,517 --> 01:27:01,800 The patient was legally brain dead 1649 01:27:01,800 --> 01:27:04,540 by all criteria, by all the Harvard criteria 1650 01:27:04,540 --> 01:27:07,157 and we kept the patient on a machine, 1651 01:27:07,157 --> 01:27:10,055 basically kept the heart breathing for three days 1652 01:27:10,055 --> 01:27:12,237 until the family could deal with it and even 1653 01:27:12,237 --> 01:27:14,349 after three days, they couldn't deal with it 1654 01:27:14,349 --> 01:27:17,786 and when the two did come out, they blamed me. 1655 01:27:17,786 --> 01:27:20,472 I was the culprit, I killed their mother. 1656 01:27:20,472 --> 01:27:21,970 - [Nurse] They said that to you? 1657 01:27:21,970 --> 01:27:24,001 - Not directly to me but because I was 1658 01:27:24,001 --> 01:27:27,621 the most visible person and you know, it' hard. 1659 01:27:27,621 --> 01:27:30,125 It really is hard when people try to blame it 1660 01:27:30,125 --> 01:27:33,692 on you because you know, the inevitable happens. 1661 01:27:33,692 --> 01:27:36,969 We have no control over the fact that their mother is brain 1662 01:27:36,969 --> 01:27:39,712 dead and I guess it's all in the way you look at death. 1663 01:27:39,712 --> 01:27:42,018 Whether you look at it legally or emotionally. 1664 01:27:42,018 --> 01:27:44,421 - That's a very hard concept I think to understand, 1665 01:27:44,421 --> 01:27:47,021 brain dead, I think that's-- - It is. 1666 01:27:47,021 --> 01:27:49,446 - That's where you get into the problem of 1667 01:27:49,446 --> 01:27:54,019 providing too much information to families and like I said, 1668 01:27:54,019 --> 01:27:56,375 it's just a difficult concept. - We shouldn't say brain dead. 1669 01:27:56,375 --> 01:27:58,773 What we should say is that your family member 1670 01:27:58,773 --> 01:28:01,654 has passed away and the only reason you see 1671 01:28:01,654 --> 01:28:03,975 a heartbeat is because we're artificially 1672 01:28:03,975 --> 01:28:06,308 keeping the body essentially 1673 01:28:07,665 --> 01:28:10,861 going, keeping the heartbeat going because of oxygen. 1674 01:28:10,861 --> 01:28:12,891 Because the longer that we procrastinate 1675 01:28:12,891 --> 01:28:16,903 in that particular instance, the longer that we keep 1676 01:28:16,903 --> 01:28:20,643 the person's heart beating, the more confused 1677 01:28:20,643 --> 01:28:22,674 the family is gonna become and if you tell 1678 01:28:22,674 --> 01:28:26,288 the family on a Monday that your mother is brain dead 1679 01:28:26,288 --> 01:28:28,919 and three days later, they're still quote 1680 01:28:28,919 --> 01:28:31,251 alive in the bed as far as they're concerned, 1681 01:28:31,251 --> 01:28:35,156 then obviously they have hope and they start to question 1682 01:28:35,156 --> 01:28:39,887 whether it is in fact true that she is brain dead. 1683 01:28:39,887 --> 01:28:42,579 - Why do, just to talk about this and then 1684 01:28:42,579 --> 01:28:44,791 to get back also to this situation which 1685 01:28:44,791 --> 01:28:46,612 you're gonna have to live through this weekend, 1686 01:28:46,612 --> 01:28:48,270 I mean that's the other piece of this 1687 01:28:48,270 --> 01:28:50,353 and what does that feel like to live through this? 1688 01:28:50,353 --> 01:28:53,370 But why do we get into saying that anyway to families? 1689 01:28:53,370 --> 01:28:56,269 That's really the issue, why do we do it? 1690 01:28:56,269 --> 01:28:58,127 - I think to protect them, I think to make it 1691 01:28:58,127 --> 01:29:01,023 easier for them I guess is kind of the, it's difficult-- 1692 01:29:01,023 --> 01:29:02,140 - [Nurse] To make it easier for them 1693 01:29:02,140 --> 01:29:04,032 or to make it easier for us? - Maybe for us. 1694 01:29:04,032 --> 01:29:06,083 It's difficult to say to someone, 1695 01:29:06,083 --> 01:29:10,416 I mean maybe it gets into how you really look at death. 1696 01:29:10,416 --> 01:29:12,762 Is the person, I mean you're in there 1697 01:29:12,762 --> 01:29:14,985 turning the person from side to side. 1698 01:29:14,985 --> 01:29:18,878 You're doing AM care but yet the person is supposedly dead. 1699 01:29:18,878 --> 01:29:20,751 - I think also to get everyone in 1700 01:29:20,751 --> 01:29:22,925 agreement that that is in fact the case 1701 01:29:22,925 --> 01:29:27,239 that someone's dead is another difficult thing. 1702 01:29:27,239 --> 01:29:29,639 My understanding is neurology 1703 01:29:29,639 --> 01:29:31,757 wanted to correct the sodium. 1704 01:29:31,757 --> 01:29:33,122 - [Nurse] Yeah. 1705 01:29:33,122 --> 01:29:34,282 And actually-- 1706 01:29:34,282 --> 01:29:36,887 - But then you start getting various-- 1707 01:29:36,887 --> 01:29:40,532 - That was to supply criteria though. 1708 01:29:40,532 --> 01:29:41,947 You know, they wanted to supply 1709 01:29:41,947 --> 01:29:45,061 the criteria for brain death, you know? 1710 01:29:45,061 --> 01:29:47,815 Not febrile, da da da da da, not hypothermic 1711 01:29:47,815 --> 01:29:49,713 and he wanted, evidently it was a case 1712 01:29:49,713 --> 01:29:52,460 of electrolytes being not in balance. 1713 01:29:52,460 --> 01:29:54,414 - [Nurse] But even after they were, the family 1714 01:29:54,414 --> 01:29:57,193 still didn't accept it, they wanted a fourth concept. 1715 01:29:57,193 --> 01:30:00,731 - But don't we tell, should we tell families that? 1716 01:30:00,731 --> 01:30:03,724 Because we involve families in the whole decision- 1717 01:30:03,724 --> 01:30:07,961 making process and the whole plan and from my experience, 1718 01:30:07,961 --> 01:30:10,955 they're involved much, much more 1719 01:30:10,955 --> 01:30:13,335 here than anywhere else I've worked. 1720 01:30:13,335 --> 01:30:15,063 I'm not sure more than they should 1721 01:30:15,063 --> 01:30:17,145 but for sure it's more than most. 1722 01:30:17,145 --> 01:30:18,548 - In some cases, it's more than they should. 1723 01:30:18,548 --> 01:30:20,915 We're giving them, we're allowing them to make 1724 01:30:20,915 --> 01:30:24,553 a decision that is not, that they know nothing about 1725 01:30:24,553 --> 01:30:28,818 and we're not informing them of what exactly is going on. 1726 01:30:28,818 --> 01:30:31,052 - Well I think they are being informed but it's 1727 01:30:31,052 --> 01:30:34,620 what they can process, I mean all the terminology. 1728 01:30:34,620 --> 01:30:37,028 We went to school four years for us to understand this. 1729 01:30:37,028 --> 01:30:38,854 I had a hard time when I first came here with brain dead, 1730 01:30:38,854 --> 01:30:40,805 I'm like yeah but the heart's beating. 1731 01:30:40,805 --> 01:30:43,113 Well wait a minute, but they're really dead? 1732 01:30:43,113 --> 01:30:44,976 And then when I learned about the Harvard criteria, 1733 01:30:44,976 --> 01:30:47,199 I even had a hard time and I'm a nurse 1734 01:30:47,199 --> 01:30:50,287 and I'm sure the families have a hard time 1735 01:30:50,287 --> 01:30:53,684 in a one hour conversation with the docs just saying "Yeah, 1736 01:30:53,684 --> 01:30:56,541 "he's dead and we're gonna take the tube out and that's it." 1737 01:30:56,541 --> 01:30:58,236 But like, wait a minute. 1738 01:30:58,236 --> 01:31:00,646 - I can understand that completely and that night 1739 01:31:00,646 --> 01:31:02,965 logically I could understand all the steps that 1740 01:31:02,965 --> 01:31:05,786 they were going through but it's very difficult 1741 01:31:05,786 --> 01:31:08,291 when you give that much energy to have basically 1742 01:31:08,291 --> 01:31:12,402 a family member put the blame on you essentially. 1743 01:31:12,402 --> 01:31:15,139 To say to you, "How could you possibly want 1744 01:31:15,139 --> 01:31:19,581 "to take that tube out, what's your motive here?" 1745 01:31:19,581 --> 01:31:22,062 I mean he went to the extent of "Is your motive 1746 01:31:22,062 --> 01:31:24,838 "that you need a bed in the Intensive Care Unit?" 1747 01:31:24,838 --> 01:31:26,730 - They said that? - Yes, I mean-- 1748 01:31:26,730 --> 01:31:28,830 - That's awful. - Because they, 1749 01:31:28,830 --> 01:31:32,100 but they didn't truly believe that, I understand that. 1750 01:31:32,100 --> 01:31:33,972 They really, truly didn't believe that. 1751 01:31:33,972 --> 01:31:37,434 The problem was is that they were under so much stress, 1752 01:31:37,434 --> 01:31:40,257 they didn't know which way to turn. 1753 01:31:40,257 --> 01:31:42,912 It was like oh my god, the day has finally come, 1754 01:31:42,912 --> 01:31:44,996 this is the end and I was the most, 1755 01:31:44,996 --> 01:31:47,243 as the nurse you're the most visible person. 1756 01:31:47,243 --> 01:31:49,646 You're there consistently throughout the whole evening, 1757 01:31:49,646 --> 01:31:52,341 I was there, neurologists come and they go 1758 01:31:52,341 --> 01:31:54,877 and I was the person that this particular son 1759 01:31:54,877 --> 01:31:58,379 decided was the person that he needed to vent his anger at. 1760 01:31:58,379 --> 01:32:00,995 - [Nurse] You were also taking care of the patient 1761 01:32:00,995 --> 01:32:04,806 who was dead but alive, I mean you were-- 1762 01:32:04,806 --> 01:32:06,575 - And that's hard to do. 1763 01:32:06,575 --> 01:32:08,577 - Adding to the anxiety. - Exactly. 1764 01:32:08,577 --> 01:32:11,679 - You somehow add to the confusion when you continue 1765 01:32:11,679 --> 01:32:16,163 to take care of someone who they understand is dead. 1766 01:32:16,163 --> 01:32:19,413 I think that you're gonna get the heat. 1767 01:32:20,306 --> 01:32:21,929 You're gonna get a tremendous amount of rage. 1768 01:32:21,929 --> 01:32:24,516 I mean you took care of them, they're dead 1769 01:32:24,516 --> 01:32:27,253 but they're alive and now you're gonna end their life. 1770 01:32:27,253 --> 01:32:29,860 I mean how do you-- - Right. 1771 01:32:29,860 --> 01:32:31,771 - I mean we could talk about it here, it sounds kind of-- 1772 01:32:31,771 --> 01:32:33,529 - [Nurse] It's not who it's more logical to put blame on. 1773 01:32:33,529 --> 01:32:35,192 - Well-- - It's confusing. 1774 01:32:35,192 --> 01:32:37,891 - It's confusing, it is confusing but I guess 1775 01:32:37,891 --> 01:32:41,407 the question is that we do tell them that way 1776 01:32:41,407 --> 01:32:43,431 to give 'em time. - Right. 1777 01:32:43,431 --> 01:32:45,391 - We were attempting to make it easier 1778 01:32:45,391 --> 01:32:48,263 on the family by allowing them, we essentially 1779 01:32:48,263 --> 01:32:50,788 controlled when we let the person go. 1780 01:32:50,788 --> 01:32:53,393 They came in on a Sunday and they were brain dead on 1781 01:32:53,393 --> 01:32:57,707 a Sunday and we manipulated it by adding stuff, depressors, 1782 01:32:57,707 --> 01:33:01,394 she was on Neo-Synephrine to keep her blood pressure up. 1783 01:33:01,394 --> 01:33:04,954 Everything was manipulated to keep her going so that 1784 01:33:04,954 --> 01:33:08,432 the family could get the consults in and could deal with it. 1785 01:33:08,432 --> 01:33:10,863 Now do we make it any easier for that family? 1786 01:33:10,863 --> 01:33:13,784 Not as far as I'm concerned because when the end 1787 01:33:13,784 --> 01:33:17,175 finally came for them, it was no easier on the Wednesday 1788 01:33:17,175 --> 01:33:20,827 than it was if they had dealt with it right then and there. 1789 01:33:20,827 --> 01:33:24,945 Go right in and say "We have all the criteria." 1790 01:33:24,945 --> 01:33:28,021 We do a CAT Scan, it shows a huge bleed. 1791 01:33:28,021 --> 01:33:30,297 We do a flow study to the brain 1792 01:33:30,297 --> 01:33:32,790 that shows absolutely no flow to the brain. 1793 01:33:32,790 --> 01:33:34,438 We do all the studies that indicate 1794 01:33:34,438 --> 01:33:37,114 whether the person is brain dead. 1795 01:33:37,114 --> 01:33:39,558 If it's true on a Sunday, then 1796 01:33:39,558 --> 01:33:41,743 I mean we didn't make it any easier. 1797 01:33:41,743 --> 01:33:43,276 - [Nurse] Did you do all that in one day 1798 01:33:43,276 --> 01:33:44,945 but they still wanted a second consult? 1799 01:33:44,945 --> 01:33:47,777 - They kept adding consults. - In response to the family? 1800 01:33:47,777 --> 01:33:48,610 - Yeah. 1801 01:33:48,610 --> 01:33:50,050 - [Nurse] You're not gonna change 1802 01:33:50,050 --> 01:33:51,954 the fact by just kinda softening it a bit. 1803 01:33:51,954 --> 01:33:53,478 You're not gonna change it. 1804 01:33:53,478 --> 01:33:56,559 - For some families you need to look at a framework. 1805 01:33:56,559 --> 01:34:00,142 You have to look at the medical assessment, 1806 01:34:01,920 --> 01:34:04,838 the Massachusetts State Law, what the criteria are 1807 01:34:04,838 --> 01:34:07,564 and I think professionals have to take a look 1808 01:34:07,564 --> 01:34:10,186 at their own morals and values before they 1809 01:34:10,186 --> 01:34:13,464 enter into each individual situation and you should 1810 01:34:13,464 --> 01:34:16,645 try and separate yourself a little bit in that respect 1811 01:34:16,645 --> 01:34:19,537 and I think the treatment for the family should be 1812 01:34:19,537 --> 01:34:21,850 Social Service and more of an emotional support 1813 01:34:21,850 --> 01:34:25,017 rather than basing their loved one's-- 1814 01:34:26,898 --> 01:34:27,764 - Destiny. 1815 01:34:27,764 --> 01:34:29,664 - Destiny, their treatment in 1816 01:34:29,664 --> 01:34:32,607 the hospital on the family's emotion. 1817 01:34:32,607 --> 01:34:34,602 I mean we're focusing on the family's emotion 1818 01:34:34,602 --> 01:34:36,807 and we're basing the patient's treatment on 1819 01:34:36,807 --> 01:34:38,675 the family's emotion and now we're talking 1820 01:34:38,675 --> 01:34:40,538 about holidays and I don't think that's the issue. 1821 01:34:40,538 --> 01:34:42,421 - We give them too much control. 1822 01:34:42,421 --> 01:34:44,580 How many times have we talked about, 1823 01:34:44,580 --> 01:34:46,653 I mean they go out and ask the family, 1824 01:34:46,653 --> 01:34:48,907 I mean a family that doesn't know anything about 1825 01:34:48,907 --> 01:34:51,449 medicine at all, "Do you want your family member 1826 01:34:51,449 --> 01:34:53,980 "to be put on pressers if they should beat it?" 1827 01:34:53,980 --> 01:34:57,221 Now I mean if I was a family member, I would be like my god, 1828 01:34:57,221 --> 01:34:59,684 and what you're asking them is to tell you 1829 01:34:59,684 --> 01:35:01,585 to deny their family member something that 1830 01:35:01,585 --> 01:35:04,701 might keep them going or alive or save them. 1831 01:35:04,701 --> 01:35:07,270 - Why are you doing that? - I think it's passing 1832 01:35:07,270 --> 01:35:09,697 the buck about who's gonna make the decision. 1833 01:35:09,697 --> 01:35:11,894 Nobody is comfortable with the decision. 1834 01:35:11,894 --> 01:35:14,023 - [Nurse] It's because you or whoever is involved 1835 01:35:14,023 --> 01:35:17,035 is supposed to know the feelings of uncomfortableness. 1836 01:35:17,035 --> 01:35:18,731 - If I was in that position, 1837 01:35:18,731 --> 01:35:21,362 I would examine my own morals and my values. 1838 01:35:21,362 --> 01:35:23,505 - [Nurse] It's the responsibility we have. 1839 01:35:23,505 --> 01:35:25,302 - [Nurse] That's not the case in 100% of the times. 1840 01:35:25,302 --> 01:35:28,281 - That has everyone zero in on that because I never 1841 01:35:28,281 --> 01:35:33,077 saw the kind of involvement with family at other places. 1842 01:35:33,077 --> 01:35:35,755 So someone from up above-- - Is it good or bad? 1843 01:35:35,755 --> 01:35:39,654 - Is giving this philosophy down to everybody. 1844 01:35:39,654 --> 01:35:42,482 That you have to include the family in the decision-making. 1845 01:35:42,482 --> 01:35:44,761 - Include them but not let them make the decision. 1846 01:35:44,761 --> 01:35:47,324 - I think we need to study and look at how do families 1847 01:35:47,324 --> 01:35:50,312 feel who've been through making this decision afterwards, 1848 01:35:50,312 --> 01:35:52,213 a few months, a few years after. 1849 01:35:52,213 --> 01:35:54,028 I think a lot of times if they don't 1850 01:35:54,028 --> 01:35:55,974 have any medical background, we really 1851 01:35:55,974 --> 01:35:58,718 put way too much responsibility on them. 1852 01:35:58,718 --> 01:36:01,521 - But the thing is that when a physician presents this 1853 01:36:01,521 --> 01:36:04,921 to the family, a physician has a very powerful perspective 1854 01:36:04,921 --> 01:36:07,477 and I really believe that he can manipulate 1855 01:36:07,477 --> 01:36:10,564 any family to believe what he wants to do 1856 01:36:10,564 --> 01:36:13,341 and it's the art of experience. 1857 01:36:13,341 --> 01:36:15,714 - By his values and what's morally right to him 1858 01:36:15,714 --> 01:36:18,022 and where he's comfortable with the whole issue. 1859 01:36:18,022 --> 01:36:20,106 - And it's only, let's be honest, 1860 01:36:20,106 --> 01:36:22,221 it's only once the decision is 1861 01:36:22,221 --> 01:36:24,452 that this person is probably going to die. 1862 01:36:24,452 --> 01:36:26,195 Before that point, they don't go out, 1863 01:36:26,195 --> 01:36:28,353 I mean that's really when we start, 1864 01:36:28,353 --> 01:36:30,225 that's when we go out and say to the family, 1865 01:36:30,225 --> 01:36:32,234 "How do you want us to do it, how should we do it?" 1866 01:36:32,234 --> 01:36:34,385 - [Nurse] Until then no one has any troublemaking decisions. 1867 01:36:34,385 --> 01:36:36,661 - No, we excuse people from the room. 1868 01:36:36,661 --> 01:36:38,315 We're involved in something with, you know, with the 1869 01:36:38,315 --> 01:36:41,048 person that you gave birth to and we'll see you in an hour. 1870 01:36:41,048 --> 01:36:42,956 We don't have then in there. 1871 01:36:42,956 --> 01:36:47,053 But it is when they're dying that we do that and I think-- 1872 01:36:47,053 --> 01:36:48,621 - [Nurse] Nobody's comfortable with it. 1873 01:36:48,621 --> 01:36:50,323 - And sometimes we're not present, we're not there 1874 01:36:50,323 --> 01:36:52,267 on the phone when the whole talking to the family, 1875 01:36:52,267 --> 01:36:54,571 we'd like to put our two cents in but, you know 1876 01:36:54,571 --> 01:36:57,347 and it's up to them how they use their choice of words. 1877 01:36:57,347 --> 01:36:59,083 - But I've been in a situation where 1878 01:36:59,083 --> 01:37:01,677 they've talked to the family, "What would you like us to do? 1879 01:37:01,677 --> 01:37:03,083 And the family said "Oh, we'd like 1880 01:37:03,083 --> 01:37:05,422 "everything done but we want him comfortable." 1881 01:37:05,422 --> 01:37:09,237 So they took that as oh, he's full code. 1882 01:37:09,237 --> 01:37:11,912 So I started talking, it was Cindy Frusi and I, 1883 01:37:11,912 --> 01:37:14,577 Cindy Frusi and I said well you know, when he-- 1884 01:37:14,577 --> 01:37:15,532 - [Nurse] Who are you talking about? 1885 01:37:15,532 --> 01:37:17,108 - This is a guy a couple years ago. 1886 01:37:17,108 --> 01:37:19,400 Cindy Frusi and I basically got a DNR status 1887 01:37:19,400 --> 01:37:22,091 on this guy at one o'clock in the morning. 1888 01:37:22,091 --> 01:37:25,027 I mean it was just, well do you realize that if he dies, 1889 01:37:25,027 --> 01:37:28,932 if he stops breathing, we will shove a tube down his throat, 1890 01:37:28,932 --> 01:37:31,173 we will press on his chest, 1891 01:37:31,173 --> 01:37:34,121 put big lines in his neck, et cetera, et cetera. 1892 01:37:34,121 --> 01:37:35,568 "Oh no, we don't want that." 1893 01:37:35,568 --> 01:37:38,047 I said "Well that's what they're asking you to decide. 1894 01:37:38,047 --> 01:37:43,047 "When you say you want everything done, that's everything." 1895 01:37:43,639 --> 01:37:45,242 So they said "Oh no, 1896 01:37:45,242 --> 01:37:46,789 "we don't want that, we want him comfortable," 1897 01:37:46,789 --> 01:37:49,021 I said "Well then that's what you have to tell us. 1898 01:37:49,021 --> 01:37:51,213 "You have to tell us that you don't want drastic 1899 01:37:51,213 --> 01:37:54,366 "measures taken and those are the big drastic measures. 1900 01:37:54,366 --> 01:37:56,536 "Those are things that you don't want to see 1901 01:37:56,536 --> 01:37:58,932 "and that you don't want to see him go through." 1902 01:37:58,932 --> 01:38:01,708 And we basically said, I basically said, 1903 01:38:01,708 --> 01:38:03,646 I forget who it was, I said "Come here, 1904 01:38:03,646 --> 01:38:05,678 "please, the family has something to tell you." 1905 01:38:05,678 --> 01:38:07,130 Da da da, "They don't want this done." 1906 01:38:07,130 --> 01:38:09,803 Okay, we have a DNR order. 1907 01:38:09,803 --> 01:38:11,924 - You were there. - One o'clock in the morning. 1908 01:38:11,924 --> 01:38:14,330 - [Nurse] Did you call the family back, Jane? 1909 01:38:14,330 --> 01:38:17,268 - They were there, they stayed through the night 1910 01:38:17,268 --> 01:38:19,344 and we put him on a morphine drip 1911 01:38:19,344 --> 01:38:22,017 and he got very short, he was a guy with 1912 01:38:22,017 --> 01:38:24,636 lung cancer or something and he was at home 1913 01:38:24,636 --> 01:38:26,455 for six months, eight months and they'd taken 1914 01:38:26,455 --> 01:38:28,976 care of him and they realized this was the end. 1915 01:38:28,976 --> 01:38:32,047 But he was in the ICU because the decision hadn't been made. 1916 01:38:32,047 --> 01:38:34,484 He was like this, being intubated 1917 01:38:34,484 --> 01:38:36,901 and we basically coordinated. 1918 01:38:38,751 --> 01:38:41,483 They physicians weren't listening to what the family 1919 01:38:41,483 --> 01:38:45,018 was saying and as you spent more time with the family, 1920 01:38:45,018 --> 01:38:47,797 as you spent more time with the family, 1921 01:38:47,797 --> 01:38:50,004 you got an idea of where they were sitting 1922 01:38:50,004 --> 01:38:52,454 and the physicians were busy. 1923 01:38:52,454 --> 01:38:54,644 So that's, I mean that's the role we play. 1924 01:38:54,644 --> 01:38:57,127 It was a true patient advocate situation, 1925 01:38:57,127 --> 01:38:59,669 patient-family advocate situation including the family, 1926 01:38:59,669 --> 01:39:01,834 you know, what really do you want to happen? 1927 01:39:01,834 --> 01:39:04,212 You don't come here without dealing with it first. 1928 01:39:04,212 --> 01:39:06,163 I mean my first month here was, 1929 01:39:06,163 --> 01:39:08,688 I mean I was an emotional wreck 1930 01:39:08,688 --> 01:39:10,928 because all my patients died. 1931 01:39:10,928 --> 01:39:13,416 I was like what was I doing? 1932 01:39:13,416 --> 01:39:15,438 It was very frustrating but then you solve it 1933 01:39:15,438 --> 01:39:18,559 and you say these people are better off dead. 1934 01:39:18,559 --> 01:39:19,891 They're more at peace, 1935 01:39:19,891 --> 01:39:21,972 but it also is the way I deal with it. 1936 01:39:21,972 --> 01:39:24,127 My religion, my morals, what I do, 1937 01:39:24,127 --> 01:39:26,702 how I live my life, my philosophy, da da da da 1938 01:39:26,702 --> 01:39:28,644 and everybody has to do that within themselves 1939 01:39:28,644 --> 01:39:30,473 and that's why everybody deals with it 1940 01:39:30,473 --> 01:39:33,973 individually and presents it individually. 1941 01:40:25,130 --> 01:40:28,048 (patient coughing) 1942 01:40:32,759 --> 01:40:35,516 - [Nurse] You need your pillow? 1943 01:40:35,516 --> 01:40:36,683 Are you there? 1944 01:40:37,798 --> 01:40:39,215 What's too tight? 1945 01:41:31,744 --> 01:41:36,161 You were a little better than what you tested before. 1946 01:41:43,327 --> 01:41:45,867 - [Doctor] Because we've all agreed that since her 1947 01:41:45,867 --> 01:41:48,596 troubles were transient, that intubation was an appropriate 1948 01:41:48,596 --> 01:41:51,957 form of therapy in spite of the fact that overall 1949 01:41:51,957 --> 01:41:55,925 in the event of death, she's not to be resuscitated. 1950 01:41:55,925 --> 01:41:57,832 - Right but I guess my concern is that 1951 01:41:57,832 --> 01:42:01,217 she's been intubated five times in six months. 1952 01:42:01,217 --> 01:42:04,443 - Yeah but each time with a reversible phenomenon. 1953 01:42:04,443 --> 01:42:06,103 Look how much better she is now. 1954 01:42:06,103 --> 01:42:07,260 - No, I agree. 1955 01:42:07,260 --> 01:42:08,618 - So I think that would still be an 1956 01:42:08,618 --> 01:42:11,400 appropriate part of regular care as opposed to-- 1957 01:42:11,400 --> 01:42:13,466 - So with any type of-- 1958 01:42:13,466 --> 01:42:18,135 - If we extubate her and then she has a VF arrest, 1959 01:42:18,135 --> 01:42:21,302 she's to go but if as part of hypoxia, 1960 01:42:22,456 --> 01:42:24,614 we decide to re-intubate her, we'll do it again. 1961 01:42:24,614 --> 01:42:26,353 I wouldn't hesitate to do that. 1962 01:42:26,353 --> 01:42:29,202 She just has marginal lungs and complicates with either 1963 01:42:29,202 --> 01:42:33,159 failure or pneumonia but those are both reversible. 1964 01:42:33,159 --> 01:42:35,975 - True but in the broad spectrum of the picture, 1965 01:42:35,975 --> 01:42:39,280 she has COPD to begin with, she's now immobile. 1966 01:42:39,280 --> 01:42:42,210 She has very poor airway clearance to begin with. 1967 01:42:42,210 --> 01:42:44,654 Aren't we talking about a chronic situation? 1968 01:42:44,654 --> 01:42:46,102 - We are because she's going to go to 1969 01:42:46,102 --> 01:42:47,679 a chronic hospital from here but still 1970 01:42:47,679 --> 01:42:49,406 she's entitled to life if she can get it. 1971 01:42:49,406 --> 01:42:52,442 - For sure, I guess what I'm actually bringing up is 1972 01:42:52,442 --> 01:42:56,883 is there any concern about perhaps traching this lady? 1973 01:42:56,883 --> 01:42:59,246 - Oh yes, depending on how reversible it is-- 1974 01:42:59,246 --> 01:43:00,486 - I guess that's what I'm asking. 1975 01:43:00,486 --> 01:43:02,779 I mean is that the only way to protect her airway? 1976 01:43:02,779 --> 01:43:04,520 - Well we're not sure that that'll protect it 1977 01:43:04,520 --> 01:43:07,083 because even a trach doesn't prevent you from aspiration. 1978 01:43:07,083 --> 01:43:09,704 - [Anne-Louise] Surely, surely but 1979 01:43:09,704 --> 01:43:12,050 and knowing how he's dealing with things, 1980 01:43:12,050 --> 01:43:13,833 if that has to end up-- - We in fact have 1981 01:43:13,833 --> 01:43:15,587 sort of started to explore that with him. 1982 01:43:15,587 --> 01:43:16,638 - You have, oh okay. 1983 01:43:16,638 --> 01:43:18,008 - What his reaction would be I don't know yet 1984 01:43:18,008 --> 01:43:19,541 because we haven't come down to the moment 1985 01:43:19,541 --> 01:43:21,162 where we've said "Well, now you must make a choice." 1986 01:43:21,162 --> 01:43:22,486 - Yes. 1987 01:43:22,486 --> 01:43:25,968 So at this point then for any respiratory compromise, 1988 01:43:25,968 --> 01:43:27,705 you would want her re-intubated. 1989 01:43:27,705 --> 01:43:29,035 - Yeah. - Okay. 1990 01:43:29,035 --> 01:43:32,202 All right, thank you very much Doctor. 1991 01:43:33,902 --> 01:43:37,068 (metallic clattering) 1992 01:43:38,967 --> 01:43:41,175 - Which we did do yesterday. - Let's do this then. 1993 01:43:41,175 --> 01:43:44,155 Let's put her on 30%, let's bring her down to four, 1994 01:43:44,155 --> 01:43:46,231 let's get a gas on four, see how she's doing and then 1995 01:43:46,231 --> 01:43:49,202 we can watch her for awhile and see how she does. 1996 01:43:49,202 --> 01:43:51,492 - The problem with her is that she really feels 1997 01:43:51,492 --> 01:43:53,642 a difference between six and four and she'll tell you 1998 01:43:53,642 --> 01:43:56,205 she's short of breath but her rate actually is 1999 01:43:56,205 --> 01:44:00,187 no faster than what it is when she's extubated. 2000 01:44:00,187 --> 01:44:04,114 Easier said than done, I mean that's how she breathes. 2001 01:44:04,114 --> 01:44:06,773 - What are the plans in terms of re-intubation? 2002 01:44:06,773 --> 01:44:09,431 - I'm glad you brought that up because I just had a 2003 01:44:09,431 --> 01:44:13,346 talk with Dr. Kerlind about that and his feeling is that, 2004 01:44:13,346 --> 01:44:16,840 he just left, if again she has any type of 2005 01:44:16,840 --> 01:44:20,349 respiratory compromise unassociated with a V-tach 2006 01:44:20,349 --> 01:44:22,867 or V-fib arrest that she is to be re-intubated. 2007 01:44:22,867 --> 01:44:27,255 So I said but she's been intubated five times in six months, 2008 01:44:27,255 --> 01:44:29,905 are we talking about something more chronic 2009 01:44:29,905 --> 01:44:31,895 in terms of protecting her airway? 2010 01:44:31,895 --> 01:44:33,773 Because she's always gonna be, 2011 01:44:33,773 --> 01:44:35,870 have a poor airway clearance. 2012 01:44:35,870 --> 01:44:38,612 She does have COPD, she does have failure. 2013 01:44:38,612 --> 01:44:41,228 And he said well he has thought about 2014 01:44:41,228 --> 01:44:43,934 the discussion of a trach with Dr. Factor 2015 01:44:43,934 --> 01:44:45,639 but hasn't yet brought it up. 2016 01:44:45,639 --> 01:44:47,387 But as it stands right now, he would want her 2017 01:44:47,387 --> 01:44:51,054 re-intubated for any respiratory compromise. 2018 01:44:54,462 --> 01:44:55,379 So-- - Okay. 2019 01:44:56,835 --> 01:44:59,418 - That's where we're at. - Okay. 2020 01:45:00,281 --> 01:45:02,648 - [Scott] Well but it sounds like we have a plan though. 2021 01:45:02,648 --> 01:45:04,991 What George is saying that you know, 2022 01:45:04,991 --> 01:45:06,527 we get her off the ventilator, 2023 01:45:06,527 --> 01:45:10,120 if she fails again, then we do a trach. 2024 01:45:10,120 --> 01:45:12,864 - He said re-intubated, yeah we have to think about a trach. 2025 01:45:12,864 --> 01:45:15,607 He's still putting the trach in a very futuristic light. 2026 01:45:15,607 --> 01:45:18,264 - [Scott] But I mean that would be the next step. 2027 01:45:18,264 --> 01:45:20,031 - Right but I'd rather hit him with it 2028 01:45:20,031 --> 01:45:22,261 before she actually gets extubated this time, 2029 01:45:22,261 --> 01:45:23,867 being that she may need to be re-intubated 2030 01:45:23,867 --> 01:45:25,433 during the night when no one's around 2031 01:45:25,433 --> 01:45:26,923 other than those of us that care for her. 2032 01:45:26,923 --> 01:45:28,419 - [Scott] But you wouldn't do a trach in the middle of-- 2033 01:45:28,419 --> 01:45:29,909 - No but that's what I'm saying. 2034 01:45:29,909 --> 01:45:31,469 She would get re-intubated and then we'd be 2035 01:45:31,469 --> 01:45:34,353 back to having this discussion again without any-- 2036 01:45:34,353 --> 01:45:36,232 - Plan. - Longer-term plan. 2037 01:45:36,232 --> 01:45:38,443 That's all I'm trying to say is that 2038 01:45:38,443 --> 01:45:40,008 there's a very good chance of that happening again. 2039 01:45:40,008 --> 01:45:41,620 She's doing fine and I think we will 2040 01:45:41,620 --> 01:45:43,327 get it dissipated by the end of the week. 2041 01:45:43,327 --> 01:45:44,862 - [Scott] It's gonna happen again, whether it'll 2042 01:45:44,862 --> 01:45:46,958 happen a month from now or two weeks from now or-- 2043 01:45:46,958 --> 01:45:48,701 - I think it's kinda cruel to keep putting this little 2044 01:45:48,701 --> 01:45:52,061 old lady through being re-intubated all the time too. 2045 01:45:52,061 --> 01:45:53,644 I mean that's not a 2046 01:45:54,707 --> 01:45:55,540 simple 2047 01:45:56,567 --> 01:45:58,094 procedure. 2048 01:45:58,094 --> 01:45:59,428 - [Scott] Right. 2049 01:46:01,570 --> 01:46:03,438 I don't know, maybe-- 2050 01:46:03,438 --> 01:46:04,770 - I don't know what his reasoning is. 2051 01:46:04,770 --> 01:46:06,054 - [Scott] Maybe he can't make up 2052 01:46:06,054 --> 01:46:09,943 his mind whether he wants to, you know, 2053 01:46:09,943 --> 01:46:13,312 whether he wants to just call it a day and 2054 01:46:13,312 --> 01:46:14,145 not 2055 01:46:16,706 --> 01:46:18,236 re-intubate her. 2056 01:46:18,236 --> 01:46:19,736 I don't know, I'll talk to him some more about it. 2057 01:46:19,736 --> 01:46:20,568 - Okay. 2058 01:46:36,037 --> 01:46:39,270 - [Nurse] So I just sense it's really difficult. 2059 01:46:39,270 --> 01:46:40,841 I get this old man and he 2060 01:46:40,841 --> 01:46:44,008 shows up with these cookies every day. 2061 01:46:45,109 --> 01:46:48,210 - You have a call, line five. 2062 01:46:48,210 --> 01:46:53,127 Dr. Factor, you can go in and see your wife if you want to. 2063 01:47:05,068 --> 01:47:06,577 - [Scott] The thing to do would be to do 2064 01:47:06,577 --> 01:47:10,327 a trach if you want to keep pressing on here. 2065 01:47:11,225 --> 01:47:14,267 - It's a terribly difficult case, her husband 2066 01:47:14,267 --> 01:47:15,517 as you know has 2067 01:47:17,300 --> 01:47:21,148 agreed that it would make no sense to do 2068 01:47:21,148 --> 01:47:24,262 a resuscitative procedure, on the other hand, 2069 01:47:24,262 --> 01:47:26,178 to keep preventing exactly this kind of 2070 01:47:26,178 --> 01:47:28,080 thing which is going on while she's alive, 2071 01:47:28,080 --> 01:47:30,057 I think it might be worth considering. 2072 01:47:30,057 --> 01:47:31,827 But she was the strong member of the family. 2073 01:47:31,827 --> 01:47:33,405 She'll have an opinion herself about whether 2074 01:47:33,405 --> 01:47:35,550 she wants to do this and she is-- 2075 01:47:35,550 --> 01:47:36,797 - I think we should talk to her about it 2076 01:47:36,797 --> 01:47:39,305 because I think that the pattern over 2077 01:47:39,305 --> 01:47:42,491 the last couple of months is pretty clear that she's, 2078 01:47:42,491 --> 01:47:45,612 I mean she's aspirated two or three times. 2079 01:47:45,612 --> 01:47:47,520 With the stroke, she's just not, 2080 01:47:47,520 --> 01:47:49,990 I suppose even with a gastrostomy 2081 01:47:49,990 --> 01:47:52,937 which was supposed to be the other thing-- 2082 01:47:52,937 --> 01:47:54,300 - She already has feeding, 2083 01:47:54,300 --> 01:47:56,349 doesn't she have a feeding gastrostomy already? 2084 01:47:56,349 --> 01:47:58,255 That just doesn't protect you. 2085 01:47:58,255 --> 01:48:00,090 - She can't handle her secretions. 2086 01:48:00,090 --> 01:48:04,007 She has no bulbar muscle, so I mean it's gonna, 2087 01:48:04,959 --> 01:48:07,370 it may be two weeks 2088 01:48:07,370 --> 01:48:08,985 but it's gonna be, 2089 01:48:08,985 --> 01:48:10,478 I think we should probably talk to her 2090 01:48:10,478 --> 01:48:11,952 about it now that she's got the tube out. 2091 01:48:11,952 --> 01:48:13,589 - [George] Well we'll discuss it with him first but 2092 01:48:13,589 --> 01:48:16,380 then I think the ultimate decision has to be made by her. 2093 01:48:16,380 --> 01:48:17,214 - Right. 2094 01:49:28,615 --> 01:49:29,865 All right, well 2095 01:49:31,594 --> 01:49:33,048 I think there are a couple of issues. 2096 01:49:33,048 --> 01:49:34,965 One is that she failed, 2097 01:49:39,976 --> 01:49:43,976 admittedly the long term problem is gonna recur. 2098 01:49:45,050 --> 01:49:46,638 Eventually she's gonna re-aspirate, 2099 01:49:46,638 --> 01:49:48,636 she's gonna get another pneumophonia 2100 01:49:48,636 --> 01:49:51,699 and if she has a trach, then you can treat this. 2101 01:49:51,699 --> 01:49:54,518 On the other hand, she may not want a trach. 2102 01:49:54,518 --> 01:49:56,712 So I mean I think that 2103 01:49:56,712 --> 01:50:00,202 I'll talk to her about a trach right now. 2104 01:50:00,202 --> 01:50:02,333 I'd like to get her opinion sort of when George 2105 01:50:02,333 --> 01:50:06,041 isn't here and sort of see what, how she feels about it 2106 01:50:06,041 --> 01:50:07,985 when her husband isn't here because he's pretty fragile. 2107 01:50:07,985 --> 01:50:10,652 So I'd like to talk to her myself about that. 2108 01:50:10,652 --> 01:50:12,109 - Nobody ever tells her what's going on, 2109 01:50:12,109 --> 01:50:14,442 certainly her husband doesn't, we don't 2110 01:50:14,442 --> 01:50:16,307 and George doesn't and she expressed that 2111 01:50:16,307 --> 01:50:20,224 frustration yesterday to Sue after George left. 2112 01:50:21,116 --> 01:50:23,052 - [Scott] Well George is never gonna either. 2113 01:50:23,052 --> 01:50:24,641 - She didn't say anything, she just rolled 2114 01:50:24,641 --> 01:50:27,463 her eyes after he had been very chipper in 2115 01:50:27,463 --> 01:50:29,198 how good she was doing and all this stuff 2116 01:50:29,198 --> 01:50:31,092 and she clearly was disgusted and frustrated. 2117 01:50:31,092 --> 01:50:32,800 - [Scott] Now and then I'll catch up with you guys. 2118 01:50:32,800 --> 01:50:35,011 - In terms of the plan for the day then, 2119 01:50:35,011 --> 01:50:37,202 we're gonna try to extubate again today? 2120 01:50:37,202 --> 01:50:38,478 - No. - No. 2121 01:50:38,478 --> 01:50:40,663 - We just buff her gases though. 2122 01:50:40,663 --> 01:50:43,527 She likes, IMVF6 seems to be a good place for her. 2123 01:50:43,527 --> 01:50:46,048 - Let me talk to her first to see how she feels. 2124 01:50:46,048 --> 01:50:48,216 Let me talk to her first and see how she feels. 2125 01:50:48,216 --> 01:50:50,609 My own personal feeling would be that 2126 01:50:50,609 --> 01:50:52,437 I would try to get her gases buffed and try 2127 01:50:52,437 --> 01:50:54,868 again tomorrow but I would do it a different way. 2128 01:50:54,868 --> 01:50:57,695 I would TP wean her and give her some diuretic 2129 01:50:57,695 --> 01:50:58,903 and see if she could-- 2130 01:50:58,903 --> 01:51:00,304 - [Anne-Louise] In the past she's always TP wean, 2131 01:51:00,304 --> 01:51:02,187 she's never been cold turkey. 2132 01:51:02,187 --> 01:51:04,476 - I think we've pulled things in a little, 2133 01:51:04,476 --> 01:51:07,195 we were a bit abrupt yesterday and that 2134 01:51:07,195 --> 01:51:11,398 she went into pulmonary edema in part because of that. 2135 01:51:11,398 --> 01:51:13,921 My inclination would be to sort of get her 2136 01:51:13,921 --> 01:51:16,045 buffed up today, give her some diuretic 2137 01:51:16,045 --> 01:51:18,689 early tomorrow morning, you know, 2138 01:51:18,689 --> 01:51:21,337 when she's on sort of four breaths and then-- 2139 01:51:21,337 --> 01:51:24,760 - [Anne-Louise] Right, we've done on IMP04 and that usually 2140 01:51:24,760 --> 01:51:28,166 pulls her longer than an hour once you TP and extubate her. 2141 01:51:28,166 --> 01:51:30,680 - Exactly and my feeling would be depending 2142 01:51:30,680 --> 01:51:33,887 on what she says today, either 2143 01:51:33,887 --> 01:51:37,996 she comes off the ventilator tomorrow and she does okay 2144 01:51:37,996 --> 01:51:41,831 and we don't re-intubate her or she doesn't 2145 01:51:41,831 --> 01:51:44,459 come off the ventilator tomorrow and she 2146 01:51:44,459 --> 01:51:49,018 ends up going for a trach if that's what she wants. 2147 01:51:49,018 --> 01:51:52,702 Is anybody else, I mean I think you know, 2148 01:51:52,702 --> 01:51:54,945 the thing that makes this case tougher than 2149 01:51:54,945 --> 01:51:58,553 some other ones is that George is not free-flowing 2150 01:51:58,553 --> 01:52:00,835 with his feelings and he really likes to keep control 2151 01:52:00,835 --> 01:52:03,636 of the case himself so that it's much more difficult 2152 01:52:03,636 --> 01:52:07,209 to sort of deal with him and say well, you know. 2153 01:52:07,209 --> 01:52:10,055 He's not inclined to sort of really open up to her 2154 01:52:10,055 --> 01:52:13,094 and tell her, he's more the kind of doctor who's 2155 01:52:13,094 --> 01:52:16,246 gonna just sorta do what he thinks needs to be done. 2156 01:52:16,246 --> 01:52:18,909 He's gonna go ahead and say "You need a trach." 2157 01:52:18,909 --> 01:52:21,129 Rather than "These are your choices." 2158 01:52:21,129 --> 01:52:23,089 - [Anne-Louise] I think you just have to take into account 2159 01:52:23,089 --> 01:52:24,993 before you speak to her that most therapies 2160 01:52:24,993 --> 01:52:27,362 she refuses from chest PT to Albuterol, 2161 01:52:27,362 --> 01:52:30,087 I mean everything is no, so you have to think 2162 01:52:30,087 --> 01:52:31,865 about that when you're asking her for her 2163 01:52:31,865 --> 01:52:34,210 honest opinion of how she feels about the trach. 2164 01:52:34,210 --> 01:52:36,068 She doesn't want to do what we do to her 2165 01:52:36,068 --> 01:52:38,710 on a day to day basis if you just went by that. 2166 01:52:38,710 --> 01:52:41,103 - If that's true-- - A really significant fact. 2167 01:52:41,103 --> 01:52:44,368 - Of course it is. - Nobody has ever asked her, 2168 01:52:44,368 --> 01:52:46,736 this isn't fair then. 2169 01:52:46,736 --> 01:52:48,555 - Who are we doing this for? - Exactly. 2170 01:52:48,555 --> 01:52:51,972 - George or her? - That's what I'm saying. 2171 01:52:53,126 --> 01:52:55,331 Clearly and with all her admissions, 2172 01:52:55,331 --> 01:52:58,081 she's said no to most everything. 2173 01:52:58,973 --> 01:53:01,536 But we don't usually give her the choice. 2174 01:53:01,536 --> 01:53:05,764 - Clearly she should be able to make the decision 2175 01:53:05,764 --> 01:53:08,207 and that's the hospital policy, right? 2176 01:53:08,207 --> 01:53:09,407 - [Scott] Right. 2177 01:53:09,407 --> 01:53:11,672 - She's certainly with it, I mean she's almost 2178 01:53:11,672 --> 01:53:15,288 always with it enough to make those decisions. 2179 01:53:15,288 --> 01:53:18,904 - [Anne-Louise] This is not her best time of the day either. 2180 01:53:18,904 --> 01:53:20,835 Around 11 or 12 o'clock, no really, 2181 01:53:20,835 --> 01:53:23,698 quite frankly it takes a long time to wake her up. 2182 01:53:23,698 --> 01:53:25,110 - I'm trying to be a little proactive here. 2183 01:53:25,110 --> 01:53:27,103 I'd like to get in there before Kerlind comes by. 2184 01:53:27,103 --> 01:53:31,170 He's doing rounds, he's not gonna be up here until 10:30. 2185 01:53:31,170 --> 01:53:33,696 So if I can talk to her now and then say to him 2186 01:53:33,696 --> 01:53:37,209 "Listen George, she doesn't want a trach." 2187 01:53:37,209 --> 01:53:41,175 Then I can take, I'm gonna have to take him on 2188 01:53:41,175 --> 01:53:44,434 because he's gonna, he'll give me a lot of crap 2189 01:53:44,434 --> 01:53:47,050 about how dare I talk to his patient, 2190 01:53:47,050 --> 01:53:49,058 you know and all the rest of this. 2191 01:53:49,058 --> 01:53:50,716 - Blame it on the husband. - What? 2192 01:53:50,716 --> 01:53:52,661 - Blame it on the husband. - No. 2193 01:53:52,661 --> 01:53:56,271 I'm a big boy, I can take care of myself. 2194 01:53:56,271 --> 01:53:57,298 - [Nurse] Are you bigger than he is? 2195 01:53:57,298 --> 01:53:58,544 - If she doesn't want the trach, 2196 01:53:58,544 --> 01:53:59,952 she has to know that the option is 2197 01:53:59,952 --> 01:54:02,943 not to be re-intubated every week 2198 01:54:02,943 --> 01:54:05,026 and that she's gonna die. 2199 01:54:06,040 --> 01:54:07,900 - I can make it clear to her what the options are, 2200 01:54:07,900 --> 01:54:10,666 I think I know what the options are. 2201 01:54:10,666 --> 01:54:12,558 But I think the thing that jacks up everyone's 2202 01:54:12,558 --> 01:54:15,827 anxiety in a case like this is that you know, 2203 01:54:15,827 --> 01:54:19,509 got an attending physician who's... 2204 01:54:19,509 --> 01:54:21,943 - [Anne-Louise] Who may not agree with her wishes. 2205 01:54:21,943 --> 01:54:24,686 - Yeah I mean you know, everything here is 2206 01:54:24,686 --> 01:54:28,339 sorta build on Quaker concept of consensus, you know? 2207 01:54:28,339 --> 01:54:30,206 So what the patient wants, the house staff wants, 2208 01:54:30,206 --> 01:54:35,070 the nurses want, the doctors want and what the family wants 2209 01:54:35,070 --> 01:54:38,993 and every time you have difficulty, it's because one of 2210 01:54:38,993 --> 01:54:43,993 those elements is out of sync and that's what we got here. 2211 01:54:44,264 --> 01:54:46,579 Not from the family, not from the patient I don't think. 2212 01:54:46,579 --> 01:54:47,939 Not from the nurses and not from 2213 01:54:47,939 --> 01:54:50,210 the staffing unit but from the doctor. 2214 01:54:50,210 --> 01:54:51,526 So let me talk to her. 2215 01:54:51,526 --> 01:54:54,109 - Still when we, she clearly is 2216 01:54:55,353 --> 01:54:56,186 agreeing. 2217 01:54:57,684 --> 01:54:59,620 - And as a matter of fact when you pushed 2218 01:54:59,620 --> 01:55:02,156 the DNR when she looked like she was going down the tubes-- 2219 01:55:02,156 --> 01:55:04,673 - I hardly pushed, all I did was ask 2220 01:55:04,673 --> 01:55:06,709 and her husband said "Oh, that's ridiculous. 2221 01:55:06,709 --> 01:55:08,755 "I wouldn't have wanted you to do that in any case." 2222 01:55:08,755 --> 01:55:11,552 But then when I presented that to Kerlind, he said fine. 2223 01:55:11,552 --> 01:55:13,414 - [Doctor] I think maybe George will be 2224 01:55:13,414 --> 01:55:14,950 relieved if we do it for him. - Yeah. 2225 01:55:14,950 --> 01:55:16,395 - [Anne-Louise] Well the one other thing you have 2226 01:55:16,395 --> 01:55:18,254 to know in terms of the doctor factor is yes, 2227 01:55:18,254 --> 01:55:19,871 he can say "Oh no, I wouldn't want 2228 01:55:19,871 --> 01:55:21,784 "you to shock her and pump on her chest." 2229 01:55:21,784 --> 01:55:23,438 And he was surprised that it took so long for us 2230 01:55:23,438 --> 01:55:25,276 to even bring it up, that's what he said to me. 2231 01:55:25,276 --> 01:55:27,680 However when she is short of breath, 2232 01:55:27,680 --> 01:55:29,258 his anxiety goes like this. 2233 01:55:29,258 --> 01:55:31,646 He drags me in there, whether it's on 2234 01:55:31,646 --> 01:55:34,348 the vent or it's extubated and I don't know-- 2235 01:55:34,348 --> 01:55:36,299 - Right but a morphine drip takes care of that. 2236 01:55:36,299 --> 01:55:38,966 - [Anne-Louise] Right, I mean... 2237 01:55:41,737 --> 01:55:44,114 - Okay. - Thank you. 2238 01:55:44,114 --> 01:55:47,364 Medical Intensive Care, can I help you? 2239 01:56:02,215 --> 01:56:03,776 - [Anne-Louise] I think all concentration 2240 01:56:03,776 --> 01:56:05,693 is taking the next breath. 2241 01:56:05,693 --> 01:56:07,559 I don't think it was anger or something. 2242 01:56:07,559 --> 01:56:09,254 - She understood everything in there. 2243 01:56:09,254 --> 01:56:10,587 - Oh, absolutely. - Definitely. 2244 01:56:10,587 --> 01:56:12,330 And I think it's great. - And Scott was good with him. 2245 01:56:12,330 --> 01:56:15,314 He really, he went over everything he talked about 2246 01:56:15,314 --> 01:56:18,388 with her and wanted me to see what she was saying 2247 01:56:18,388 --> 01:56:21,177 and it sounds to me and it looks to me like she 2248 01:56:21,177 --> 01:56:23,866 was in complete understanding of the options 2249 01:56:23,866 --> 01:56:26,441 and I did ask her, I said "All the other times, this is 2250 01:56:26,441 --> 01:56:28,730 "the sixth time that you've been put on the breathing 2251 01:56:28,730 --> 01:56:32,210 "machine, did you want us to do it all these times?" 2252 01:56:32,210 --> 01:56:33,866 - I know, I knew how she felt. 2253 01:56:33,866 --> 01:56:35,684 - [Anne-Louise] That's why I felt like I had to apologize 2254 01:56:35,684 --> 01:56:38,710 to her because I said sometimes we just get overtaken 2255 01:56:38,710 --> 01:56:41,037 with treating the fact that you're not breathing well 2256 01:56:41,037 --> 01:56:43,940 and we need to do something about that. 2257 01:56:43,940 --> 01:56:47,982 - Sometimes he'll go in there and like once she reaches for 2258 01:56:47,982 --> 01:56:51,096 the tube or whatever and she looks right at him and it's 2259 01:56:51,096 --> 01:56:55,128 like, she just looks at him as if to say what are you doing? 2260 01:56:55,128 --> 01:56:57,421 She's trying in her own way to subtly 2261 01:56:57,421 --> 01:57:00,233 indicate to him because it's obvious she's 2262 01:57:00,233 --> 01:57:03,291 been the strong one and is trying to help him. 2263 01:57:03,291 --> 01:57:04,851 - Right. - She's trying to help him 2264 01:57:04,851 --> 01:57:06,698 deal with her death, it's amazing. 2265 01:57:06,698 --> 01:57:09,193 - And that is the dynamics of their relationship. 2266 01:57:09,193 --> 01:57:11,895 I mean that she really has always been strong 2267 01:57:11,895 --> 01:57:13,754 and that he is absolutely so devoted 2268 01:57:13,754 --> 01:57:16,687 and at a loss without her and to have her 2269 01:57:16,687 --> 01:57:19,460 even be like this, to come to see her, 2270 01:57:19,460 --> 01:57:21,285 to at least have her be alive is 2271 01:57:21,285 --> 01:57:23,082 better to him than anything else. 2272 01:57:23,082 --> 01:57:24,208 - I agree, I agree. 2273 01:57:24,208 --> 01:57:25,739 - And that's where the problem is gonna lie, 2274 01:57:25,739 --> 01:57:27,648 especially if she crumps once she gets 2275 01:57:27,648 --> 01:57:30,059 extubated and the choice is made not to re-intubate. 2276 01:57:30,059 --> 01:57:31,682 - When she takes a turn for the worse, 2277 01:57:31,682 --> 01:57:33,800 I mean is he accepting death when he's running 2278 01:57:33,800 --> 01:57:36,977 to grab a stethoscope to listen or the blood pressure 2279 01:57:36,977 --> 01:57:40,368 dampened out on the thing, oh my god, her blood pressure and 2280 01:57:40,368 --> 01:57:42,853 it's like he wants somebody in there to fix it right away. 2281 01:57:42,853 --> 01:57:44,753 - [Anne-Louise] Meanwhile, 2282 01:57:44,753 --> 01:57:46,778 he hasn't come to terms with the words, 2283 01:57:46,778 --> 01:57:48,687 that he said no, I don't want her resuscitated. 2284 01:57:48,687 --> 01:57:51,112 But the event of a cardiac arrest 2285 01:57:51,112 --> 01:57:52,844 for Bernice is so minimal. 2286 01:57:52,844 --> 01:57:54,748 - That's why he could do it. - Right. 2287 01:57:54,748 --> 01:57:57,482 And that's why we got half of what I call a code status. 2288 01:57:57,482 --> 01:58:01,543 - But denying somebody a tube is a lot different from 2289 01:58:01,543 --> 01:58:04,789 defibrillating them once they've stopped breathing 2290 01:58:04,789 --> 01:58:07,183 or their heart has stopped it's totally different. 2291 01:58:07,183 --> 01:58:10,063 Especially since he's a physician and he realizes 2292 01:58:10,063 --> 01:58:13,156 to his own extent the difference between the two things. 2293 01:58:13,156 --> 01:58:14,362 - [Anne-Louise] Correct. 2294 01:58:14,362 --> 01:58:17,166 - But I'm glad you said something, that was wonderful. 2295 01:58:17,166 --> 01:58:20,137 - Well thanks Sue, I appreciate it. 2296 01:58:20,137 --> 01:58:23,782 - I spoke with Mrs. Factor and I've written a note here. 2297 01:58:23,782 --> 01:58:25,562 I had a long discussion with Mrs. Factor which 2298 01:58:25,562 --> 01:58:27,936 revolved around two areas, tracheostomy and re-intubation. 2299 01:58:27,936 --> 01:58:29,755 Mrs. Factor feels quite strongly that she does not want 2300 01:58:29,755 --> 01:58:31,573 to have a tracheostomy even though she realizes she will 2301 01:58:31,573 --> 01:58:34,061 die if she comes off the ventilator and is not re-intubated. 2302 01:58:34,061 --> 01:58:36,002 She's been re-intubated five times in the past two months 2303 01:58:36,002 --> 01:58:38,307 and feels that she has been through too much already. 2304 01:58:38,307 --> 01:58:39,841 She would also prefer not to have been 2305 01:58:39,841 --> 01:58:41,795 intubated at all the last two times 2306 01:58:41,795 --> 01:58:43,383 that I have seen her this month. 2307 01:58:43,383 --> 01:58:45,529 Given her wishes and the hopelessness of the situation, 2308 01:58:45,529 --> 01:58:47,313 I think her wishes are reasonable and will 2309 01:58:47,313 --> 01:58:49,058 discuss this with Dr. Kerlind to develop 2310 01:58:49,058 --> 01:58:51,968 a plan that incorporates Mrs. Factor's wishes. 2311 01:58:51,968 --> 01:58:55,111 She made it pretty clear that she, 2312 01:58:55,111 --> 01:58:58,611 as she put it, she thinks George is crazy. 2313 01:58:59,724 --> 01:59:01,250 - Is that what she said? 2314 01:59:01,250 --> 01:59:02,707 How did she communicate that to you? 2315 01:59:02,707 --> 01:59:04,112 I'm just curious. 2316 01:59:04,112 --> 01:59:06,112 - She mouthed the words. 2317 01:59:07,652 --> 01:59:10,145 I almost cried in there, I tell ya. 2318 01:59:10,145 --> 01:59:12,290 I think she's more difficult for me 2319 01:59:12,290 --> 01:59:15,046 than this lady, this lady's dead already. 2320 01:59:15,046 --> 01:59:18,702 You guys are flogging yourself but just she's gone. 2321 01:59:18,702 --> 01:59:21,370 Bernice is a lot harder problem. 2322 01:59:24,221 --> 01:59:27,545 A lot harder to walk into somebody's room who's 2323 01:59:27,545 --> 01:59:31,441 awake and alert and say "These are the options. 2324 01:59:31,441 --> 01:59:33,057 "Life in an institution with a tube in 2325 01:59:33,057 --> 01:59:37,307 "your throat on a machine or you can die tomorrow." 2326 01:59:39,061 --> 01:59:41,302 She had it much easier. 2327 01:59:41,302 --> 01:59:42,585 She didn't have to make the choice. 2328 01:59:42,585 --> 01:59:44,930 It happened real quick, she was out. 2329 01:59:44,930 --> 01:59:49,477 Just do it and be gone, it's a much better way to go. 2330 01:59:49,477 --> 01:59:50,660 I mean look what's happened to her. 2331 01:59:50,660 --> 01:59:51,942 She's been around for two months, 2332 01:59:51,942 --> 01:59:53,179 the doctor hasn't told her what's going on. 2333 01:59:53,179 --> 01:59:55,080 She's been intubated five times. 2334 01:59:55,080 --> 01:59:58,163 (electronic beeping) 2335 02:00:06,212 --> 02:00:08,638 I had a conversation with Mrs. Factor this morning. 2336 02:00:08,638 --> 02:00:10,212 - [George] Yeah. 2337 02:00:10,212 --> 02:00:13,333 - She is adamant about she wants that 2338 02:00:13,333 --> 02:00:16,730 tube out and she does not want a tracheostomy. 2339 02:00:16,730 --> 02:00:18,093 - [George] All right. 2340 02:00:18,093 --> 02:00:19,169 Well that's her privilege. 2341 02:00:19,169 --> 02:00:22,149 I rather thought that that's what she would say. 2342 02:00:22,149 --> 02:00:24,399 - [Scott] She is quite, 2343 02:00:24,399 --> 02:00:27,004 you have to know she said that she's, 2344 02:00:27,004 --> 02:00:28,326 I think when we re-intubated her 2345 02:00:28,326 --> 02:00:30,579 yesterday, she was really furious. 2346 02:00:30,579 --> 02:00:33,945 - Before she entered the hospital, 2347 02:00:33,945 --> 02:00:37,112 she set very rigid limits to her care. 2348 02:00:38,400 --> 02:00:41,673 Limits which were not in her own best interest. 2349 02:00:41,673 --> 02:00:43,422 - [Scott] I'm sure that's probably true. 2350 02:00:43,422 --> 02:00:47,244 - Always bargaining to accept the lesser 2351 02:00:47,244 --> 02:00:49,235 of two therapies and in part that's one 2352 02:00:49,235 --> 02:00:52,508 of the reasons that she has been so ill. 2353 02:00:52,508 --> 02:00:55,856 Not her stroke, which is major but with regard 2354 02:00:55,856 --> 02:00:58,260 to other aspects, both her heart failure 2355 02:00:58,260 --> 02:01:01,444 and her chronic lung disease, her overweight, 2356 02:01:01,444 --> 02:01:04,013 her obesity and hypertension, always accepting 2357 02:01:04,013 --> 02:01:06,798 the minimal amount of therapy and that only 2358 02:01:06,798 --> 02:01:10,772 after pushing and compromising and as you know, 2359 02:01:10,772 --> 02:01:14,054 her husband or physician was never able to 2360 02:01:14,054 --> 02:01:16,711 get her to agree with more than she wanted to 2361 02:01:16,711 --> 02:01:20,526 because she was the dominant member of the family. 2362 02:01:20,526 --> 02:01:22,059 - Well you know, 2363 02:01:22,059 --> 02:01:25,263 I mean I have to say looking at her situation now, 2364 02:01:25,263 --> 02:01:28,274 it's probably not unreasonable, you never know what 2365 02:01:28,274 --> 02:01:30,550 you'd do in that situation, it's really hard to say. 2366 02:01:30,550 --> 02:01:33,395 We'll try again to wean her tomorrow. 2367 02:01:33,395 --> 02:01:34,746 - [George] That's the last crack at it. 2368 02:01:34,746 --> 02:01:36,820 - Well no, I think you know, 2369 02:01:36,820 --> 02:01:38,994 see I'm not so pessimistic in the short term. 2370 02:01:38,994 --> 02:01:41,616 I always get 'em off but I mean 2371 02:01:41,616 --> 02:01:44,013 I don't know, I can't guarantee that she's not 2372 02:01:44,013 --> 02:01:47,290 gonna have, that she's gonna last for along time. 2373 02:01:47,290 --> 02:01:48,572 - [George] See the problem is that 2374 02:01:48,572 --> 02:01:50,312 she's gonna be left with the stiff ventricle. 2375 02:01:50,312 --> 02:01:51,489 - Right, right. 2376 02:01:51,489 --> 02:01:53,780 But I'd give her some diuretic before 2377 02:01:53,780 --> 02:01:55,514 and if she doesn't want it back in, fine. 2378 02:01:55,514 --> 02:01:57,057 - [George] No I mean in terms 2379 02:01:57,057 --> 02:01:58,828 of what's likely to happen under there. 2380 02:01:58,828 --> 02:02:00,439 - Well I mean it's, you know, 2381 02:02:00,439 --> 02:02:05,190 we're talking days, at the best days to you know, weeks. 2382 02:02:05,190 --> 02:02:08,912 Because she's gonna re-aspirate too. 2383 02:02:08,912 --> 02:02:11,718 I mean I think she made it very clear that 2384 02:02:11,718 --> 02:02:14,443 she knew that this meant that she was gonna die. 2385 02:02:14,443 --> 02:02:16,343 - And I think she does. - Yeah. 2386 02:02:16,343 --> 02:02:18,373 She understood that very clear when I 2387 02:02:18,373 --> 02:02:20,727 told it to her and I asked her, I said 2388 02:02:20,727 --> 02:02:23,503 "How do you think your husband will feel about this?" 2389 02:02:23,503 --> 02:02:24,503 And she said 2390 02:02:25,614 --> 02:02:27,114 "He'll accept it." 2391 02:02:29,881 --> 02:02:33,668 - But he's having a very hard time living with this. 2392 02:02:33,668 --> 02:02:36,961 He came over to my office yesterday afternoon 2393 02:02:36,961 --> 02:02:39,274 and he didn't have an appointment, 2394 02:02:39,274 --> 02:02:41,377 I said "What are you doing here?" 2395 02:02:41,377 --> 02:02:44,236 And I indicated that I knew what was going on and he 2396 02:02:44,236 --> 02:02:47,340 says "Well I just wanted to talk to you for a minute." 2397 02:02:47,340 --> 02:02:49,073 But I think what he really wanted to know was 2398 02:02:49,073 --> 02:02:50,983 did I really know and understand everything that 2399 02:02:50,983 --> 02:02:54,139 was going on and I think also he just wanted somebody 2400 02:02:54,139 --> 02:02:58,740 to talk to, to feel that somebody knew how he felt. 2401 02:02:58,740 --> 02:03:01,101 - [Scott] I think that probably the way to deal with 2402 02:03:01,101 --> 02:03:04,261 him is to just say look you know, we talked to her 2403 02:03:04,261 --> 02:03:06,203 and this is what she wants, this is what we can do. 2404 02:03:06,203 --> 02:03:08,461 We've done everything we can and-- 2405 02:03:08,461 --> 02:03:09,953 - It'll be, he understands it. 2406 02:03:09,953 --> 02:03:12,653 - No, I think he's ready. - He's ready for that. 2407 02:03:12,653 --> 02:03:13,855 - Hi. 2408 02:03:13,855 --> 02:03:15,934 - As is the family of this man. 2409 02:03:15,934 --> 02:03:18,872 - Okay well I don't know him well enough. 2410 02:03:18,872 --> 02:03:21,687 Maybe we'll get him off, what do you think? 2411 02:03:21,687 --> 02:03:24,585 - The last two days he had been going 2412 02:03:24,585 --> 02:03:28,091 so steadily downhill on maximum therapy. 2413 02:03:28,091 --> 02:03:31,758 He's been on 60 milligrams of prednisone, on 2414 02:03:33,676 --> 02:03:34,843 large doses of 2415 02:03:36,004 --> 02:03:37,993 bronchodilators, 2416 02:03:37,993 --> 02:03:40,621 adrenergic stimulators. 2417 02:03:40,621 --> 02:03:42,750 This has been going on such a long time 2418 02:03:42,750 --> 02:03:44,692 and it's like her, a combination of 2419 02:03:44,692 --> 02:03:47,331 cardiac failure and chronic lung disease 2420 02:03:47,331 --> 02:03:48,941 that I am very pessimistic-- 2421 02:03:48,941 --> 02:03:50,361 - It sounds like the family, 2422 02:03:50,361 --> 02:03:51,895 his family have made it pretty clear that they 2423 02:03:51,895 --> 02:03:56,448 did not want super aggressive things done for him. 2424 02:03:56,448 --> 02:03:58,360 - Again, there are strong 2425 02:03:58,360 --> 02:04:00,723 resemblances between the two cases. 2426 02:04:00,723 --> 02:04:03,724 He himself is the strong member of the family. 2427 02:04:03,724 --> 02:04:06,252 He runs it and there's a good deal of 2428 02:04:06,252 --> 02:04:08,899 resentment among others about the amount 2429 02:04:08,899 --> 02:04:13,244 of care and attention that he has required, 2430 02:04:13,244 --> 02:04:15,886 particularly with people not blood relatives but to whom 2431 02:04:15,886 --> 02:04:20,143 a lot of the responsibility has fallen and it's not easy. 2432 02:04:20,143 --> 02:04:21,393 - [Scott] Okay. 2433 02:04:41,819 --> 02:04:44,632 - I know how unhappy you are 2434 02:04:44,632 --> 02:04:47,799 that the tube had to go back in again. 2435 02:04:49,655 --> 02:04:51,238 But I was concerned 2436 02:04:52,936 --> 02:04:56,269 that you were getting so tired yesterday 2437 02:04:57,914 --> 02:04:58,747 that even 2438 02:05:00,108 --> 02:05:03,856 though we could expect good results, 2439 02:05:03,856 --> 02:05:06,851 you couldn't do it by yourself. 2440 02:05:06,851 --> 02:05:11,851 I also know that this is against your long term wishes 2441 02:05:12,009 --> 02:05:14,660 and Dr. Weiss and I have had a chat 2442 02:05:14,660 --> 02:05:19,660 about tracheostomy and I've explained to him that you 2443 02:05:19,666 --> 02:05:24,166 are a very intelligent and strong woman who has always 2444 02:05:25,108 --> 02:05:28,214 known what she wanted to do about her own health 2445 02:05:28,214 --> 02:05:29,881 and that your wishes 2446 02:05:30,733 --> 02:05:33,654 would be exactly what we would live by 2447 02:05:33,654 --> 02:05:35,966 and would be our guidelines. 2448 02:05:35,966 --> 02:05:38,549 That's what you want, isn't it? 2449 02:05:39,861 --> 02:05:40,694 Okay. 2450 02:05:45,418 --> 02:05:46,418 I anticipate 2451 02:05:47,889 --> 02:05:50,964 that we will be able to get this tube out 2452 02:05:50,964 --> 02:05:52,997 and that you will be able to 2453 02:05:52,997 --> 02:05:55,747 breathe the next time without it. 2454 02:05:56,734 --> 02:05:58,567 You just got congested 2455 02:05:59,873 --> 02:06:03,725 fairly quickly after it was taken out last time. 2456 02:06:03,725 --> 02:06:05,865 I think we will do better next time 2457 02:06:05,865 --> 02:06:08,198 and you will breathe easier. 2458 02:06:09,920 --> 02:06:13,699 Do I understand correctly however that if you should 2459 02:06:13,699 --> 02:06:17,741 tire a lot, then you don't want us to put it back in again? 2460 02:06:17,741 --> 02:06:19,074 Is that correct? 2461 02:06:23,118 --> 02:06:26,287 Do you understand what I'm saying? 2462 02:06:26,287 --> 02:06:28,287 Okay, if you should tire 2463 02:06:29,752 --> 02:06:32,335 after we take it out next time, 2464 02:06:33,724 --> 02:06:35,641 we'll have two choices. 2465 02:06:36,994 --> 02:06:39,161 We can either leave it out 2466 02:06:40,635 --> 02:06:43,192 or if we think you would benefit by it, 2467 02:06:43,192 --> 02:06:45,192 we could put it back in. 2468 02:06:46,125 --> 02:06:47,571 All right? 2469 02:06:47,571 --> 02:06:48,895 Okay. 2470 02:06:48,895 --> 02:06:52,361 Would you want us to put it back in again 2471 02:06:52,361 --> 02:06:55,028 if you start to tire without it? 2472 02:06:58,215 --> 02:06:59,584 Would you like to think about it 2473 02:06:59,584 --> 02:07:02,179 first before we make a final decision? 2474 02:07:02,179 --> 02:07:04,085 We've known each other a long time and you can 2475 02:07:04,085 --> 02:07:07,344 be perfectly honest in telling me what you want 2476 02:07:07,344 --> 02:07:10,011 and I will abide by your wishes. 2477 02:07:11,373 --> 02:07:12,206 Okay? 2478 02:07:13,763 --> 02:07:17,596 All right, you think about it and let me know. 2479 02:07:27,319 --> 02:07:30,013 Let's see if you can breathe against the machine. 2480 02:07:30,013 --> 02:07:31,263 All the way in. 2481 02:07:32,244 --> 02:07:33,984 All the way in. 2482 02:07:33,984 --> 02:07:34,817 Good. 2483 02:07:36,721 --> 02:07:39,096 I'll come back later, you think about it and we'll 2484 02:07:39,096 --> 02:07:41,876 talk again before we make the final effort to 2485 02:07:41,876 --> 02:07:45,415 take it out so we'll understand each other completely. 2486 02:07:45,415 --> 02:07:46,248 All right? 2487 02:07:47,365 --> 02:07:49,191 Are you tired now? 2488 02:07:49,191 --> 02:07:50,684 All right, then doze off and I'll 2489 02:07:50,684 --> 02:07:54,259 come back and we'll talk again later. 2490 02:07:54,259 --> 02:07:56,342 - Thank you, Dr. Kerlind. 2491 02:08:14,074 --> 02:08:15,678 I just want to make sure that you 2492 02:08:15,678 --> 02:08:18,069 understand what the options are 2493 02:08:18,069 --> 02:08:21,728 and Dr. Kerlind explained them to you very nicely. 2494 02:08:21,728 --> 02:08:25,267 If in fact we're able to take this tube out 2495 02:08:25,267 --> 02:08:28,463 and take you off of the breathing machine, 2496 02:08:28,463 --> 02:08:31,622 would it be your wish to not go back onto it 2497 02:08:31,622 --> 02:08:35,426 if in fact you were becoming tired and needing, 2498 02:08:35,426 --> 02:08:38,325 needing the support of a respirator? 2499 02:08:38,325 --> 02:08:41,242 Okay, that's the question. 2500 02:08:41,242 --> 02:08:44,032 Now you've been on it quite a few times so far. 2501 02:08:44,032 --> 02:08:47,722 So it's not that you don't know what it's like. 2502 02:08:47,722 --> 02:08:50,051 But it's very important that we understand what 2503 02:08:50,051 --> 02:08:54,384 you want so that we can abide and go by your wishes. 2504 02:08:55,778 --> 02:08:58,734 Being that we're working on trying to get, 2505 02:08:58,734 --> 02:09:00,672 are you paying attention to me? 2506 02:09:00,672 --> 02:09:04,543 Being that we're trying to understand what you want, 2507 02:09:04,543 --> 02:09:07,943 it's so important for what's going to be with you. 2508 02:09:07,943 --> 02:09:09,839 I know it seems like everyone keeps asking you 2509 02:09:09,839 --> 02:09:12,052 the same questions and hoe many times do we need 2510 02:09:12,052 --> 02:09:17,052 to hear it but that's what we do, we like to hear it 2511 02:09:17,166 --> 02:09:21,269 to make sure that if you change your mind again, 2512 02:09:21,269 --> 02:09:23,356 that we know about it. 2513 02:09:23,356 --> 02:09:24,425 Okay? 2514 02:09:24,425 --> 02:09:26,793 So I'll let it rest for now. 2515 02:09:26,793 --> 02:09:27,626 Okay. 2516 02:09:28,989 --> 02:09:31,056 Ask me anytime you want to. 2517 02:09:31,056 --> 02:09:34,932 I can understand you pretty well most of the time. 2518 02:09:34,932 --> 02:09:36,544 All right? 2519 02:09:36,544 --> 02:09:37,377 Okay. 2520 02:09:43,514 --> 02:09:45,931 (chattering) 2521 02:09:51,104 --> 02:09:53,351 Dr. Kerlind talked to her again. 2522 02:09:53,351 --> 02:09:56,627 He couldn't quite get her to have the same 2523 02:09:56,627 --> 02:09:59,992 blatant yes-no response to things and he left it 2524 02:09:59,992 --> 02:10:01,995 with her that he would get back with her later 2525 02:10:01,995 --> 02:10:03,931 in the day and that she oughta think about it. 2526 02:10:03,931 --> 02:10:04,894 - Okay. 2527 02:10:04,894 --> 02:10:05,760 So... - Okay. 2528 02:10:05,760 --> 02:10:08,287 - And I went over it again with her and she's 2529 02:10:08,287 --> 02:10:10,604 kind of irritated that I keep doing that. 2530 02:10:10,604 --> 02:10:12,176 So I said I'm gonna leave it alone but 2531 02:10:12,176 --> 02:10:14,484 I want you to stop us at any time if 2532 02:10:14,484 --> 02:10:16,191 there's something you want to know about 2533 02:10:16,191 --> 02:10:17,727 or you want to discuss it and we keep 2534 02:10:17,727 --> 02:10:19,587 asking you because we want to make sure 2535 02:10:19,587 --> 02:10:21,417 because you always have the option to change your mind. 2536 02:10:21,417 --> 02:10:22,256 - Right. 2537 02:10:22,256 --> 02:10:24,543 - So that's where we're at. 2538 02:10:24,543 --> 02:10:25,376 - Okay. 2539 02:10:43,845 --> 02:10:46,428 - In lieu of yesterday's events 2540 02:10:47,653 --> 02:10:52,190 and after minor discussion with Scott in which he really 2541 02:10:52,190 --> 02:10:55,293 felt that the reason she failed was because of failure 2542 02:10:55,293 --> 02:10:58,298 only and my feeling was that from Sue and from 2543 02:10:58,298 --> 02:11:00,205 what I looked at at the flow sheet that it was 2544 02:11:00,205 --> 02:11:02,747 a combination of increased sputum production 2545 02:11:02,747 --> 02:11:06,208 as well as failure and it wasn't water from failure. 2546 02:11:06,208 --> 02:11:08,184 She has had increased sputum production 2547 02:11:08,184 --> 02:11:10,635 at least 24 hours prior to that when I 2548 02:11:10,635 --> 02:11:12,750 was here on Tuesday, acutely. 2549 02:11:12,750 --> 02:11:14,119 - [Nurse] When Katie heard that she 2550 02:11:14,119 --> 02:11:16,595 got x-rayed last night, she was like... 2551 02:11:16,595 --> 02:11:19,512 - Forget it, well anyway to make a long story short, 2552 02:11:19,512 --> 02:11:23,787 after evaluating her and having had the word trach 2553 02:11:23,787 --> 02:11:26,906 was mentioned yesterday both by Scott as well 2554 02:11:26,906 --> 02:11:31,258 as it showed up in Dr. Kerlind's note as well, 2555 02:11:31,258 --> 02:11:33,181 Scott said "Why haven't we ever 2556 02:11:33,181 --> 02:11:35,822 "asked Bernice what she wants?" 2557 02:11:35,822 --> 02:11:37,681 And we all kinda looked at each other 2558 02:11:37,681 --> 02:11:40,627 and said "Well, why don't we?" 2559 02:11:40,627 --> 02:11:43,687 My feeling in asking her what she wanted was a few things. 2560 02:11:43,687 --> 02:11:45,474 Number one, eight o'clock, nine o'clock 2561 02:11:45,474 --> 02:11:47,639 in the morning is not her best hour. 2562 02:11:47,639 --> 02:11:49,004 I said 11 would be better, 2563 02:11:49,004 --> 02:11:51,133 she tends to take a slow day waking up. 2564 02:11:51,133 --> 02:11:53,128 The mechanics never are great in the morning, 2565 02:11:53,128 --> 02:11:56,478 not that they're ever great but you don't get a good effort. 2566 02:11:56,478 --> 02:11:59,616 My other feeling was like okay, so what if she's 2567 02:11:59,616 --> 02:12:02,436 able to articulate in whatever form that she can 2568 02:12:02,436 --> 02:12:05,362 that she isn't willing to be trached and would 2569 02:12:05,362 --> 02:12:08,747 like to be extubated and not re-intubated for instance? 2570 02:12:08,747 --> 02:12:11,096 What gives us the feeling that number one, 2571 02:12:11,096 --> 02:12:12,959 Dr. Kerlind would also feel like that's 2572 02:12:12,959 --> 02:12:16,941 a good idea and want to go along with the situation 2573 02:12:16,941 --> 02:12:20,269 as well as her husband and at that point I felt 2574 02:12:20,269 --> 02:12:22,522 like it was a great idea to ask her but once 2575 02:12:22,522 --> 02:12:25,500 we had asked her and got a good idea from her, 2576 02:12:25,500 --> 02:12:28,098 then everything had to be focused through Dr. Kerlind. 2577 02:12:28,098 --> 02:12:30,257 I don't think that by any of us that 2578 02:12:30,257 --> 02:12:33,157 Dr. Factor needs to be approached by house staff, 2579 02:12:33,157 --> 02:12:36,824 nursing, even Scott unless George Kerlind gives Scott the-- 2580 02:12:36,824 --> 02:12:39,386 - It was only appropriate-- - In that one setting because 2581 02:12:39,386 --> 02:12:42,361 we were talking about a very acute demise 2582 02:12:42,361 --> 02:12:44,409 and I just said for the sake of all of us 2583 02:12:44,409 --> 02:12:47,192 that have to care for her daily, for us to be 2584 02:12:47,192 --> 02:12:49,139 the one to go to him with something that he 2585 02:12:49,139 --> 02:12:51,585 has encouraged from George Kerlind would not 2586 02:12:51,585 --> 02:12:54,293 be beneficial to the situation as a whole. 2587 02:12:54,293 --> 02:12:56,657 To make a long story short, Scott went in after rounds, 2588 02:12:56,657 --> 02:12:59,140 talked with her, called me into the room. 2589 02:12:59,140 --> 02:13:03,745 He wanted me to sort of interpret and watch him talk 2590 02:13:03,745 --> 02:13:06,172 and I will tell you, I've never seen Bernice 2591 02:13:06,172 --> 02:13:10,089 be quite so definite and it was as clear as day 2592 02:13:10,934 --> 02:13:12,964 her answers to all these questions and Scott 2593 02:13:12,964 --> 02:13:15,602 went through the gamut by saying that 2594 02:13:15,602 --> 02:13:18,044 these are the choices, we're finding that 2595 02:13:18,044 --> 02:13:20,361 you're having problems with your heart 2596 02:13:20,361 --> 02:13:22,175 in terms of going into some congestive 2597 02:13:22,175 --> 02:13:24,053 heart failure and having your lungs fill up. 2598 02:13:24,053 --> 02:13:26,016 We also find that because of the fact that 2599 02:13:26,016 --> 02:13:28,538 you've had a stroke and your cough isn't good 2600 02:13:28,538 --> 02:13:31,267 that you have problems with pneumonia and that 2601 02:13:31,267 --> 02:13:33,580 these are problems that you probably will 2602 02:13:33,580 --> 02:13:36,236 have throughout the duration of your life. 2603 02:13:36,236 --> 02:13:38,511 These are the choices we want to present to you 2604 02:13:38,511 --> 02:13:40,901 and we want to know how you really feel about these 2605 02:13:40,901 --> 02:13:44,994 choices so that we can better help negotiate your care. 2606 02:13:44,994 --> 02:13:47,370 When explained about the trach, the answer was 2607 02:13:47,370 --> 02:13:51,918 definitely no with a shake of the head, with-- 2608 02:13:51,918 --> 02:13:53,656 - The hand. - With the hand. 2609 02:13:53,656 --> 02:13:57,889 Saying the word operation, the fact that there would 2610 02:13:57,889 --> 02:14:00,423 be an airway in her neck and if we needed to put her 2611 02:14:00,423 --> 02:14:03,166 on a ventilator as we needed, that there would be 2612 02:14:03,166 --> 02:14:07,666 a way to do that without putting a tube down into her. 2613 02:14:08,561 --> 02:14:11,528 Then the other choice was that we would try our best 2614 02:14:11,528 --> 02:14:14,746 at this particular point to improve her pneumonia 2615 02:14:14,746 --> 02:14:17,604 and then be able to take her off the tube 2616 02:14:17,604 --> 02:14:20,323 and make her comfortable so that her breathing 2617 02:14:20,323 --> 02:14:23,673 should be easy enough that she would be comfortable 2618 02:14:23,673 --> 02:14:26,461 but that if in fact she tired and seemed to need 2619 02:14:26,461 --> 02:14:30,487 the tube back, that we wouldn't put it back if she 2620 02:14:30,487 --> 02:14:34,431 didn't want it back but we wanted to talk about it now. 2621 02:14:34,431 --> 02:14:36,638 - What'd she say to that? - We had to break that up 2622 02:14:36,638 --> 02:14:39,120 because that was kind of a long story. 2623 02:14:39,120 --> 02:14:41,239 First I started by saying to her, 2624 02:14:41,239 --> 02:14:43,687 "All the times that we've put you on the breathing machine, 2625 02:14:43,687 --> 02:14:45,257 "have you wanted to be on it? 2626 02:14:45,257 --> 02:14:47,120 "Have you wanted to be on it any of the times?" 2627 02:14:47,120 --> 02:14:48,114 No. 2628 02:14:48,114 --> 02:14:49,655 I did say to her, "Do you realize that 2629 02:14:49,655 --> 02:14:53,062 "you've been on it six times already?" 2630 02:14:53,062 --> 02:14:53,895 Yes. 2631 02:14:54,882 --> 02:14:58,725 Then we went on to say "Do you realize that even 2632 02:14:58,725 --> 02:15:01,671 "if we make you comfortable off of the breathing machine, 2633 02:15:01,671 --> 02:15:03,832 "that if you need it back and we don't give it 2634 02:15:03,832 --> 02:15:06,074 "back to you because you don't want it back, 2635 02:15:06,074 --> 02:15:07,729 "that you probably will die?" 2636 02:15:07,729 --> 02:15:09,109 Yes. 2637 02:15:09,109 --> 02:15:12,928 Is that acceptable to you knowing that 2638 02:15:12,928 --> 02:15:16,134 you probably will die if you need it back and we-- 2639 02:15:16,134 --> 02:15:17,498 - Don't give it to you. - Don't give it back. 2640 02:15:17,498 --> 02:15:19,225 - Because you don't want it. - Yes, do you want it? 2641 02:15:19,225 --> 02:15:20,058 - No. 2642 02:15:20,058 --> 02:15:22,459 So I felt like we broke up the concepts 2643 02:15:22,459 --> 02:15:25,192 in four or five different ways so that she could, 2644 02:15:25,192 --> 02:15:26,557 we'd be able to decipher-- 2645 02:15:26,557 --> 02:15:27,961 - [Nurse] You applied it in different situations 2646 02:15:27,961 --> 02:15:29,159 and she said no to all, she was consistent. 2647 02:15:29,159 --> 02:15:30,564 - She was consistent. 2648 02:15:30,564 --> 02:15:33,421 We told her that we would do our best 2649 02:15:33,421 --> 02:15:36,111 to make Dr. Kerlind aware of her wishes 2650 02:15:36,111 --> 02:15:38,433 and that we would go to bat for her in terms 2651 02:15:38,433 --> 02:15:41,059 of Dr. Kerlind as well as with her husband 2652 02:15:41,059 --> 02:15:43,290 and then I did say to her, "Do you think 2653 02:15:43,290 --> 02:15:45,615 "that your husband will be able to 2654 02:15:45,615 --> 02:15:47,573 "support you in your decision?" 2655 02:15:47,573 --> 02:15:49,789 And she said "Yes." 2656 02:15:49,789 --> 02:15:52,105 And we left it at that. 2657 02:15:52,105 --> 02:15:54,143 Dr. Kerlind came in later on, 2658 02:15:54,143 --> 02:15:58,226 had a similar discussion with her and she wasn't, 2659 02:15:59,399 --> 02:16:02,103 she wasn't able to give quite as snappy of 2660 02:16:02,103 --> 02:16:05,182 a yes or no answer to what he was asking her, 2661 02:16:05,182 --> 02:16:06,644 which was the same things that 2662 02:16:06,644 --> 02:16:08,931 Scott and I had talked to her about. 2663 02:16:08,931 --> 02:16:11,373 She wasn't given a lot of time either. 2664 02:16:11,373 --> 02:16:12,945 You know Bernice, she's not real quick 2665 02:16:12,945 --> 02:16:14,843 with her answers unless there's a definite, 2666 02:16:14,843 --> 02:16:16,709 right, you have to be patient to sort of 2667 02:16:16,709 --> 02:16:19,211 give her the time so that she can make the effort 2668 02:16:19,211 --> 02:16:22,271 and because she wasn't real snappy with her decision, 2669 02:16:22,271 --> 02:16:25,434 Dr. Kerlind did say to her that he understood 2670 02:16:25,434 --> 02:16:27,706 how she was feeling and that he really thinks 2671 02:16:27,706 --> 02:16:29,793 it's an important decision and that she give it 2672 02:16:29,793 --> 02:16:31,853 some more thought and that he would be back 2673 02:16:31,853 --> 02:16:35,326 later in the day to discuss it with her again. 2674 02:16:35,326 --> 02:16:38,503 Later in the afternoon, the plan as it stands 2675 02:16:38,503 --> 02:16:42,395 right now is that if we don't see Dr. Kerlind 2676 02:16:42,395 --> 02:16:46,012 by around this time, that Karen Ballen would call him 2677 02:16:46,012 --> 02:16:48,967 and say that we would really like to take the time 2678 02:16:48,967 --> 02:16:52,629 to get together with Dr. Factor while his son is 2679 02:16:52,629 --> 02:16:55,505 going to be here through Sunday and also because 2680 02:16:55,505 --> 02:16:59,834 we plan to continue the weaning process as her pneumonia 2681 02:16:59,834 --> 02:17:02,412 improves but we need to sit down and talk with them now. 2682 02:17:02,412 --> 02:17:04,789 If it's something that he doesn't have time 2683 02:17:04,789 --> 02:17:06,768 to get into or he doesn't have a chance to speak 2684 02:17:06,768 --> 02:17:09,519 to them, being that he's been rounding all day, 2685 02:17:09,519 --> 02:17:12,609 that he needs to let us know that and Scott 2686 02:17:12,609 --> 02:17:14,652 is gonna be up later in the evening and would 2687 02:17:14,652 --> 02:17:17,556 be glad to be involved in actually holding 2688 02:17:17,556 --> 02:17:20,406 the meeting or be there when Dr. Kerlind speaks 2689 02:17:20,406 --> 02:17:22,754 with them but that we need to all sit down. 2690 02:17:22,754 --> 02:17:24,907 So a sort of impromptu family meeting, 2691 02:17:24,907 --> 02:17:27,112 whether it's today or tomorrow but we feel like we 2692 02:17:27,112 --> 02:17:31,862 need to get the ball in motion and that's where we're at. 2693 02:17:32,829 --> 02:17:34,529 - [Doctor] I guess there are just sort of a lot of issues 2694 02:17:34,529 --> 02:17:38,054 about what are we gonna do, should we try to take the tube 2695 02:17:38,054 --> 02:17:41,402 out tomorrow and see if she flies, if she doesn't fly-- 2696 02:17:41,402 --> 02:17:43,009 - As long as it is-- - Put it back in, or? 2697 02:17:43,009 --> 02:17:44,625 - Well that is something that I agreed 2698 02:17:44,625 --> 02:17:46,946 I would re-discuss with her because although 2699 02:17:46,946 --> 02:17:49,559 she apparently, Scott got the impression that 2700 02:17:49,559 --> 02:17:52,502 she said to him enough, I don't want to be re-intubated 2701 02:17:52,502 --> 02:17:55,419 but when I went in and took it up with her this morning, 2702 02:17:55,419 --> 02:17:59,116 I was by no means convinced that it was clear in her 2703 02:17:59,116 --> 02:18:01,599 mind that that's what she wanted to do and I left it 2704 02:18:01,599 --> 02:18:04,048 with her to cogitate it a little bit and then decide. 2705 02:18:04,048 --> 02:18:06,708 So I think that that'll be something that we'll 2706 02:18:06,708 --> 02:18:08,338 take up with her again. 2707 02:18:08,338 --> 02:18:11,563 In any event, I hope that if we get her dry enough in 2708 02:18:11,563 --> 02:18:15,155 advance, that we will at least get it out with impunity. 2709 02:18:15,155 --> 02:18:16,937 Then the issue of putting it 2710 02:18:16,937 --> 02:18:19,445 back in again will be another matter. 2711 02:18:19,445 --> 02:18:20,352 - Okay. 2712 02:18:20,352 --> 02:18:22,974 Because I guess the son is only gonna be here 'til Sunday, 2713 02:18:22,974 --> 02:18:27,119 so it would be nice if we could have him-- 2714 02:18:27,119 --> 02:18:30,036 - Get her as dry as we can and then 2715 02:18:31,424 --> 02:18:33,342 bite the bullet. - Okay. 2716 02:18:39,144 --> 02:18:42,178 - [Doctor] We need to talk to you and find out what you'd 2717 02:18:42,178 --> 02:18:46,678 like us to do about the tube okay, the breathing tube. 2718 02:18:50,486 --> 02:18:54,153 - [Scott] Are you tired of talking about it? 2719 02:18:56,778 --> 02:18:59,165 - [Doctor] We want to find out what you want to do, okay? 2720 02:18:59,165 --> 02:19:00,498 You're the boss. 2721 02:19:02,547 --> 02:19:03,964 - You don't know? 2722 02:19:05,153 --> 02:19:06,978 You're not sure what, remember I told you 2723 02:19:06,978 --> 02:19:09,602 yesterday what the two choices were. 2724 02:19:09,602 --> 02:19:12,840 I think that we can try to take the tube out 2725 02:19:12,840 --> 02:19:16,035 and not put it back in the way we did this last time. 2726 02:19:16,035 --> 02:19:18,182 But there's a good chance that if we do that, 2727 02:19:18,182 --> 02:19:19,514 that you may die 2728 02:19:20,728 --> 02:19:22,839 and I think the other possibility 2729 02:19:22,839 --> 02:19:26,476 is to do an operation and to put a hole here 2730 02:19:26,476 --> 02:19:30,437 and put a permanent tube in here, okay? 2731 02:19:30,437 --> 02:19:32,688 Do what's called a tracheostomy 2732 02:19:32,688 --> 02:19:36,130 and when Anne-Louise and I, your nurse right over there. 2733 02:19:36,130 --> 02:19:39,074 - She knows me. - When we talked yesterday, 2734 02:19:39,074 --> 02:19:41,375 I got the impression that what you wanted to do 2735 02:19:41,375 --> 02:19:45,887 was to have the tube out and not have it put back in. 2736 02:19:45,887 --> 02:19:48,302 But it's important for me to know what you want 2737 02:19:48,302 --> 02:19:50,875 because Dr. Kerlind's gonna come back here today 2738 02:19:50,875 --> 02:19:53,542 and he's gonna want to know too. 2739 02:19:57,865 --> 02:19:59,115 You don't know. 2740 02:19:59,984 --> 02:20:03,234 It's hard for you to make up your mind. 2741 02:20:04,305 --> 02:20:05,972 It's a tough choice. 2742 02:20:07,086 --> 02:20:09,191 It's a pretty tough choice, you're right. 2743 02:20:09,191 --> 02:20:11,108 It's not a good choice. 2744 02:20:13,028 --> 02:20:14,028 I think that 2745 02:20:16,875 --> 02:20:18,929 it's very important for us to do 2746 02:20:18,929 --> 02:20:21,755 what you want and I think that knowing, 2747 02:20:21,755 --> 02:20:24,505 even knowing those choices, okay, 2748 02:20:25,449 --> 02:20:27,782 it's hard for somebody who's 2749 02:20:29,041 --> 02:20:30,708 not a doctor to know 2750 02:20:32,823 --> 02:20:35,155 what's the right thing to do 2751 02:20:36,442 --> 02:20:38,967 and I think a lot of it has to do with how you 2752 02:20:38,967 --> 02:20:43,722 feel about what's happened so far in the hospital. 2753 02:20:43,722 --> 02:20:45,889 My sense of things is that 2754 02:20:52,681 --> 02:20:55,289 if you really want to go on 2755 02:20:55,289 --> 02:20:58,569 and you want to live and you want to keep going, 2756 02:20:58,569 --> 02:21:01,319 the tube here is the thing to do. 2757 02:21:02,173 --> 02:21:04,090 To do the tracheostomy. 2758 02:21:13,083 --> 02:21:15,570 I'm sorry, I didn't catch that. 2759 02:21:15,570 --> 02:21:17,430 - Are you saying that you still 2760 02:21:17,430 --> 02:21:20,418 can't decide between the two, Bernice? 2761 02:21:20,418 --> 02:21:22,288 Is that what you're saying, okay. 2762 02:21:22,288 --> 02:21:25,195 Do you need more time to think about it? 2763 02:21:25,195 --> 02:21:26,890 - All right, that's all right. - That's all right. 2764 02:21:26,890 --> 02:21:29,334 You got as much time as you want. 2765 02:21:29,334 --> 02:21:31,616 - Is there something that we can answer about 2766 02:21:31,616 --> 02:21:34,733 either of the options more clearly for you? 2767 02:21:34,733 --> 02:21:36,449 - [Scott] Is there anybody that you would like to 2768 02:21:36,449 --> 02:21:40,449 talk to about this that would be helpful to you? 2769 02:21:45,246 --> 02:21:46,233 - No? 2770 02:21:46,233 --> 02:21:48,885 - What are your worries about it? 2771 02:21:48,885 --> 02:21:50,218 Don't wanna die? 2772 02:21:51,776 --> 02:21:53,693 Not worried about that. 2773 02:21:54,564 --> 02:21:56,754 Worried about your husband? 2774 02:21:56,754 --> 02:21:58,254 How he'll take it? 2775 02:22:00,069 --> 02:22:02,158 I mean whether he'll get upset 2776 02:22:02,158 --> 02:22:06,075 and have a heart attack or something like that? 2777 02:22:09,127 --> 02:22:12,294 Well that's a possibility I think. 2778 02:22:12,294 --> 02:22:16,469 It's possible that he won't take it very well. 2779 02:22:16,469 --> 02:22:18,363 It's hard to know, you know? 2780 02:22:18,363 --> 02:22:20,233 I think that that's a real possibility, 2781 02:22:20,233 --> 02:22:23,018 that he won't take it very well. 2782 02:22:23,018 --> 02:22:25,390 I think that there may be things that we can do to, 2783 02:22:25,390 --> 02:22:27,795 you mean either way, either doing the tracheostomy 2784 02:22:27,795 --> 02:22:31,818 or doing it, he won't take either one very well or that he 2785 02:22:31,818 --> 02:22:36,568 particularly wouldn't take your wanting to call it quits, 2786 02:22:38,933 --> 02:22:39,766 which one? 2787 02:22:40,887 --> 02:22:43,014 - Is it calling it quits that would upset him, 2788 02:22:43,014 --> 02:22:46,347 Bernice, more than having the operation? 2789 02:22:48,128 --> 02:22:49,903 - Either one. - Either one. 2790 02:22:49,903 --> 02:22:51,071 - It's gonna upset him. 2791 02:22:51,071 --> 02:22:54,238 - Either one is gonna upset him, yeah. 2792 02:23:00,827 --> 02:23:04,918 Well there's not a lot of good answers here. 2793 02:23:04,918 --> 02:23:06,694 Unfortunately. 2794 02:23:06,694 --> 02:23:08,980 - [Nurse] Dr. Ballind, you have a call line four. 2795 02:23:08,980 --> 02:23:11,012 - But I think that if you want to go ahead 2796 02:23:11,012 --> 02:23:15,096 and have this tracheostomy, that's not, you know, 2797 02:23:17,008 --> 02:23:18,753 an end of the world kind of a thing. 2798 02:23:18,753 --> 02:23:21,669 It's a small operation, it's not a big operation 2799 02:23:21,669 --> 02:23:24,852 but it would mean that there would be a permanent tube here. 2800 02:23:24,852 --> 02:23:28,043 All that this will do, this operation, 2801 02:23:28,043 --> 02:23:30,756 will make it easier to put you on the machine, 2802 02:23:30,756 --> 02:23:34,199 make it easier for you to go on the machine 2803 02:23:34,199 --> 02:23:36,266 if you have to go on the machine. 2804 02:23:36,266 --> 02:23:38,387 That's what it'll do. 2805 02:23:38,387 --> 02:23:40,290 It's not gonna change anything with the stroke 2806 02:23:40,290 --> 02:23:41,957 or with the breathing because those are problems 2807 02:23:41,957 --> 02:23:44,766 we can't really do much about, they're sorta there 2808 02:23:44,766 --> 02:23:46,466 and they're gonna either get better on their own 2809 02:23:46,466 --> 02:23:50,242 or not get better on their own as the case may be. 2810 02:23:50,242 --> 02:23:51,242 You with me? 2811 02:23:57,260 --> 02:24:01,448 Are you with me there, did you understand that? 2812 02:24:01,448 --> 02:24:04,762 You don't understand that, you do understand that? 2813 02:24:04,762 --> 02:24:07,753 - Are you telling us enough? 2814 02:24:07,753 --> 02:24:09,038 Yeah, okay. 2815 02:24:09,038 --> 02:24:11,539 You just wanna think about it? 2816 02:24:11,539 --> 02:24:13,652 - [Scott] Just wanna think about it for awhile. 2817 02:24:13,652 --> 02:24:16,008 Okay, we can't wait too long though because 2818 02:24:16,008 --> 02:24:18,030 eventually we're gonna have to do something 2819 02:24:18,030 --> 02:24:22,017 about this because it's been in for a long time. 2820 02:24:22,017 --> 02:24:22,924 - Okay? 2821 02:24:22,924 --> 02:24:25,065 - The feeling that I'm getting from you is 2822 02:24:25,065 --> 02:24:27,290 that you're not sure whether you want to 2823 02:24:27,290 --> 02:24:30,623 have the tube out or have the operation. 2824 02:24:33,270 --> 02:24:35,687 I don't know what that means. 2825 02:24:37,714 --> 02:24:39,414 You don't want to have the tube out 2826 02:24:39,414 --> 02:24:42,553 or you don't wanna have the operation? 2827 02:24:42,553 --> 02:24:43,833 No. 2828 02:24:43,833 --> 02:24:46,102 You want the tube out? 2829 02:24:46,102 --> 02:24:46,935 You want, 2830 02:24:48,165 --> 02:24:50,372 do you want the operation? 2831 02:24:50,372 --> 02:24:52,955 Yes, you do want the operation. 2832 02:24:53,943 --> 02:24:56,079 - Is that what you're saying, Bernice? 2833 02:24:56,079 --> 02:24:57,474 - You don't know. - You don't know. 2834 02:24:57,474 --> 02:24:59,419 - Okay, so you wanna think about it. 2835 02:24:59,419 --> 02:25:01,920 You want some time to think about it. 2836 02:25:01,920 --> 02:25:03,206 - Go away. - Go away. 2837 02:25:03,206 --> 02:25:04,705 - All right. - Don't feel bad, I get that. 2838 02:25:04,705 --> 02:25:08,145 - Let me take a listen to you before we go, okay? 2839 02:25:08,145 --> 02:25:10,124 - You've got time to think about it. 2840 02:25:10,124 --> 02:25:11,837 - [Anne-Louise] They're gonna listen to your lungs, Bernice. 2841 02:25:11,837 --> 02:25:14,530 - Exactly the answer that I got from her yesterday, 2842 02:25:14,530 --> 02:25:15,769 that she was uncertain. 2843 02:25:15,769 --> 02:25:17,635 I came in after my conversation with you 2844 02:25:17,635 --> 02:25:19,711 and thought well, she's made up her mind. 2845 02:25:19,711 --> 02:25:23,029 But after I discussed it-- - She hasn't made up her mind. 2846 02:25:23,029 --> 02:25:24,559 - No, she has not made up her mind. 2847 02:25:24,559 --> 02:25:27,603 - I think she's mostly worried about her husband, 2848 02:25:27,603 --> 02:25:29,736 that's what it sounds like when you talk to her. 2849 02:25:29,736 --> 02:25:33,135 I think she's got ambivalent feelings herself about the-- 2850 02:25:33,135 --> 02:25:34,887 - I have to admit, if I were there, I'm not so 2851 02:25:34,887 --> 02:25:36,744 sure how certain I would be about what I wanted. 2852 02:25:36,744 --> 02:25:38,195 - God only knows, yep. 2853 02:25:38,195 --> 02:25:39,278 Okay, well... 2854 02:25:41,127 --> 02:25:43,294 Richard's on this weekend. 2855 02:25:59,336 --> 02:26:00,941 - [George] Other people go off duty 2856 02:26:00,941 --> 02:26:03,000 but your old friend is always around. 2857 02:26:03,000 --> 02:26:08,000 So you and I can peacefully discuss this at some length. 2858 02:26:08,153 --> 02:26:11,937 My understanding yesterday is that you weren't 2859 02:26:11,937 --> 02:26:15,806 quite sure what you wanted to do about this business. 2860 02:26:15,806 --> 02:26:17,332 Is that right? 2861 02:26:17,332 --> 02:26:18,907 Okay. 2862 02:26:18,907 --> 02:26:21,407 You take all the time you need 2863 02:26:22,931 --> 02:26:25,882 and I must say that whatever we do, 2864 02:26:25,882 --> 02:26:27,701 we can undo it if we have to too. 2865 02:26:27,701 --> 02:26:29,991 These are not decisions that are 2866 02:26:29,991 --> 02:26:33,074 cast in cement and cannot be changed. 2867 02:26:34,220 --> 02:26:37,034 But on a nice day when the sun is shining, 2868 02:26:37,034 --> 02:26:41,451 it seems pretty good to be around and Harry's around. 2869 02:26:42,413 --> 02:26:44,582 I spoke with him yesterday afternoon. 2870 02:26:44,582 --> 02:26:49,236 He wanted to be sure that I understood exactly 2871 02:26:49,236 --> 02:26:51,403 what his feelings were and 2872 02:26:52,454 --> 02:26:55,450 what he thought yours were too. 2873 02:26:55,450 --> 02:26:58,325 You just be confident that your 2874 02:26:58,325 --> 02:27:01,825 interests come first with everybody, okay? 2875 02:27:06,287 --> 02:27:08,980 - We need to get her sort of 2876 02:27:08,980 --> 02:27:09,813 maximally 2877 02:27:11,382 --> 02:27:12,965 set up here so that 2878 02:27:14,372 --> 02:27:15,658 if she makes a decision, 2879 02:27:15,658 --> 02:27:18,685 she either goes for a trach on Monday 2880 02:27:18,685 --> 02:27:21,264 at the beginning part of the week 2881 02:27:21,264 --> 02:27:24,368 or we extubate her Saturday or Sunday 2882 02:27:24,368 --> 02:27:27,666 and see if she flies on her own 2883 02:27:27,666 --> 02:27:30,617 and I can understand her ambivalence about it. 2884 02:27:30,617 --> 02:27:32,784 It's a difficult decision. 2885 02:27:34,405 --> 02:27:35,337 Hard to know. 2886 02:27:35,337 --> 02:27:37,567 - [Nurse] There should be a decision beforehand. 2887 02:27:37,567 --> 02:27:38,874 - Oh absolutely, absolutely. 2888 02:27:38,874 --> 02:27:40,166 - [Nurse] I would not extubate her 2889 02:27:40,166 --> 02:27:42,705 until we knew what we were gonna do after. 2890 02:27:42,705 --> 02:27:44,304 - Yes, I don't think there's any question about that. 2891 02:27:44,304 --> 02:27:46,468 - [Nurse] Especially with her past track record. 2892 02:27:46,468 --> 02:27:47,962 It's important. 2893 02:27:47,962 --> 02:27:51,382 - Okay, so that's that. - Any other thoughts, George? 2894 02:27:51,382 --> 02:27:54,282 - My thought is that as she feels better, 2895 02:27:54,282 --> 02:27:57,736 she is not quite sure that she wants to let go. 2896 02:27:57,736 --> 02:28:00,408 Today she sorta has a certain spontaneity 2897 02:28:00,408 --> 02:28:03,417 and a certain smile to her face which she 2898 02:28:03,417 --> 02:28:07,261 had a little bit of yesterday and zero the day before 2899 02:28:07,261 --> 02:28:10,481 and so maybe what she really is trying to 2900 02:28:10,481 --> 02:28:12,849 say to us now is that I'm not giving up. 2901 02:28:12,849 --> 02:28:15,429 - [Scott] What about getting Prikslow here bout a trach? 2902 02:28:15,429 --> 02:28:18,146 - [George] I think we ought to have him at least 2903 02:28:18,146 --> 02:28:23,146 look at the issue and be prepared to go ahead and I'll-- 2904 02:28:23,177 --> 02:28:25,930 - [Scott] She'll make her decision on the weekend. 2905 02:28:25,930 --> 02:28:29,818 - And I will, Dr. Factor came up to my office yesterday. 2906 02:28:29,818 --> 02:28:31,809 Hard to understand what he was trying to say to me. 2907 02:28:31,809 --> 02:28:33,963 He just came and he just sorta wanted to hold my hand 2908 02:28:33,963 --> 02:28:36,869 for a minute so he was able to get some feeling somebody 2909 02:28:36,869 --> 02:28:41,714 really knows what's going on and knows that I'm suffering 2910 02:28:41,714 --> 02:28:44,297 and that's literally all I did. 2911 02:28:45,847 --> 02:28:48,494 So I think that he, rather than lose her 2912 02:28:48,494 --> 02:28:52,224 would certainly go for doing a procedure. 2913 02:28:52,224 --> 02:28:54,057 - Okay. - Okay, thanks. 2914 02:28:56,921 --> 02:28:59,179 - She's clearly, I mean she's clearly giving us 2915 02:28:59,179 --> 02:29:01,127 a different message than she gave yesterday. 2916 02:29:01,127 --> 02:29:03,412 She said a totally different thing 2917 02:29:03,412 --> 02:29:05,547 to us today than she did before. 2918 02:29:05,547 --> 02:29:07,342 - It's hard. 2919 02:29:07,342 --> 02:29:11,092 - Well but I, you know I mean as George said, 2920 02:29:12,990 --> 02:29:14,072 if that was me in that bed, 2921 02:29:14,072 --> 02:29:16,989 I don't know what the hell I'd say. 2922 02:29:32,242 --> 02:29:34,567 - He's pulling temper tantrums in the room that aren't 2923 02:29:34,567 --> 02:29:37,527 based on anything because he doesn't know anything. 2924 02:29:37,527 --> 02:29:40,024 He's teary-eyed, he's getting frustrated. 2925 02:29:40,024 --> 02:29:42,635 He started yelling and her arm, 2926 02:29:42,635 --> 02:29:44,290 he was hold her hand and she was 2927 02:29:44,290 --> 02:29:46,127 pulling him back and getting her upset. 2928 02:29:46,127 --> 02:29:47,665 I can't have that happen in the room. 2929 02:29:47,665 --> 02:29:49,128 - [Scott] He can't go in there then. 2930 02:29:49,128 --> 02:29:52,007 - But he, his son said to him "Dad, control yourself." 2931 02:29:52,007 --> 02:29:54,237 And my feeling is I told George Kerlind that 2932 02:29:54,237 --> 02:29:56,843 the behavior needs to be addressed and the longer 2933 02:29:56,843 --> 02:29:59,946 we keep Dr. Factor in the dark about all these 2934 02:29:59,946 --> 02:30:01,823 decisions that are being made, the worse 2935 02:30:01,823 --> 02:30:04,022 this is gonna be and I can't take care of him 2936 02:30:04,022 --> 02:30:05,891 and take care of her at the same time. 2937 02:30:05,891 --> 02:30:08,458 - [Scott] Karen and I can talk to him. 2938 02:30:08,458 --> 02:30:10,071 - [Nurse] But why don't you kick him out? 2939 02:30:10,071 --> 02:30:12,102 - I did, he left because she was pulling him 2940 02:30:12,102 --> 02:30:14,301 back and I said "Bernice, he has to leave." 2941 02:30:14,301 --> 02:30:16,559 I don't want to fight with him because 2942 02:30:16,559 --> 02:30:18,918 I am her caretaker, that's my concern. 2943 02:30:18,918 --> 02:30:21,198 She's already ostracized one 2944 02:30:21,198 --> 02:30:23,544 caretaker and that's why I had 2945 02:30:23,544 --> 02:30:25,546 to speak to George Kerlind about this. 2946 02:30:25,546 --> 02:30:28,260 - [Scott] I think that I'd like to talk to the son anyway 2947 02:30:28,260 --> 02:30:32,341 and Karen and I will talk to the son, I haven't met him. 2948 02:30:32,341 --> 02:30:35,856 - Okay well sooner than later 'cause the father has 2949 02:30:35,856 --> 02:30:38,642 probably gone up to OBGYN to have his coffee up there. 2950 02:30:38,642 --> 02:30:41,121 That's where his escape area is. 2951 02:30:41,121 --> 02:30:43,652 So anytime, the son is here and in the room with 2952 02:30:43,652 --> 02:30:45,754 the mother and I'm sure he would be glad to talk. 2953 02:30:45,754 --> 02:30:47,210 - [Scott] Did you talk to him at all 2954 02:30:47,210 --> 02:30:50,148 about the discussions we had yesterday? 2955 02:30:50,148 --> 02:30:52,096 - I asked Dr. Factor when he went up to 2956 02:30:52,096 --> 02:30:55,480 visit Dr. Kerlind yesterday what was said 2957 02:30:55,480 --> 02:30:58,505 and he said as George Kerlind did basically 2958 02:30:58,505 --> 02:31:00,795 I just needed a friend, I needed to let him 2959 02:31:00,795 --> 02:31:02,821 know how upset I am that my son is leaving 2960 02:31:02,821 --> 02:31:04,934 and that I'm gonna be alone again 2961 02:31:04,934 --> 02:31:07,434 and that the situation is too real. 2962 02:31:07,434 --> 02:31:08,869 Those are his words. 2963 02:31:08,869 --> 02:31:12,434 No discussions about anything concerning the tube. 2964 02:31:12,434 --> 02:31:15,012 When he came into the room just now, 2965 02:31:15,012 --> 02:31:17,834 Bernice and I were talking and I asked her 2966 02:31:17,834 --> 02:31:20,167 about this morning and whether she'd given it any thought. 2967 02:31:20,167 --> 02:31:21,000 No. 2968 02:31:21,000 --> 02:31:22,320 I said are you going to give it some thought? 2969 02:31:22,320 --> 02:31:23,153 Yes. 2970 02:31:23,153 --> 02:31:24,269 I said would you like me to go over 2971 02:31:24,269 --> 02:31:25,470 the things that you're giving thought to? 2972 02:31:25,470 --> 02:31:26,303 Yes. 2973 02:31:26,303 --> 02:31:27,835 I mentioned the options. 2974 02:31:27,835 --> 02:31:30,586 He walked in and said to me, "Oh, 2975 02:31:30,586 --> 02:31:32,771 "what is it that Bernice wanted to talk to you about?" 2976 02:31:32,771 --> 02:31:35,069 I said "Oh, the tube." 2977 02:31:35,069 --> 02:31:37,419 And that was it and he didn't get into it anymore. 2978 02:31:37,419 --> 02:31:39,344 - Then he went bananas. - Then he held her hand 2979 02:31:39,344 --> 02:31:41,157 and then he went bananas. 2980 02:31:41,157 --> 02:31:45,282 I think his anxiety is escalating and... 2981 02:31:45,282 --> 02:31:46,567 - [Karen] All right, well we can 2982 02:31:46,567 --> 02:31:47,996 talk to the son in like 10 minutes. 2983 02:31:47,996 --> 02:31:49,380 - [Scott] I'd like to talk to the son anyway 2984 02:31:49,380 --> 02:31:50,650 just because I'd be interested to-- 2985 02:31:50,650 --> 02:31:52,222 - You need to meet him. - Well-- 2986 02:31:52,222 --> 02:31:53,866 - In terms of-- - I'd be interested, yeah. 2987 02:31:53,866 --> 02:31:55,227 I think somebody should meet him and then 2988 02:31:55,227 --> 02:31:57,969 I can tell him that, who's the visit next month? 2989 02:31:57,969 --> 02:31:59,715 - I don't know. 2990 02:31:59,715 --> 02:32:02,462 - Have to find out who the attending is next month but 2991 02:32:02,462 --> 02:32:03,865 I can at least tell Schwartstein 2992 02:32:03,865 --> 02:32:07,292 who's on for the weekend sort of what, 2993 02:32:07,292 --> 02:32:09,909 it's a really difficult situation. 2994 02:32:09,909 --> 02:32:11,678 - [Anne-Louise] It's very difficult and he's in 2995 02:32:11,678 --> 02:32:13,363 a difficult position because he hates to leave 2996 02:32:13,363 --> 02:32:15,508 his father knowing his father is decompensating. 2997 02:32:15,508 --> 02:32:16,415 - Right. 2998 02:32:16,415 --> 02:32:19,121 - But you have to take care-- - Yeah and I can't-- 2999 02:32:19,121 --> 02:32:21,411 - Of her and if you have to kick him out, then I mean-- 3000 02:32:21,411 --> 02:32:23,589 - [Anne-Louise] But just understand that the last time 3001 02:32:23,589 --> 02:32:26,027 this all happened is because of kicking him out. 3002 02:32:26,027 --> 02:32:28,229 - Right but he has to be-- - What happened? 3003 02:32:28,229 --> 02:32:30,011 - He basically went to war with the nurse 3004 02:32:30,011 --> 02:32:32,627 taking care of her when the patient was on 3005 02:32:32,627 --> 02:32:34,761 her head getting dopamine, not doing well 3006 02:32:34,761 --> 02:32:36,998 and Colleen was pulled in two different directions 3007 02:32:36,998 --> 02:32:39,400 and he thinks he has dismissed her from the case 3008 02:32:39,400 --> 02:32:42,173 and I have told Dr. Kerlind as well as Dr. Factor 3009 02:32:42,173 --> 02:32:44,530 that nobody dismisses nursing from the case. 3010 02:32:44,530 --> 02:32:46,543 Nursing can dismiss themselves if they don't think 3011 02:32:46,543 --> 02:32:49,366 they're in the best interests of the family or the patient 3012 02:32:49,366 --> 02:32:51,508 and that's the case but he can't continue 3013 02:32:51,508 --> 02:32:54,617 to behave this way and decide how things 3014 02:32:54,617 --> 02:32:57,641 are gonna be handled in terms of care, that's all. 3015 02:32:57,641 --> 02:32:59,547 - [Scott] That's the problem, he can't go in there 3016 02:32:59,547 --> 02:33:03,552 if he's gonna abuse the nurse, it's ridiculous. 3017 02:33:03,552 --> 02:33:05,560 - Okay, thank you. - Okay, thanks Anne-Louise. 3018 02:33:05,560 --> 02:33:09,129 - Great. (chuckles) 3019 02:33:09,129 --> 02:33:11,286 - What happened was basically that was the night 3020 02:33:11,286 --> 02:33:13,702 she was doing really bad and she was on pressers 3021 02:33:13,702 --> 02:33:16,966 and he would not leave the room. 3022 02:33:16,966 --> 02:33:20,533 He was just you know, just being a nuisance 3023 02:33:20,533 --> 02:33:23,136 and Colleen just had to kick him out and you know, 3024 02:33:23,136 --> 02:33:25,394 we all said he had to leave and then we were like 3025 02:33:25,394 --> 02:33:27,891 ready to call security to get him out, you know? 3026 02:33:27,891 --> 02:33:29,507 - He was running down the hall like 3027 02:33:29,507 --> 02:33:30,915 this with his hands over his ears, 3028 02:33:30,915 --> 02:33:32,744 "I'm not gonna listen to you, I'm not gonna listen to you. 3029 02:33:32,744 --> 02:33:35,069 "Just go away, leave me alone." 3030 02:33:35,069 --> 02:33:37,273 - It was just a very bad situation. 3031 02:33:37,273 --> 02:33:39,698 - Well you know what Freud said, 3032 02:33:39,698 --> 02:33:42,865 neurosis is no excuse for bad manners. 3033 02:33:48,387 --> 02:33:51,744 - You want me to fix this hand? 3034 02:33:51,744 --> 02:33:53,827 Do you want me to fix it? 3035 02:33:59,237 --> 02:34:00,479 Oh. 3036 02:34:00,479 --> 02:34:03,470 Yeah, it's a little swollen 3037 02:34:03,470 --> 02:34:06,053 but that will be taken care of. 3038 02:34:07,188 --> 02:34:09,355 No need to worry about it. 3039 02:34:10,793 --> 02:34:13,153 It's part of the sickness that 3040 02:34:13,153 --> 02:34:16,351 you can't move the muscles yet. 3041 02:34:16,351 --> 02:34:19,269 That means more healing time, dear. 3042 02:34:20,155 --> 02:34:21,655 More healing time. 3043 02:34:22,845 --> 02:34:24,345 More healing time. 3044 02:34:27,597 --> 02:34:29,097 More healing time. 3045 02:34:53,907 --> 02:34:55,519 - I knew her when she came in 3046 02:34:55,519 --> 02:34:59,355 the first time with her stroke and aspiration. 3047 02:34:59,355 --> 02:35:01,509 I thought at that point that she 3048 02:35:01,509 --> 02:35:05,622 and the husband didn't want this sort of long course. 3049 02:35:05,622 --> 02:35:07,792 So what happened in the meantime? 3050 02:35:07,792 --> 02:35:12,792 - There's been a large debate about this and currently 3051 02:35:12,924 --> 02:35:16,621 she and her family are considering whether to get trached 3052 02:35:16,621 --> 02:35:20,903 or just to bag it and the husband wants her to get 3053 02:35:20,903 --> 02:35:24,313 trached and she hasn't decide yet what she wants to do. 3054 02:35:24,313 --> 02:35:27,190 - She's been addressed in the past three days-- 3055 02:35:27,190 --> 02:35:28,593 - Exactly the most up-to-date. 3056 02:35:28,593 --> 02:35:33,343 - She was a pretty convincing no to Scott and Anne-Louise 3057 02:35:34,201 --> 02:35:36,351 and-- - Two days ago. 3058 02:35:36,351 --> 02:35:39,205 - Two days ago and yesterday Anne-Louise did say she 3059 02:35:39,205 --> 02:35:42,315 was more ambivalent after thinking it over for a day. 3060 02:35:42,315 --> 02:35:44,815 When she talks to Dr. Kerlind, 3061 02:35:46,912 --> 02:35:49,750 it's, he's not as convinced but 3062 02:35:49,750 --> 02:35:53,158 you know an hour after Scott and Anne-Louise 3063 02:35:53,158 --> 02:35:55,025 talked to her, Dr. Kerlind talked to her 3064 02:35:55,025 --> 02:35:59,113 and still wasn't convinced of her wishes. 3065 02:35:59,113 --> 02:36:02,030 It was uncertain whether she was as 3066 02:36:03,538 --> 02:36:06,359 convincing to him as she was to Scott or whether 3067 02:36:06,359 --> 02:36:08,390 his interpretation of it wasn't, 3068 02:36:08,390 --> 02:36:11,544 whether he didn't let her answer, you know? 3069 02:36:11,544 --> 02:36:14,544 It's been a debate and it's ongoing. 3070 02:36:16,362 --> 02:36:18,718 The thing is that the son will be here until tomorrow 3071 02:36:18,718 --> 02:36:21,235 and will help Dr. Factor cope with exactly what's going on. 3072 02:36:21,235 --> 02:36:23,010 So hopefully we'll have-- 3073 02:36:23,010 --> 02:36:25,471 - [Doctor] She's been intubated for how long now? 3074 02:36:25,471 --> 02:36:26,633 - 14 days. 3075 02:36:26,633 --> 02:36:28,869 - [Nurse] Seven times in the last two months. 3076 02:36:28,869 --> 02:36:30,407 - [Doctor] What about this most recent? 3077 02:36:30,407 --> 02:36:32,612 - 14 days. - Active discussion really 3078 02:36:32,612 --> 02:36:36,011 about tracheostomy versus no intubation has 3079 02:36:36,011 --> 02:36:38,576 been going on about four days now where 3080 02:36:38,576 --> 02:36:40,439 it's really been pushed on on all fronts. 3081 02:36:40,439 --> 02:36:42,524 - Are you pushing to do a trach in the next couple of days? 3082 02:36:42,524 --> 02:36:45,117 - No, I mean, no I think we can-- 3083 02:36:45,117 --> 02:36:47,688 - A week or 10 days. - In the next week. 3084 02:36:47,688 --> 02:36:50,267 I mean this is sort of silly to keep on-- 3085 02:36:50,267 --> 02:36:51,470 - She's basically been in 3086 02:36:51,470 --> 02:36:54,440 the hospital for the last four months now. 3087 02:36:54,440 --> 02:36:57,011 - She actually looks, 3088 02:36:57,011 --> 02:36:59,628 in the next 24 or 36 hours I think it would be 3089 02:36:59,628 --> 02:37:02,043 optimal to extubate her to give her a fair chance. 3090 02:37:02,043 --> 02:37:04,451 I think Wednesday she wasn't given a fair chance. 3091 02:37:04,451 --> 02:37:06,025 She was being suctioned every hour, 3092 02:37:06,025 --> 02:37:08,169 she was still two kilos too wet. 3093 02:37:08,169 --> 02:37:09,951 Now her weight's down to 63, 3094 02:37:09,951 --> 02:37:11,280 which is what we were aiming for. 3095 02:37:11,280 --> 02:37:14,973 Secretions are down to suction every four hours or so. 3096 02:37:14,973 --> 02:37:17,618 To give her a fair chance at extubation 3097 02:37:17,618 --> 02:37:21,512 but I don't think long term our options are changing. 3098 02:37:21,512 --> 02:37:23,376 - I think when we extubate her, 3099 02:37:23,376 --> 02:37:26,544 we have to have a plan about what we're gonna do. 3100 02:37:26,544 --> 02:37:28,065 - It's not fair to her. - The other issue for 3101 02:37:28,065 --> 02:37:30,092 the long term management of her is that maybe 3102 02:37:30,092 --> 02:37:33,421 she needs a trach for bronchopulmonary hygiene-- 3103 02:37:33,421 --> 02:37:35,155 - I think she does. - And for her aspiration. 3104 02:37:35,155 --> 02:37:37,319 - I think it should be done. 3105 02:37:37,319 --> 02:37:38,931 - Even if she's not ventilated. 3106 02:37:38,931 --> 02:37:41,368 - Right, I agree, right. 3107 02:37:41,368 --> 02:37:43,732 - But I think she should have that option 3108 02:37:43,732 --> 02:37:46,144 and not Dr. Factor and that's what was stressed 3109 02:37:46,144 --> 02:37:49,846 yesterday was that she was our primary concern. 3110 02:37:49,846 --> 02:37:52,791 Not that he wasn't but she was our primary concern. 3111 02:37:52,791 --> 02:37:55,172 - But she has a lot of ambivalence about-- 3112 02:37:55,172 --> 02:37:57,172 - I believe, yes. - Yeah. 3113 02:37:58,804 --> 02:38:01,092 - But I don't think, I think she has a lot of 3114 02:38:01,092 --> 02:38:03,946 ambivalence about being re-intubated, I agree with that. 3115 02:38:03,946 --> 02:38:05,942 But I think that tracheostomy should be 3116 02:38:05,942 --> 02:38:09,259 explained to her fully and completely. 3117 02:38:09,259 --> 02:38:11,244 To say that number one, it's not a cure. 3118 02:38:11,244 --> 02:38:13,593 Number two, she's gonna stay just like this 3119 02:38:13,593 --> 02:38:15,868 but easier to put her on and off the machine. 3120 02:38:15,868 --> 02:38:18,262 Now if she wants that for the remaining of her days, 3121 02:38:18,262 --> 02:38:19,958 that's her decision but I think 3122 02:38:19,958 --> 02:38:21,452 that has to be explained to her. 3123 02:38:21,452 --> 02:38:22,860 It's not like she's gonna get, 3124 02:38:22,860 --> 02:38:24,642 her paresis is gonna resolve because-- 3125 02:38:24,642 --> 02:38:26,223 - Right. - Which, 3126 02:38:26,223 --> 02:38:28,081 I mean she's not a stupid woman either 3127 02:38:28,081 --> 02:38:29,766 and I think that could be very-- 3128 02:38:29,766 --> 02:38:32,306 - [Doctor] She's the leader of the family. 3129 02:38:32,306 --> 02:38:35,496 - [Doctor] I just think let's address what's important. 3130 02:38:35,496 --> 02:38:37,693 - All right, well I'll talk to Dr. Kerlind again. 3131 02:38:37,693 --> 02:38:39,973 - [George] The good things are that you're 3132 02:38:39,973 --> 02:38:42,578 breathing better and your lungs are clear 3133 02:38:42,578 --> 02:38:46,890 and your heart is breathing slowly and regularly 3134 02:38:46,890 --> 02:38:48,172 and the bad thing from your point 3135 02:38:48,172 --> 02:38:50,369 of view is that tube is still there. 3136 02:38:50,369 --> 02:38:53,322 But after we get enough water off 3137 02:38:53,322 --> 02:38:56,711 and you've had a couple of really good days, 3138 02:38:56,711 --> 02:38:59,898 we'll try pulling it out and see how you do without it. 3139 02:38:59,898 --> 02:39:00,815 Okay? Good. 3140 02:39:13,180 --> 02:39:15,427 - [Nurse] I told her, so that I'm answering, 3141 02:39:15,427 --> 02:39:17,015 hey this is right, Karen wanted to do it. 3142 02:39:17,015 --> 02:39:18,951 - Jane talked to her yesterday about 3143 02:39:18,951 --> 02:39:21,726 sort of her wishes and her plans for the future 3144 02:39:21,726 --> 02:39:24,792 and she expressed a desire to be trached 3145 02:39:24,792 --> 02:39:26,402 even if it meant that she would be 3146 02:39:26,402 --> 02:39:28,255 institutionalized for the rest of her life, 3147 02:39:28,255 --> 02:39:29,945 that it would mean an institutional existence 3148 02:39:29,945 --> 02:39:32,487 in a nursing home or a hospital or something. 3149 02:39:32,487 --> 02:39:36,270 - Never going home, being in a chronic facility, 3150 02:39:36,270 --> 02:39:38,365 living out the rest of her days as she is, 3151 02:39:38,365 --> 02:39:42,365 not getting any better and she said that's okay. 3152 02:39:43,917 --> 02:39:45,859 We have consensus and I think Doctor-- 3153 02:39:45,859 --> 02:39:49,306 - You thought she was pretty-- - She was pretty clear. 3154 02:39:49,306 --> 02:39:51,546 - Awake yesterday. - Yeah, she was pretty clear. 3155 02:39:51,546 --> 02:39:54,902 - But I don't think that this sort of question needs to be 3156 02:39:54,902 --> 02:39:58,038 re-addressed then every 24 hours. 3157 02:39:58,038 --> 02:39:59,904 If she's at a time when she's-- 3158 02:39:59,904 --> 02:40:01,822 - But she was originally addressed on Thursday 3159 02:40:01,822 --> 02:40:03,772 and she's been thinking about it and her thing 3160 02:40:03,772 --> 02:40:06,149 has changed and I think it's good to clarify. 3161 02:40:06,149 --> 02:40:07,500 - [Doctor] We have consensus 3162 02:40:07,500 --> 02:40:09,362 and the son's gonna leave today, right? 3163 02:40:09,362 --> 02:40:11,244 - [Nurse] I assume so, I don't know for a fact. 3164 02:40:11,244 --> 02:40:12,984 - Then we can talk with her tomorrow. 3165 02:40:12,984 --> 02:40:14,661 - Good because then it becomes obviously 3166 02:40:14,661 --> 02:40:17,438 trivial to wean at that point once you have the trach. 3167 02:40:17,438 --> 02:40:19,336 - That leads to my next point which is we were 3168 02:40:19,336 --> 02:40:21,765 talking about trying to wean and maybe extubate, 3169 02:40:21,765 --> 02:40:24,250 try to extubate this weekend but we didn't want to extubate 3170 02:40:24,250 --> 02:40:26,440 her until we had a plan about what was gonna happen. 3171 02:40:26,440 --> 02:40:28,437 But now I think it's silly and we should just 3172 02:40:28,437 --> 02:40:30,921 wait until she gets trached and then try to wean her. 3173 02:40:30,921 --> 02:40:32,533 - That sounds good. - So, she can either, 3174 02:40:32,533 --> 02:40:35,759 I guess we could still put her on brigs and exercise 3175 02:40:35,759 --> 02:40:39,777 or give her some, that sorta thing but in terms of being 3176 02:40:39,777 --> 02:40:41,978 really vigorous in trying to get her off the ventilator, 3177 02:40:41,978 --> 02:40:43,421 I don't think that's appropriate because 3178 02:40:43,421 --> 02:40:47,754 she's gonna have to be on the vent to get her trach. 3179 02:40:49,839 --> 02:40:52,634 - How are you this morning? 3180 02:40:52,634 --> 02:40:56,051 You look a little worried there, are you? 3181 02:41:04,704 --> 02:41:08,075 Are you frightened about something? 3182 02:41:08,075 --> 02:41:09,944 About this procedure that they talked 3183 02:41:09,944 --> 02:41:13,774 to you about, is that what's worrying you? 3184 02:41:13,774 --> 02:41:16,940 Let me explain it to you a little bit. 3185 02:41:18,672 --> 02:41:20,505 Two or three times now 3186 02:41:22,061 --> 02:41:26,657 when your breathing has suddenly become very difficult, 3187 02:41:26,657 --> 02:41:28,238 we've had to put that tube down 3188 02:41:28,238 --> 02:41:31,405 your throat to help you breath, right? 3189 02:41:32,907 --> 02:41:33,740 Okay. 3190 02:41:36,039 --> 02:41:39,194 We're about to take it out again 3191 02:41:39,194 --> 02:41:42,612 because you've done well after the last episode 3192 02:41:42,612 --> 02:41:44,195 but we're concerned 3193 02:41:45,299 --> 02:41:47,949 that if we do and we have to do it again, 3194 02:41:47,949 --> 02:41:49,805 it will just irritate your throat 3195 02:41:49,805 --> 02:41:52,472 a great deal in going in and out 3196 02:41:53,369 --> 02:41:57,791 and so the lung people, the pulmonary consultants 3197 02:41:57,791 --> 02:42:02,432 have suggested that we do what's called a tracheostomy 3198 02:42:02,432 --> 02:42:06,932 by making an opening here which will give us an access 3199 02:42:08,790 --> 02:42:13,273 to your airway so that we can suction it out 3200 02:42:13,273 --> 02:42:16,106 so that the breathing can be easy. 3201 02:42:17,012 --> 02:42:20,471 This does not have to be anything permanent. 3202 02:42:20,471 --> 02:42:25,310 In the past we have closed these over with some people. 3203 02:42:25,310 --> 02:42:28,076 Is everything that I've said clear so far? 3204 02:42:28,076 --> 02:42:28,909 Okay. 3205 02:42:29,892 --> 02:42:33,839 Now, I think the important thing is that nobody 3206 02:42:33,839 --> 02:42:37,839 will do anything to you without your permission. 3207 02:42:39,400 --> 02:42:42,043 So what you have to tell me is does this 3208 02:42:42,043 --> 02:42:45,543 make sense to you to go ahead and do this? 3209 02:42:48,192 --> 02:42:49,692 What do you think? 3210 02:42:51,658 --> 02:42:56,325 You're not sure, okay, do you want me to decide for you? 3211 02:42:57,671 --> 02:42:58,869 Okay. 3212 02:42:58,869 --> 02:43:03,369 I think we will because Dr. Schwartstein whom you know 3213 02:43:04,343 --> 02:43:07,731 is a lung consultant and Dr. Weiss who is the senior 3214 02:43:07,731 --> 02:43:12,510 lung consultant and was on this Board for a whole month 3215 02:43:12,510 --> 02:43:16,326 both think it's to your best interests and will provide 3216 02:43:16,326 --> 02:43:21,043 more comfort for you and ease in taking care of you 3217 02:43:21,043 --> 02:43:24,993 compared to having this tube in your nose and down 3218 02:43:24,993 --> 02:43:28,825 into your airway or down your throat into your airway. 3219 02:43:28,825 --> 02:43:32,939 These tubes will come out after the procedure. 3220 02:43:32,939 --> 02:43:36,355 So there'll be some payoff for you in doing it. 3221 02:43:36,355 --> 02:43:38,417 Is everything I've said clear to you? 3222 02:43:38,417 --> 02:43:41,012 These are our options at this time. 3223 02:43:41,012 --> 02:43:43,873 We'll talk and in the meantime, 3224 02:43:43,873 --> 02:43:46,231 we'll try and arrange time in case we all 3225 02:43:46,231 --> 02:43:49,981 agree that that's the right procedure for us. 3226 02:43:55,491 --> 02:43:57,074 I'll see you later. 3227 02:43:59,377 --> 02:44:03,619 - [Scott] He's always on the side of letting 'em live. 3228 02:44:03,619 --> 02:44:06,612 - Well if it's not-- - Doing everything possible. 3229 02:44:06,612 --> 02:44:08,398 - I think he also is ageist, 3230 02:44:08,398 --> 02:44:10,010 it's hard not to be when you're young. 3231 02:44:10,010 --> 02:44:11,790 - [Scott] But look, he's a layperson. 3232 02:44:11,790 --> 02:44:13,643 - But that's the point. 3233 02:44:13,643 --> 02:44:15,050 - You would not, 3234 02:44:15,050 --> 02:44:17,740 I mean you're supposed to know your business. 3235 02:44:17,740 --> 02:44:19,225 What does he do, he's a lawyer? 3236 02:44:19,225 --> 02:44:20,705 - He's a lawyer. - He's a lawyer, right? 3237 02:44:20,705 --> 02:44:21,788 If it came to 3238 02:44:23,731 --> 02:44:26,451 a tort case or whatever and he said Rachel, 3239 02:44:26,451 --> 02:44:28,646 we have to do this, this and this, 3240 02:44:28,646 --> 02:44:29,927 you would ask him some questions 3241 02:44:29,927 --> 02:44:32,002 about it but he's the professional, not you. 3242 02:44:32,002 --> 02:44:34,262 - I know, I would trust him. - Whereas your job 3243 02:44:34,262 --> 02:44:36,246 is to interpret all of this stuff. 3244 02:44:36,246 --> 02:44:39,583 - See if I came home and I said I have this clinic patient, 3245 02:44:39,583 --> 02:44:43,047 she has this hopeless tumor, there's like one in a million. 3246 02:44:43,047 --> 02:44:45,835 She's 35 years old, she just had baby 3247 02:44:45,835 --> 02:44:50,835 and I can't see putting her through the torture of chemo, 3248 02:44:50,976 --> 02:44:52,509 his response would be that's 3249 02:44:52,509 --> 02:44:55,622 not your choice, that's her choice. 3250 02:44:55,622 --> 02:44:58,071 - Well I think that that's partly right 3251 02:44:58,071 --> 02:44:59,646 in the sense of saying that-- 3252 02:44:59,646 --> 02:45:03,309 - He would probably feel that she should choose the chemo. 3253 02:45:03,309 --> 02:45:05,812 - Well but she should have the choice of understanding, 3254 02:45:05,812 --> 02:45:07,635 making an informed decision about, 3255 02:45:07,635 --> 02:45:10,632 I mean this gets into not the question of DNR 3256 02:45:10,632 --> 02:45:14,196 but sort of what is the physician's responsibility? 3257 02:45:14,196 --> 02:45:18,279 What is an informed choice and what is, you know? 3258 02:45:19,434 --> 02:45:21,851 The problem is that you know, 3259 02:45:24,694 --> 02:45:27,004 it's always informed in quotes, you know? 3260 02:45:27,004 --> 02:45:29,445 It's yes, we can cure your leukemia but you're gonna 3261 02:45:29,445 --> 02:45:31,640 have to spend the next year in the hospital and people 3262 02:45:31,640 --> 02:45:35,954 are gonna stick needles in your body every day and 3263 02:45:35,954 --> 02:45:38,323 you know, horrible things and you'll be tortured 3264 02:45:38,323 --> 02:45:42,139 in ways you never dreamed could possibly occur. 3265 02:45:42,139 --> 02:45:43,639 But you will live. 3266 02:45:44,702 --> 02:45:46,029 Some people would say well, 3267 02:45:46,029 --> 02:45:48,946 that's the definition of Purgatory. 3268 02:45:49,790 --> 02:45:51,769 And some people would say no, 3269 02:45:51,769 --> 02:45:53,973 I take my chances, I'm going right to heaven. 3270 02:45:53,973 --> 02:45:56,973 Do not pass Go, do not collect $200. 3271 02:45:57,905 --> 02:45:59,238 I mean you know, 3272 02:46:02,153 --> 02:46:05,012 the question is what is informed-- 3273 02:46:05,012 --> 02:46:06,460 - Well that's the thing. 3274 02:46:06,460 --> 02:46:09,000 It just strikes me how as this layperson who's 3275 02:46:09,000 --> 02:46:12,080 sort of lived with me through medical school and all, 3276 02:46:12,080 --> 02:46:14,568 he still always comes down on the side of 3277 02:46:14,568 --> 02:46:17,590 the hope and the chance even though you know, 3278 02:46:17,590 --> 02:46:20,002 he's heard quite graphic descriptions 3279 02:46:20,002 --> 02:46:24,083 of the chi chi that goes on and so then when I say, 3280 02:46:24,083 --> 02:46:27,891 he says it should be her choice and I say yes but you know, 3281 02:46:27,891 --> 02:46:30,504 who's giving her the information to make that choice? 3282 02:46:30,504 --> 02:46:32,736 It's me and I cannot help, 3283 02:46:32,736 --> 02:46:37,736 my bias must come through, I'm human, I'm not a computer. 3284 02:46:37,957 --> 02:46:42,790 - Well right, I guess I think as long as you realize that, 3285 02:46:43,908 --> 02:46:48,655 I think as much as doctors try to be objective-- 3286 02:46:48,655 --> 02:46:52,618 - It's impossible. - Nobody is totally objective. 3287 02:46:52,618 --> 02:46:54,472 We slant the news and sorta say look, 3288 02:46:54,472 --> 02:46:57,044 I think you should do this and this and this. 3289 02:46:57,044 --> 02:47:01,515 I am quite nihilistic about what actually happens. 3290 02:47:01,515 --> 02:47:02,515 I think that 3291 02:47:08,061 --> 02:47:10,894 from a personal point of view, I think you do 3292 02:47:10,894 --> 02:47:14,193 real well with the infectious diseases and if you can 3293 02:47:14,193 --> 02:47:16,184 exercise, keep your weight down, don't smoke-- 3294 02:47:16,184 --> 02:47:17,511 - [Doctor] That's easy. 3295 02:47:17,511 --> 02:47:21,556 - Then you've done pretty much what you can but you know, 3296 02:47:21,556 --> 02:47:25,721 a lot of this stuff that goes on is just not 3297 02:47:25,721 --> 02:47:29,399 really relevant to making quality of life 3298 02:47:29,399 --> 02:47:32,649 or length of life all that much better. 3299 02:47:33,534 --> 02:47:35,856 - To give people quality of life, 3300 02:47:35,856 --> 02:47:38,655 you could like be a furniture salesman or something. 3301 02:47:38,655 --> 02:47:40,739 (laughs) 3302 02:47:42,136 --> 02:47:45,065 It's easy to fix things that are fixable. 3303 02:47:45,065 --> 02:47:48,458 - Well it's really rolling the rock up the hill 3304 02:47:48,458 --> 02:47:51,375 and having it come back down again. 3305 02:47:53,268 --> 02:47:55,685 That's a lot of what this is. 3306 02:48:04,982 --> 02:48:07,345 - The instances when it's important to 3307 02:48:07,345 --> 02:48:10,012 start raising the question about 3308 02:48:11,817 --> 02:48:15,900 withdrawing or withholding or stopping treatment, 3309 02:48:17,391 --> 02:48:21,248 I'm gonna use the phrase raise the question a lot 3310 02:48:21,248 --> 02:48:24,655 because at no point in this discussion, 3311 02:48:24,655 --> 02:48:27,310 because this is all theoretical and hypothetical, 3312 02:48:27,310 --> 02:48:30,137 am I advocating in any of the instances I'm going 3313 02:48:30,137 --> 02:48:33,291 to talk about that it's absolutely the right thing to do. 3314 02:48:33,291 --> 02:48:36,290 There is never an absolute in these situations because 3315 02:48:36,290 --> 02:48:40,805 the clinical contingencies as well as people's moral 3316 02:48:40,805 --> 02:48:44,294 and religious feelings have as much to do with 3317 02:48:44,294 --> 02:48:47,413 these kinds of decisions as any theoretical basis. 3318 02:48:47,413 --> 02:48:50,413 So having said that, let me proceed. 3319 02:48:51,269 --> 02:48:54,350 There are probably four instances, 3320 02:48:54,350 --> 02:48:57,098 kind of general situations that we confront 3321 02:48:57,098 --> 02:49:00,871 particularly in critical care settings but throughout 3322 02:49:00,871 --> 02:49:04,470 interdisciplinary clinical practice where it's appropriate 3323 02:49:04,470 --> 02:49:08,793 to raise the question about stopping treatment. 3324 02:49:08,793 --> 02:49:11,762 The first of those is very easy and it has 3325 02:49:11,762 --> 02:49:14,784 to do with what we talked about last week. 3326 02:49:14,784 --> 02:49:18,425 When the clinical diagnosis of brain death has been made, 3327 02:49:18,425 --> 02:49:23,020 any of the support therapies that have been initiated 3328 02:49:23,020 --> 02:49:25,902 can and should be stopped. 3329 02:49:25,902 --> 02:49:29,069 That seems fairly obvious and probably 3330 02:49:30,232 --> 02:49:34,475 is fairly obvious but we've all been in the situation where 3331 02:49:34,475 --> 02:49:37,839 we find ourselves or we are working with 3332 02:49:37,839 --> 02:49:41,734 physician colleagues who ask families permission 3333 02:49:41,734 --> 02:49:43,848 to turn off life-support systems in 3334 02:49:43,848 --> 02:49:46,619 the event of a brain death diagnosis. 3335 02:49:46,619 --> 02:49:49,856 I think a combination of things result in 3336 02:49:49,856 --> 02:49:53,860 those awful situations where patients' families 3337 02:49:53,860 --> 02:49:55,929 either can't digest or can't accept or can't 3338 02:49:55,929 --> 02:49:59,027 understand the clinical diagnosis of brain death 3339 02:49:59,027 --> 02:50:01,443 and therefore have a difficult time going along 3340 02:50:01,443 --> 02:50:03,811 with the termination of life-support systems. 3341 02:50:03,811 --> 02:50:07,499 For one thing, we as clinicians have to accept 3342 02:50:07,499 --> 02:50:10,528 a lot of the blame ourselves, as we said last week, 3343 02:50:10,528 --> 02:50:13,797 we tend when we go out to talk to patients' families, 3344 02:50:13,797 --> 02:50:15,879 sometimes to soften the blow 3345 02:50:15,879 --> 02:50:19,922 with euphemisms that only confuse the issue. 3346 02:50:19,922 --> 02:50:23,248 Even saying brain death as opposed to death 3347 02:50:23,248 --> 02:50:26,801 sometimes confuses the issue because we imply that 3348 02:50:26,801 --> 02:50:30,582 the person isn't really dead and while the diagnosis 3349 02:50:30,582 --> 02:50:33,330 of brain death is made differently and there's 3350 02:50:33,330 --> 02:50:36,742 a different clinical picture than physiological 3351 02:50:36,742 --> 02:50:39,473 death as the distinction has been made, 3352 02:50:39,473 --> 02:50:42,894 dead is dead and as hard as that is, 3353 02:50:42,894 --> 02:50:45,927 it's more compassionate if we kind of give all 3354 02:50:45,927 --> 02:50:48,168 the bad news at once and then rally all of our 3355 02:50:48,168 --> 02:50:52,232 resources to support these patients' families 3356 02:50:52,232 --> 02:50:55,806 through this horrendous news rather than thinking 3357 02:50:55,806 --> 02:50:58,916 that we're buffering them from the ultimate hurt 3358 02:50:58,916 --> 02:51:01,329 and really confusing the issue and either giving them false 3359 02:51:01,329 --> 02:51:06,162 hope or presenting them with options that are not options. 3360 02:52:37,072 --> 02:52:39,435 - How are you holding up? - I'm fine. 3361 02:52:39,435 --> 02:52:41,622 - You doing all right? - I try. 3362 02:52:41,622 --> 02:52:43,604 Yeah, it's hard but-- 3363 02:52:43,604 --> 02:52:45,889 - Okay, is there anything I can do for you? 3364 02:52:45,889 --> 02:52:47,083 - No, not now. 3365 02:52:47,083 --> 02:52:48,494 - Have you been using the medicines at all? 3366 02:52:48,494 --> 02:52:49,896 - No. - Okay. 3367 02:52:49,896 --> 02:52:52,833 Well if things get to you, you can use them. 3368 02:52:52,833 --> 02:52:57,833 Did Al give them to you? - No, he's waiting you know. 3369 02:52:57,994 --> 02:52:59,828 But I tried to be calm 3370 02:53:03,655 --> 02:53:06,151 and I wanna feel everything right now. 3371 02:53:06,151 --> 02:53:09,234 I don't wanna take something and feel 3372 02:53:10,241 --> 02:53:14,324 something different, I wanna feel whatever comes. 3373 02:53:15,525 --> 02:53:17,025 - Okay, all right. 3374 02:53:17,929 --> 02:53:20,140 Okay, anything else? - No. 3375 02:53:20,140 --> 02:53:21,915 - Okay, I'll see you tomorrow then okay? 3376 02:53:21,915 --> 02:53:23,582 - Thank you, Doctor. 3377 02:53:35,095 --> 02:53:37,825 - We're just listening to your lungs. 3378 02:53:37,825 --> 02:53:40,408 - Mr. Cabra, how are you doing? 3379 02:53:41,253 --> 02:53:42,086 Any pain? 3380 02:53:43,654 --> 02:53:45,487 - No, good. - No, good. 3381 02:53:47,444 --> 02:53:50,694 He's still got that flush in his mouth. 3382 02:53:53,900 --> 02:53:55,183 - [Sue] I'm just gonna test this 3383 02:53:55,183 --> 02:53:58,016 and make sure it doesn't look bad. 3384 02:54:03,961 --> 02:54:06,434 - [Doctor] I plugged his morphine and his saline line, Sue. 3385 02:54:06,434 --> 02:54:07,267 - [Sue] Excuse me? 3386 02:54:07,267 --> 02:54:09,161 - [Doctor] I plugged his morphine and his saline line. 3387 02:54:09,161 --> 02:54:11,947 - [Sue] Fine, that's fine. 3388 02:54:11,947 --> 02:54:15,136 - Since last night, he's had really 3389 02:54:15,136 --> 02:54:18,741 a deterioration, we're not sure exactly what's going on. 3390 02:54:18,741 --> 02:54:20,396 He continues to have episodes 3391 02:54:20,396 --> 02:54:22,396 where his blood pressure drops. 3392 02:54:22,396 --> 02:54:24,507 - That's the first time that happened today, right? 3393 02:54:24,507 --> 02:54:26,908 - Pardon me. - This happened before? 3394 02:54:26,908 --> 02:54:28,978 - It's happened since last night, just today, 3395 02:54:28,978 --> 02:54:31,840 since early this morning some time during the night. 3396 02:54:31,840 --> 02:54:34,453 He's had episodes where his blood pressure drops 3397 02:54:34,453 --> 02:54:37,812 and where sometimes his heart rate drops as well 3398 02:54:37,812 --> 02:54:39,956 and the amount of oxygen he's getting 3399 02:54:39,956 --> 02:54:43,011 into his bloodstream is less than usual 3400 02:54:43,011 --> 02:54:46,547 and you know that it's already not very much. 3401 02:54:46,547 --> 02:54:47,910 Are you his wife? - Yes. 3402 02:54:47,910 --> 02:54:49,374 - That's what I thought. 3403 02:54:49,374 --> 02:54:52,952 It's already not, he doesn't get enough oxygen 3404 02:54:52,952 --> 02:54:56,473 into his bloodstream but these new episodes 3405 02:54:56,473 --> 02:54:59,413 where his heart rate and his blood pressure change, 3406 02:54:59,413 --> 02:55:01,315 we're not sure what's causing those. 3407 02:55:01,315 --> 02:55:03,827 It may be an effect of having 3408 02:55:03,827 --> 02:55:07,052 prolonged periods without enough oxygen. 3409 02:55:07,052 --> 02:55:10,573 It may be something else going on but we're not sure. 3410 02:55:10,573 --> 02:55:13,768 It's not surprising that a really prolonged course 3411 02:55:13,768 --> 02:55:16,603 like he's had in which he's been critically ill for 3412 02:55:16,603 --> 02:55:20,464 a long period of time that he should now become unstable. 3413 02:55:20,464 --> 02:55:23,425 But that's not surprising and that's really 3414 02:55:23,425 --> 02:55:26,778 what he's doing now and he's never had problems 3415 02:55:26,778 --> 02:55:29,356 with his heart before and I think the problems with 3416 02:55:29,356 --> 02:55:34,249 his heart really reflect what's going on with his lungs. 3417 02:55:34,249 --> 02:55:36,984 - So what's gonna happen now? - Well, 3418 02:55:36,984 --> 02:55:39,586 I don't think I can tell you what's going to happen to him. 3419 02:55:39,586 --> 02:55:41,994 We're trying to find out exactly what's wrong. 3420 02:55:41,994 --> 02:55:44,297 We're gonna get another chest x-ray. 3421 02:55:44,297 --> 02:55:46,872 We've gotten EKGs and we're sending off 3422 02:55:46,872 --> 02:55:49,200 blood cultures to see if there's an infection. 3423 02:55:49,200 --> 02:55:52,373 But so far those have been unrevealing. 3424 02:55:52,373 --> 02:55:55,706 - Let me know anything with the results. 3425 02:55:57,019 --> 02:56:00,851 - Okay, I know you understand that his overall 3426 02:56:01,838 --> 02:56:04,747 prognosis is not very good. 3427 02:56:04,747 --> 02:56:06,369 - Yeah, I know. - In fact it's very poor. 3428 02:56:06,369 --> 02:56:08,276 - They told me everything and I want 3429 02:56:08,276 --> 02:56:10,796 you to be straight, tell me whatever it is. 3430 02:56:10,796 --> 02:56:12,647 - Okay. - Okay, I can handle it. 3431 02:56:12,647 --> 02:56:15,570 - I think we can expect given what's happened to him 3432 02:56:15,570 --> 02:56:18,321 so far and what the course of his disease has been, 3433 02:56:18,321 --> 02:56:21,486 I think we can expect him to continue to get worse 3434 02:56:21,486 --> 02:56:26,261 and this may be the beginning of a more rapid decline. 3435 02:56:26,261 --> 02:56:29,160 We can still look for treatable causes and try 3436 02:56:29,160 --> 02:56:33,667 to reverse it but it may not be anything reversible. 3437 02:56:33,667 --> 02:56:38,231 There may be very little that we can do in this situation. 3438 02:56:38,231 --> 02:56:40,719 As I said, we'll keep trying 3439 02:56:40,719 --> 02:56:43,335 and above all we're trying to 3440 02:56:43,335 --> 02:56:46,752 keep him as comfortable as possible also. 3441 02:56:49,110 --> 02:56:52,766 I know that the doctors that you know a little 3442 02:56:52,766 --> 02:56:55,556 bit better have brought up the issue of whether 3443 02:56:55,556 --> 02:56:59,473 he should be resuscitated should his heart stop 3444 02:57:00,450 --> 02:57:02,593 and that's something that the family needs to 3445 02:57:02,593 --> 02:57:04,753 think about again because now he's starting 3446 02:57:04,753 --> 02:57:08,892 to show signs of his heart having problems. 3447 02:57:08,892 --> 02:57:12,044 If that gets worse, it may come to the fact 3448 02:57:12,044 --> 02:57:15,740 that his heart will stop and that there's 3449 02:57:15,740 --> 02:57:19,345 very little that we can do except to try, 3450 02:57:19,345 --> 02:57:22,145 we can try to restart his heart with very 3451 02:57:22,145 --> 02:57:25,504 heroic measures like using electric shocks 3452 02:57:25,504 --> 02:57:28,724 and pounding on his chest but in his case, 3453 02:57:28,724 --> 02:57:32,251 that's not going to change the overall picture 3454 02:57:32,251 --> 02:57:36,902 at all and it's not likely to be too successful but 3455 02:57:36,902 --> 02:57:39,675 it's something that we need to bring up with you again. 3456 02:57:39,675 --> 02:57:41,583 I know we've brought that up before 3457 02:57:41,583 --> 02:57:44,524 and you may want to talk about it and then 3458 02:57:44,524 --> 02:57:46,690 talk to us about it again. 3459 02:57:50,646 --> 02:57:53,841 It's a very hard thing to bring up. 3460 02:57:53,841 --> 02:57:55,174 - I know. - Yeah. 3461 02:57:56,968 --> 02:57:58,916 Why don't you talk with the rest of the family and we'll 3462 02:57:58,916 --> 02:58:01,738 continue trying to get his blood pressure stabilized now. 3463 02:58:01,738 --> 02:58:02,775 - Okay. - Okay? 3464 02:58:02,775 --> 02:58:03,724 - Okay, thank you. 3465 02:58:03,724 --> 02:58:06,349 - We're doing all that we can for him now, as I said. 3466 02:58:06,349 --> 02:58:07,839 We're trying to find the cause 3467 02:58:07,839 --> 02:58:10,422 of this and trying to treat it. 3468 02:58:11,369 --> 02:58:14,601 It just may be the end of his disease 3469 02:58:14,601 --> 02:58:17,305 and it may not be something treatable 3470 02:58:17,305 --> 02:58:19,612 and I want you to know that and we're not giving up 3471 02:58:19,612 --> 02:58:24,243 on him or anything but I think you need to understand that. 3472 02:58:24,243 --> 02:58:25,401 Okay? - Thank you. 3473 02:58:25,401 --> 02:58:29,318 - We'll let you know when you can come back in. 3474 02:58:39,339 --> 02:58:40,922 - The only think that I really can think of 3475 02:58:40,922 --> 02:58:43,731 is that he's got some autonomic dysfunction 3476 02:58:43,731 --> 02:58:45,674 just 'cause of nerve irritation. 3477 02:58:45,674 --> 02:58:47,556 No other explanation really fits very well. 3478 02:58:47,556 --> 02:58:48,764 - [Dr. Brisol] I know. 3479 02:58:48,764 --> 02:58:50,443 That's the problem, nothing really fits. 3480 02:58:50,443 --> 02:58:53,009 There's definitely a change and I don't know what it is. 3481 02:58:53,009 --> 02:58:54,946 His mental status is different also. 3482 02:58:54,946 --> 02:58:56,642 - He's much less responsive. - He's not responsive. 3483 02:58:56,642 --> 02:58:58,623 - He was less responsive this morning. 3484 02:58:58,623 --> 02:59:00,576 - [Dr. Brisol] And they keep backing off, backing off, 3485 02:59:00,576 --> 02:59:04,420 backing off on the sedation and he's still not responding. 3486 02:59:04,420 --> 02:59:07,170 In fact becoming less responsive. 3487 02:59:09,012 --> 02:59:12,509 - I think from a practical point of view basically 3488 02:59:12,509 --> 02:59:15,715 our options are to give him fluids 3489 02:59:15,715 --> 02:59:18,705 and then use pressers if he needs it. 3490 02:59:18,705 --> 02:59:21,723 The last couple days, his weight's not 3491 02:59:21,723 --> 02:59:24,366 changed a great deal, he's been sort of even. 3492 02:59:24,366 --> 02:59:26,767 He probably has some sense of a loss 3493 02:59:26,767 --> 02:59:28,634 in addition to what they're measuring. 3494 02:59:28,634 --> 02:59:31,000 So you may be just a touch behind. 3495 02:59:31,000 --> 02:59:32,948 - [Dr. Brisol] We just gave him a unit of blood 3496 02:59:32,948 --> 02:59:36,887 in addition to fluids and he did this after that. 3497 02:59:36,887 --> 02:59:38,630 We can keep pushing on that. 3498 02:59:38,630 --> 02:59:42,720 - It took us a few liters to catch up the other day. 3499 02:59:42,720 --> 02:59:44,914 - I have a feeling that's not gonna be it. 3500 02:59:44,914 --> 02:59:47,848 I saw the family and they have actually 3501 02:59:47,848 --> 02:59:49,708 been in the room when this happened, 3502 02:59:49,708 --> 02:59:52,200 the wife was in the room and I just 3503 02:59:52,200 --> 02:59:54,686 told her that he was deteriorating somewhat, 3504 02:59:54,686 --> 02:59:57,297 that he was becoming a little bit unstable 3505 02:59:57,297 --> 02:59:59,902 in terms of his heart and that it may, 3506 02:59:59,902 --> 03:00:01,813 it might be something we could fix but it 3507 03:00:01,813 --> 03:00:04,346 might be just sort of the end-stage of everything 3508 03:00:04,346 --> 03:00:06,666 that's gone on and the result of the disease 3509 03:00:06,666 --> 03:00:09,749 in his lungs and she understood that. 3510 03:00:11,364 --> 03:00:12,981 - I've tried to prepare her for the fact 3511 03:00:12,981 --> 03:00:16,282 that he's on the edge and even very small 3512 03:00:16,282 --> 03:00:20,387 changes are gonna make a big difference. 3513 03:00:20,387 --> 03:00:22,291 I think that deep in her heart she understands that, 3514 03:00:22,291 --> 03:00:24,065 though I'm not sure she really wants to believe it. 3515 03:00:24,065 --> 03:00:27,559 - Yeah, it seemed like she understood that. 3516 03:00:27,559 --> 03:00:30,420 - I know you talked with Dr. Brisol 3517 03:00:30,420 --> 03:00:33,157 inside and she called me and I came by 3518 03:00:33,157 --> 03:00:35,855 to just have a brief look and talk with her. 3519 03:00:35,855 --> 03:00:38,807 He did this same sort of thing about three days ago 3520 03:00:38,807 --> 03:00:42,148 but only for a couple of hours and then it went away. 3521 03:00:42,148 --> 03:00:45,511 His blood pressure dropped and his pulse dropped 3522 03:00:45,511 --> 03:00:47,172 and then it went away very quickly 3523 03:00:47,172 --> 03:00:50,005 and we never knew why it happened. 3524 03:00:51,008 --> 03:00:55,497 But this has been going on off and on for most of the day. 3525 03:00:55,497 --> 03:00:57,140 It's had times when it's been better 3526 03:00:57,140 --> 03:01:00,228 and times when it's been worse and we 3527 03:01:00,228 --> 03:01:03,229 don't really have a good explanation for it. 3528 03:01:03,229 --> 03:01:05,092 We've given him some blood, 3529 03:01:05,092 --> 03:01:08,543 we were giving him some intravenous fluids, 3530 03:01:08,543 --> 03:01:12,519 none of that so far has made a very big difference. 3531 03:01:12,519 --> 03:01:14,599 He may be a little bit better, 3532 03:01:14,599 --> 03:01:16,814 his blood pressure is up a little bit right now but 3533 03:01:16,814 --> 03:01:20,019 I'm not sure that it's really been any substantial change. 3534 03:01:20,019 --> 03:01:21,960 - Do you know for how long? 3535 03:01:21,960 --> 03:01:26,085 Because maybe because of the transfusion? 3536 03:01:26,085 --> 03:01:27,984 - Well, I don't know if he's gotten 3537 03:01:27,984 --> 03:01:30,783 better because of the transfusion or not. 3538 03:01:30,783 --> 03:01:32,679 He hasn't gotten substantially better. 3539 03:01:32,679 --> 03:01:36,535 I think the point really is that he's not 3540 03:01:36,535 --> 03:01:38,886 as well as he was let's say yesterday. 3541 03:01:38,886 --> 03:01:42,085 I don't understand why there's been this change. 3542 03:01:42,085 --> 03:01:45,032 His oxygen levels in his blood are basically 3543 03:01:45,032 --> 03:01:47,766 the same but for some reason or another, 3544 03:01:47,766 --> 03:01:49,640 his heart just slows down and it pumps 3545 03:01:49,640 --> 03:01:52,491 less hard and his blood pressure goes down 3546 03:01:52,491 --> 03:01:55,034 and it's a worrisome type of thing and it's 3547 03:01:55,034 --> 03:01:57,119 worrisome in particular when we don't have 3548 03:01:57,119 --> 03:02:00,709 an explanation for it, when we don't understand it. 3549 03:02:00,709 --> 03:02:03,065 Because then we don't know specifically 3550 03:02:03,065 --> 03:02:05,482 what to do to make it better. 3551 03:02:06,897 --> 03:02:11,422 From a practical point of view, what we will do is 3552 03:02:11,422 --> 03:02:14,663 give him the fluids and give him the blood. 3553 03:02:14,663 --> 03:02:15,496 All right. 3554 03:02:17,065 --> 03:02:19,337 And if necessary we will give him 3555 03:02:19,337 --> 03:02:23,315 some medicine to help stimulate his heart. 3556 03:02:23,315 --> 03:02:26,030 Those medicines have their own problems, 3557 03:02:26,030 --> 03:02:28,795 they carry their own risks and dangers. 3558 03:02:28,795 --> 03:02:32,982 Our concern is that if we can't find an explanation 3559 03:02:32,982 --> 03:02:37,280 for this and the medicines and the fluids don't help him, 3560 03:02:37,280 --> 03:02:41,280 that we may run out of things to do to help him. 3561 03:02:42,652 --> 03:02:46,420 I just want you to understand that he's really very 3562 03:02:46,420 --> 03:02:51,087 much on the edge, that he doesn't have a lot of reserve. 3563 03:02:53,313 --> 03:02:57,400 But as we've talked about before, we'll do what we can. 3564 03:02:57,400 --> 03:03:00,480 You just need to understand that it's obviously a very 3565 03:03:00,480 --> 03:03:02,882 critical situation. - Yes, I understand 3566 03:03:02,882 --> 03:03:05,751 and I'm aware of everything and I want you 3567 03:03:05,751 --> 03:03:08,668 to tell me straight whatever it is. 3568 03:03:10,314 --> 03:03:13,672 - So, I've talked with Dr. Brisol and we have 3569 03:03:13,672 --> 03:03:17,681 a plan for the evening and we'll just try that. 3570 03:03:17,681 --> 03:03:19,627 See how it goes. 3571 03:03:19,627 --> 03:03:21,494 All right? - Okay. 3572 03:03:21,494 --> 03:03:24,991 - Do you have any questions for me or any other thoughts? 3573 03:03:24,991 --> 03:03:28,147 - [Mrs. Cabra] No, just if the medicine, 3574 03:03:28,147 --> 03:03:33,147 whatever you're trying to do, it doesn't work, nothing can-- 3575 03:03:33,377 --> 03:03:34,703 - I don't think there's anything 3576 03:03:34,703 --> 03:03:37,096 else we could do to stimulate his heart 3577 03:03:37,096 --> 03:03:40,572 and get it pumping harder than those medicines. 3578 03:03:40,572 --> 03:03:44,439 They're very powerful, potent medicines. 3579 03:03:44,439 --> 03:03:46,679 But I don't think that there would be other tricks 3580 03:03:46,679 --> 03:03:51,153 that we would have that we could use to help him out. 3581 03:03:51,153 --> 03:03:54,359 So these things really have to work for him. 3582 03:03:54,359 --> 03:03:56,393 - [Mrs. Cabra] If the medicine works, 3583 03:03:56,393 --> 03:03:59,426 you have to continue to give him the medicine every day, or? 3584 03:03:59,426 --> 03:04:02,282 - This medicine would be given intravenously 3585 03:04:02,282 --> 03:04:06,146 continuously, it would just go in him 3586 03:04:06,146 --> 03:04:08,186 right around the clock, okay? 3587 03:04:08,186 --> 03:04:09,851 It's not medicine that we would 3588 03:04:09,851 --> 03:04:12,205 give one shot of and see how it did. 3589 03:04:12,205 --> 03:04:13,748 - [Mrs. Cabra] How is he now, 3590 03:04:13,748 --> 03:04:15,389 his blood pressure really high or? 3591 03:04:15,389 --> 03:04:17,776 - It's a tiny bit higher but not very much higher. 3592 03:04:17,776 --> 03:04:20,294 It was 77, it's 82 now but that's not 3593 03:04:20,294 --> 03:04:22,822 really a big difference and I'm not sure 3594 03:04:22,822 --> 03:04:25,671 that's an indication that it's getting better. 3595 03:04:25,671 --> 03:04:27,501 In fact I think it really 3596 03:04:27,501 --> 03:04:30,834 has to be viewed as just being the same. 3597 03:04:33,733 --> 03:04:36,775 We're gonna try more fluids and more blood first 3598 03:04:36,775 --> 03:04:38,942 and see how he does, okay? 3599 03:04:40,734 --> 03:04:43,126 I assume as we've talked about before 3600 03:04:43,126 --> 03:04:46,079 that you'd like us to continue to do what we can to-- 3601 03:04:46,079 --> 03:04:48,329 - [Mrs. Cabra] Yes, please. 3602 03:04:49,331 --> 03:04:52,581 She told me about you know, the shocks. 3603 03:04:53,987 --> 03:04:56,497 But I can't make that decision. 3604 03:04:56,497 --> 03:04:57,914 it's hard to say. 3605 03:05:00,023 --> 03:05:02,434 I can't. - I understand. 3606 03:05:02,434 --> 03:05:05,104 - [Mrs. Cabra] So I want everything to help him. 3607 03:05:05,104 --> 03:05:07,379 - Okay, we understand and we don't 3608 03:05:07,379 --> 03:05:09,443 think that that's an unreasonable position. 3609 03:05:09,443 --> 03:05:12,296 We think it's a very difficult decision. 3610 03:05:12,296 --> 03:05:14,879 We have a hard time with it too 3611 03:05:17,762 --> 03:05:20,095 because he's a young man and 3612 03:05:21,116 --> 03:05:23,170 he's otherwise quite healthy 3613 03:05:23,170 --> 03:05:25,320 and we'd like him to pull through. 3614 03:05:25,320 --> 03:05:28,461 We're just concerned about his chances. 3615 03:05:28,461 --> 03:05:31,663 But we will follow your wishes and we will do all that 3616 03:05:31,663 --> 03:05:34,114 and we'll try out best, okay? 3617 03:05:34,114 --> 03:05:38,112 - [Mrs. Cabra] Because I can't make that decision with him. 3618 03:05:38,112 --> 03:05:40,403 - That's fine, okay? 3619 03:05:40,403 --> 03:05:42,828 Your decision is not necessarily a bad one. 3620 03:05:42,828 --> 03:05:47,202 It's a hard one but it's not a bad one, okay? 3621 03:05:47,202 --> 03:05:50,969 - Okay, Doctor. - So we'll just have to see. 3622 03:05:50,969 --> 03:05:52,948 And if there are any major changes, 3623 03:05:52,948 --> 03:05:55,204 Dr. Brisol will call me back. 3624 03:05:55,204 --> 03:05:57,251 - Okay, Doctor. - All right? 3625 03:05:57,251 --> 03:05:59,334 - Okay, thank you. - Okay. 3626 03:06:33,744 --> 03:06:37,988 - [Nurse] Get ya a chair so that you can sit by the edge. 3627 03:06:37,988 --> 03:06:39,655 I can put that down. 3628 03:06:47,522 --> 03:06:48,939 - Today you know, 3629 03:06:50,348 --> 03:06:53,332 his blood count isn't getting higher, 3630 03:06:53,332 --> 03:06:57,311 so they had to put in again more blood. 3631 03:06:57,311 --> 03:06:58,728 He hung in there. 3632 03:06:59,920 --> 03:07:02,474 But nothing's changed, you know? 3633 03:07:02,474 --> 03:07:05,557 I think he's getting worse every day. 3634 03:07:07,861 --> 03:07:09,194 Yes, I think so. 3635 03:07:10,446 --> 03:07:14,368 Yesterday they told me, had to prepare me about 3636 03:07:14,368 --> 03:07:18,701 if they had to use electric shock in case his blood, 3637 03:07:20,904 --> 03:07:22,821 his heart start to stop 3638 03:07:25,227 --> 03:07:28,048 and they tell me I had to make that decision 3639 03:07:28,048 --> 03:07:32,807 if they want to use it or, but I can't, I can't do it. 3640 03:07:32,807 --> 03:07:36,307 I can't make that decision, it's too hard. 3641 03:07:39,974 --> 03:07:42,160 He's too young, you know? 3642 03:07:42,160 --> 03:07:43,993 And I want to give him 3643 03:07:45,752 --> 03:07:47,335 any chance to live, 3644 03:07:48,303 --> 03:07:49,470 I know he's... 3645 03:08:05,634 --> 03:08:08,717 Oh yeah, he's hung in there you know? 3646 03:08:09,938 --> 03:08:12,763 He wants us there to believe because I know, 3647 03:08:12,763 --> 03:08:15,879 I know he, you know, he doesn't, 3648 03:08:15,879 --> 03:08:18,962 he hung in there with all that stuff. 3649 03:08:20,663 --> 03:08:22,746 Yes, yeah he's conscious. 3650 03:08:23,715 --> 03:08:28,215 Yesterday I talked to him and I tried to encourage him 3651 03:08:32,812 --> 03:08:36,229 and I know he was conscious in that time. 3652 03:08:37,472 --> 03:08:39,139 But yesterday night, 3653 03:08:40,900 --> 03:08:41,733 he was 3654 03:08:43,028 --> 03:08:46,643 and this morning when I came, he opened his eyes 3655 03:08:46,643 --> 03:08:49,893 and now he's sedated and he's sleeping. 3656 03:09:30,391 --> 03:09:34,308 (high pitched electronic beep) 3657 03:10:07,337 --> 03:10:09,114 - [Doctor] What's there? 3658 03:10:09,114 --> 03:10:11,780 (phone ringing) 3659 03:10:39,285 --> 03:10:43,013 - The one thing that she has conceded at this point 3660 03:10:43,013 --> 03:10:48,013 is to not shock him if he were to have a cardiac arrest. 3661 03:10:48,491 --> 03:10:50,934 Basically what I told her and what she'd like 3662 03:10:50,934 --> 03:10:55,503 is for us to do everything up to the point of shocking. 3663 03:10:55,503 --> 03:10:58,130 In other words, continue to use pressers 3664 03:10:58,130 --> 03:11:00,500 if he becomes hypertensive, to give him 3665 03:11:00,500 --> 03:11:03,734 fluid resuscitation if he needs it. 3666 03:11:03,734 --> 03:11:06,556 But not to shock him. - Okay. 3667 03:11:06,556 --> 03:11:09,576 - If he were to arrest, I think that's reasonable 3668 03:11:09,576 --> 03:11:12,277 at this point. - Okay, fine. 3669 03:11:12,277 --> 03:11:14,175 - I'll write an order. - He goes for his surgery. 3670 03:11:14,175 --> 03:11:16,419 - Yeah and he needs to have a trach, 3671 03:11:16,419 --> 03:11:19,747 he needs to have a line, send him for those things. 3672 03:11:19,747 --> 03:11:24,299 - [Doctor] If he arrests though, we do CPR, et cetera? 3673 03:11:24,299 --> 03:11:25,132 - No, no. 3674 03:11:26,153 --> 03:11:27,789 If he were to have a cardiac arrest, 3675 03:11:27,789 --> 03:11:30,316 you don't do any CPR or any shock. 3676 03:11:30,316 --> 03:11:32,725 But if he becomes hypotensive, 3677 03:11:32,725 --> 03:11:36,139 give him fluids and give him pressers. 3678 03:11:36,139 --> 03:11:39,398 - [Doctor] All right sounds, yeah that sounds reasonable. 3679 03:11:39,398 --> 03:11:41,306 - Okay, I'll write an order. 3680 03:11:41,306 --> 03:11:45,165 - Okay, all right thanks. - I'll write an order. 3681 03:11:45,165 --> 03:11:46,998 - Thanks a lot. - Yeah. 3682 03:11:52,570 --> 03:11:54,110 - [Scott] The other important thing for everybody to 3683 03:11:54,110 --> 03:11:58,925 note is why don't you tell 'em about Larry and the family? 3684 03:11:58,925 --> 03:12:03,038 - Oh yeah, actually Larry's been on the phone with you. 3685 03:12:03,038 --> 03:12:04,616 Maybe you could tell everybody 3686 03:12:04,616 --> 03:12:06,931 the situation in which it occurred. 3687 03:12:06,931 --> 03:12:07,764 - Yeah. 3688 03:12:08,752 --> 03:12:12,408 Just briefly he spoke with the wife at length 3689 03:12:12,408 --> 03:12:15,075 and she's comfortable having him 3690 03:12:16,600 --> 03:12:19,517 not have cardiac resuscitation done 3691 03:12:20,486 --> 03:12:23,260 should he required that. 3692 03:12:23,260 --> 03:12:26,347 She said no shocking and no CPR, 3693 03:12:26,347 --> 03:12:29,137 although she still would be, 3694 03:12:29,137 --> 03:12:32,333 want us to be very aggressive about 3695 03:12:32,333 --> 03:12:34,843 antibiotic treatment, pressers, et cetera. 3696 03:12:34,843 --> 03:12:37,173 Everything short of CPR. 3697 03:12:37,173 --> 03:12:39,117 - [Scott] This is, I mean it becomes 3698 03:12:39,117 --> 03:12:40,811 a little bit of an academic issue because 3699 03:12:40,811 --> 03:12:42,390 that's not what's gonna happen to this guy. 3700 03:12:42,390 --> 03:12:45,554 That's not the way he's gonna expire if that's what happens. 3701 03:12:45,554 --> 03:12:49,340 He's gonna pop a flip or just get septic-- 3702 03:12:49,340 --> 03:12:52,287 Well it could eventually but I think that 3703 03:12:52,287 --> 03:12:55,954 it is important for the people to know that. 3704 03:13:03,779 --> 03:13:06,696 - [Doctor] The pulses, good pulses. 3705 03:13:38,953 --> 03:13:42,703 - [Doctor] He got a chest x-ray this morning. 3706 03:14:05,711 --> 03:14:07,850 - I didn't want to, 3707 03:14:07,850 --> 03:14:11,839 I said to Larry and Fabricio last, yesterday 3708 03:14:11,839 --> 03:14:14,347 in the rounds I said "He ain't gonna make it." 3709 03:14:14,347 --> 03:14:16,044 Even before he came back from 3710 03:14:16,044 --> 03:14:19,185 the Pickman and he looked worse. 3711 03:14:19,185 --> 03:14:22,140 - You haven't been the first one to say that. 3712 03:14:22,140 --> 03:14:23,967 I've been saying it for three weeks. 3713 03:14:23,967 --> 03:14:25,795 - [Dr. Brisol] I think the problem with 3714 03:14:25,795 --> 03:14:27,983 the attending is that it's a chemotherapy complication. 3715 03:14:27,983 --> 03:14:31,429 - The guy has quote "a cure" unquote from his embryonal cell 3716 03:14:31,429 --> 03:14:34,288 carcinoma so now he's dying of iatrogenic complications. 3717 03:14:34,288 --> 03:14:38,871 So everybody feels guilty. - It's a very touchy subject. 3718 03:14:41,795 --> 03:14:43,241 - I know, it's too bad people 3719 03:14:43,241 --> 03:14:45,094 can't deconflict themselves from that. 3720 03:14:45,094 --> 03:14:48,162 They get so invested in the treatment. 3721 03:14:48,162 --> 03:14:50,995 I don't know, young guy, you know? 3722 03:14:52,288 --> 03:14:54,871 But what a horrible way to die. 3723 03:14:59,540 --> 03:15:01,279 Larry's usually pretty reasonable too. 3724 03:15:01,279 --> 03:15:02,602 He's not usually difficult to 3725 03:15:02,602 --> 03:15:04,344 deal with about this kind of stuff. 3726 03:15:04,344 --> 03:15:06,344 He's one of the more, there are some of those 3727 03:15:06,344 --> 03:15:10,817 oncologists who really they border on fantasy-- 3728 03:15:10,817 --> 03:15:13,265 - Psychosis. - All the time, yeah. 3729 03:15:13,265 --> 03:15:15,506 - [Doctor] We just dealt with one of them up here. 3730 03:15:15,506 --> 03:15:17,422 - [Dr. Brisol] The other night when he dropped his pressure, 3731 03:15:17,422 --> 03:15:19,958 two nights ago or whenever it was, 3732 03:15:19,958 --> 03:15:21,565 I guess it would be four nights ago, 3733 03:15:21,565 --> 03:15:24,534 I called him and he said "Start him on pressers." 3734 03:15:24,534 --> 03:15:25,951 Do this, do that. 3735 03:15:27,472 --> 03:15:30,662 We didn't reach that point but he clearly wanted it. 3736 03:15:30,662 --> 03:15:33,032 - I have a feeling that there's not, 3737 03:15:33,032 --> 03:15:36,222 when you can't find any place to put a line in the guy 3738 03:15:36,222 --> 03:15:41,222 and he's on gentamycin and then he's gonna get the you know, 3739 03:15:41,404 --> 03:15:43,301 the antibiotic for the Andromeda Strain, 3740 03:15:43,301 --> 03:15:46,465 you're sorta stuck in the last ditch here. 3741 03:15:46,465 --> 03:15:48,660 So I don't think, at least she agreed 3742 03:15:48,660 --> 03:15:52,368 to not having us pound on his chest. 3743 03:15:52,368 --> 03:15:55,868 Some small victory. - Major accomplishment. 3744 03:16:18,375 --> 03:16:20,960 - [Nurse] Dr. Zuma, you have a call on line four. 3745 03:16:20,960 --> 03:16:24,210 Dr. Zuma, you have a call on line four. 3746 03:16:37,800 --> 03:16:41,226 - The wife, I've never met the wife. 3747 03:16:41,226 --> 03:16:42,678 I know 3748 03:16:42,678 --> 03:16:43,511 but 3749 03:16:44,415 --> 03:16:46,608 did she come in and see him? - Yeah, oh yeah. 3750 03:16:46,608 --> 03:16:48,251 - They have kids, how many kids? 3751 03:16:48,251 --> 03:16:49,583 Three kids, how old? 3752 03:16:49,583 --> 03:16:52,953 - Did you see those heartbreaking letters up on the wall? 3753 03:16:52,953 --> 03:16:54,453 - 12. - Nine, five. 3754 03:16:55,432 --> 03:16:56,998 - These letters up on the wall, 3755 03:16:56,998 --> 03:16:58,661 "Dear daddy, I miss you so much. 3756 03:16:58,661 --> 03:17:00,678 "I pray for you to get better every day." 3757 03:17:00,678 --> 03:17:04,009 Things like that, heartbreaking. 3758 03:17:04,009 --> 03:17:07,676 - [Doctor] They had the priest in yesterday. 3759 03:17:13,869 --> 03:17:15,202 - Well you know, 3760 03:17:18,361 --> 03:17:22,720 it's hard to know what to do at this point. 3761 03:17:22,720 --> 03:17:23,637 I wonder... 3762 03:17:27,368 --> 03:17:28,201 Well, 3763 03:17:29,818 --> 03:17:32,068 the longer we keep him out, 3764 03:17:35,414 --> 03:17:40,414 I mean the longer we're sorta guaranteeing he's never gonna, 3765 03:17:41,896 --> 03:17:46,896 if he's got a chance it lies in getting his chest tube out, 3766 03:17:47,301 --> 03:17:50,550 lighting up the mussitation, putting him on a T-piece, 3767 03:17:50,550 --> 03:17:53,604 seeing if he can breathe on his own, all that kinda stuff. 3768 03:17:53,604 --> 03:17:56,090 If we don't do that kinda stuff then 3769 03:17:56,090 --> 03:17:59,007 he's just sittin' there waiting to get infected, 3770 03:17:59,007 --> 03:18:00,257 waiting to die. 3771 03:18:01,419 --> 03:18:04,347 I'm not sure he can tolerate any of that stuff. 3772 03:18:04,347 --> 03:18:06,118 I think we may be at the point here where 3773 03:18:06,118 --> 03:18:09,701 his lungs are so bad that he's not gonna... 3774 03:18:17,135 --> 03:18:19,042 I guess maybe what we oughta do 3775 03:18:19,042 --> 03:18:21,014 is just take some small steps. 3776 03:18:21,014 --> 03:18:22,579 My own feeling is that if the chest 3777 03:18:22,579 --> 03:18:24,407 surgeons feel comfortable taking out his tube, 3778 03:18:24,407 --> 03:18:25,768 I would probably take out his tube. 3779 03:18:25,768 --> 03:18:27,814 The reason I say that is that eventually 3780 03:18:27,814 --> 03:18:30,321 he's gonna get an empyema there, he's gonna get 3781 03:18:30,321 --> 03:18:33,399 an infection in sorta the hole open to the outside. 3782 03:18:33,399 --> 03:18:37,574 So okay, he's been on the ventilator now for three weeks 3783 03:18:37,574 --> 03:18:40,544 and he's not been leaking for over a week. 3784 03:18:40,544 --> 03:18:44,476 So let's take it out and then I think we gotta 3785 03:18:44,476 --> 03:18:47,427 see if we can pump a few more calories into the guy. 3786 03:18:47,427 --> 03:18:50,669 See if we can feed him some more 3787 03:18:50,669 --> 03:18:51,502 and 3788 03:18:53,398 --> 03:18:57,111 then I guess the final thing would be 3789 03:18:57,111 --> 03:18:59,564 once we've sort of got that under control 3790 03:18:59,564 --> 03:19:01,463 would be to lighten up on his sedation and see 3791 03:19:01,463 --> 03:19:04,126 if we can get him to breathe on his own some. 3792 03:19:04,126 --> 03:19:05,783 - It sounds like he is taking breaths. 3793 03:19:05,783 --> 03:19:07,519 - That was what happened the past couple days 3794 03:19:07,519 --> 03:19:10,547 but again the ventilators, he's up to 30 popping off. 3795 03:19:10,547 --> 03:19:14,997 - Listen, when he goes on his own, he's got no lungs there. 3796 03:19:14,997 --> 03:19:16,818 He's gonna be-- 3797 03:19:16,818 --> 03:19:19,488 - That's what he's doing now. - Some amount of restriction 3798 03:19:19,488 --> 03:19:23,905 and low lung volume always with him, it's pretty bad. 3799 03:19:25,488 --> 03:19:26,982 - I'm sorry, what? - Could you measure that? 3800 03:19:26,982 --> 03:19:29,054 I mean could his lungs be so restrictive that it would be 3801 03:19:29,054 --> 03:19:33,506 impossible for a human to ventilate those kind of lungs? 3802 03:19:33,506 --> 03:19:36,540 - That's possible, in general-- 3803 03:19:36,540 --> 03:19:38,372 - [Doctor] That was my impression of the situation. 3804 03:19:38,372 --> 03:19:39,990 - That may be where we're at. 3805 03:19:39,990 --> 03:19:44,887 I think, that's the terminal stage of pulmonary fibrosis 3806 03:19:44,887 --> 03:19:47,523 which is basically what bleomycin is is a pulmonary 3807 03:19:47,523 --> 03:19:50,951 fibrotic disease and in the terminal stage of any 3808 03:19:50,951 --> 03:19:53,645 sort of fibrotic lung disease, CO2 retention 3809 03:19:53,645 --> 03:19:55,518 is sort of a pre-morbid phenomenon. 3810 03:19:55,518 --> 03:19:58,608 They just, you know they run with a low CO2 3811 03:19:58,608 --> 03:20:00,972 because they've had such tremendous respiratory 3812 03:20:00,972 --> 03:20:03,792 stimulus from the proprioceptive influences of 3813 03:20:03,792 --> 03:20:07,394 the small lung that they breathe, they're 3814 03:20:07,394 --> 03:20:10,337 maximally stimulated and then when they just 3815 03:20:10,337 --> 03:20:13,241 can't do it anymore, then their CO2 rises 3816 03:20:13,241 --> 03:20:16,551 and that may be where he's at, in which case, 3817 03:20:16,551 --> 03:20:18,926 we have a sort of significant problem because 3818 03:20:18,926 --> 03:20:21,221 if we have to keep him sedated to have him 3819 03:20:21,221 --> 03:20:23,255 breathe in the ventilator, then we're never 3820 03:20:23,255 --> 03:20:25,121 gonna be able to feed him and it's just 3821 03:20:25,121 --> 03:20:29,522 a question of weeks to months before he dies. 3822 03:20:29,522 --> 03:20:33,983 I think that overall that's sort of where I see things 3823 03:20:33,983 --> 03:20:37,088 being at, on the other hand, 3824 03:20:37,088 --> 03:20:39,921 we're talking three kids here, so. 3825 03:20:41,427 --> 03:20:43,328 It's hard to, 3826 03:20:43,328 --> 03:20:47,285 I guess what, given that he's as sick as he is, 3827 03:20:47,285 --> 03:20:49,337 we ought not to make a lot of sudden moves. 3828 03:20:49,337 --> 03:20:51,842 We oughta do just one small thing at a time 3829 03:20:51,842 --> 03:20:54,410 and not jump in there and really start 3830 03:20:54,410 --> 03:20:57,919 flailing away with a lot of major league changes. 3831 03:20:57,919 --> 03:20:59,752 I think that you know, 3832 03:21:02,530 --> 03:21:05,846 the kinds of things that you could do would be 3833 03:21:05,846 --> 03:21:07,646 take the chest tube out, see if you can get 3834 03:21:07,646 --> 03:21:10,417 a little more calories into the guy. 3835 03:21:10,417 --> 03:21:13,105 Small stuff and then eventually 3836 03:21:13,105 --> 03:21:14,967 gradually lighten up on his sedation 3837 03:21:14,967 --> 03:21:17,800 and see if we can breathe for him. 3838 03:21:18,997 --> 03:21:21,639 If we can still breathe for him with him getting 3839 03:21:21,639 --> 03:21:25,288 less sedation, I mean at some point you gotta try that. 3840 03:21:25,288 --> 03:21:29,423 - Well that test is what they're trying to do now 3841 03:21:29,423 --> 03:21:32,131 and he has a heart rate of 150 and a respiratory 3842 03:21:32,131 --> 03:21:35,278 rate of 30 and a peak pressure of 60 to 70. 3843 03:21:35,278 --> 03:21:36,931 This is... 3844 03:21:36,931 --> 03:21:39,347 - So then-- - When they lighten him up? 3845 03:21:39,347 --> 03:21:44,286 - They've decreased the morphine over the past 24 hours. 3846 03:21:44,286 --> 03:21:47,272 He hasn't been getting morphine balls, so it's just Valium 3847 03:21:47,272 --> 03:21:49,128 and he still has a heart rate of 130 3848 03:21:49,128 --> 03:21:51,795 and respiratory rate of 24 to 30. 3849 03:21:51,795 --> 03:21:54,084 - [Scott] That's not so bad. 3850 03:21:54,084 --> 03:21:56,673 Young guy, his heart's okay. - What do we wanna 3851 03:21:56,673 --> 03:21:57,999 go with? 3852 03:21:57,999 --> 03:22:00,034 - [Dr. Brisol] He can tolerate a tachycardia 3853 03:22:00,034 --> 03:22:03,341 in the setting of trying to lighten him up. 3854 03:22:03,341 --> 03:22:05,071 - I guess I would try to do, 3855 03:22:05,071 --> 03:22:08,044 I mean maybe the way to do this is to 3856 03:22:08,044 --> 03:22:09,789 take out the chest tube and see if we 3857 03:22:09,789 --> 03:22:11,655 can feed him and get him a little stronger 3858 03:22:11,655 --> 03:22:14,454 and then start doing the stuff with the ventilator 3859 03:22:14,454 --> 03:22:16,948 and to not push too hard on that at the moment 3860 03:22:16,948 --> 03:22:19,434 and to put that off for a few days. 3861 03:22:19,434 --> 03:22:22,494 I guess that's what I'd do. 3862 03:22:22,494 --> 03:22:27,435 - [Doctor] Yeah and it might help his semi-pneumonia too. 3863 03:22:27,435 --> 03:22:29,214 - To the extent that he does have an infection, 3864 03:22:29,214 --> 03:22:32,555 I'm not sure that we want to rip him off the ventilator now. 3865 03:22:32,555 --> 03:22:34,695 I would vote for no sudden moves, you know? 3866 03:22:34,695 --> 03:22:36,431 Small things, take the chest tube out, 3867 03:22:36,431 --> 03:22:38,090 see if we can get some more calories into him. 3868 03:22:38,090 --> 03:22:39,956 Don't lighten him up too much. 3869 03:22:39,956 --> 03:22:42,026 Ventilate him 'til we get him to the point where 3870 03:22:42,026 --> 03:22:44,679 we get the fever totally under control. 3871 03:22:44,679 --> 03:22:46,886 Give him a couple more days of antibiotics and then 3872 03:22:46,886 --> 03:22:49,122 maybe the beginning of the week we'll try to lighten up, 3873 03:22:49,122 --> 03:22:51,485 cut back on the sedation and see 3874 03:22:51,485 --> 03:22:54,199 if we can get him to breathe on his own. 3875 03:22:54,199 --> 03:22:56,607 - Assuming the best possible scenario just for 3876 03:22:56,607 --> 03:22:59,600 my own education, should he come off the vent 3877 03:22:59,600 --> 03:23:04,251 and actually do okay and eventually even go home, what's 3878 03:23:04,251 --> 03:23:08,762 the best he could hope for in terms of his functioning? 3879 03:23:08,762 --> 03:23:10,168 - I can't believe we're looking at 3880 03:23:10,168 --> 03:23:13,206 anything more than months here. 3881 03:23:13,206 --> 03:23:15,695 - Months of survival and at best, 3882 03:23:15,695 --> 03:23:18,133 he would not be able to walk around very much. 3883 03:23:18,133 --> 03:23:19,829 - He's never gonna walk around. 3884 03:23:19,829 --> 03:23:20,662 - Okay. 3885 03:23:22,400 --> 03:23:26,421 - I think the best we can hope for is chronic care. 3886 03:23:26,421 --> 03:23:29,408 I'm not even sure we can get to that. 3887 03:23:29,408 --> 03:23:30,741 That's the best. 3888 03:23:31,722 --> 03:23:35,055 I think that that's maybe one in 10,000. 3889 03:23:36,730 --> 03:23:39,374 Maybe even one in a million, I don't know, it's hard to say. 3890 03:23:39,374 --> 03:23:40,874 But I mean I just, 3891 03:23:42,358 --> 03:23:46,858 based on past experience I think it's pretty hopeless. 3892 03:23:49,557 --> 03:23:50,557 So I mean I, 3893 03:23:51,714 --> 03:23:54,080 I guess I would vote for sorta just more of the same. 3894 03:23:54,080 --> 03:23:57,184 Take the chest tube out, keep him on the medication 3895 03:23:57,184 --> 03:24:00,868 and see if we can get some more calories into the guy. 3896 03:24:00,868 --> 03:24:03,543 Then we'll try at the beginning part of the week to 3897 03:24:03,543 --> 03:24:05,692 see what we can do about the ventilator but I just, 3898 03:24:05,692 --> 03:24:08,914 I don't hold out a lot of hope for that. 3899 03:24:08,914 --> 03:24:10,780 It'd be worth a try, look I've been wrong before. 3900 03:24:10,780 --> 03:24:13,780 You never can tell, you have to try. 3901 03:24:37,617 --> 03:24:40,284 (phone ringing) 3902 03:24:41,299 --> 03:24:43,382 - Medical Intensive Care. 3903 03:25:11,648 --> 03:25:14,731 - [Nurse] No, I got 'em, I'm all set. 3904 03:25:23,507 --> 03:25:27,590 Hi, I got a call from Russ Philips on the biopsy. 3905 03:25:36,415 --> 03:25:39,864 - She wants to play out the string so, 3906 03:25:39,864 --> 03:25:42,702 I think he did too, he's got three little kids. 3907 03:25:42,702 --> 03:25:45,106 We're doing everything we can do. 3908 03:25:45,106 --> 03:25:46,471 It's just not working. 3909 03:25:46,471 --> 03:25:48,157 - I saw Dr. Shuleman this morning, 3910 03:25:48,157 --> 03:25:51,143 just to update everyone on the family. 3911 03:25:51,143 --> 03:25:56,143 He talked to Mrs. Cabra yesterday and sort of kind of 3912 03:25:56,168 --> 03:25:59,739 gave her a very grim picture of how things were going 3913 03:25:59,739 --> 03:26:03,487 and just sort of let her know in no uncertain terms 3914 03:26:03,487 --> 03:26:06,429 that he was taking a turn for the worse and that-- 3915 03:26:06,429 --> 03:26:08,798 - [Scott] I think that's important that she know that. 3916 03:26:08,798 --> 03:26:11,867 - She still wants everything short of CPR done for him. 3917 03:26:11,867 --> 03:26:13,859 She still wants all that done. - Fine, not a problem. 3918 03:26:13,859 --> 03:26:15,773 - It's been made very clear to her. 3919 03:26:15,773 --> 03:26:17,773 - [Scott] Not a problem. 3920 03:26:18,749 --> 03:26:20,771 - Has he been on any steroids? 3921 03:26:20,771 --> 03:26:23,000 - Not since he came in. 3922 03:26:23,000 --> 03:26:27,417 - [Doctor] Is there any, would there be any benefit-- 3923 03:26:28,840 --> 03:26:31,173 - Then just wait over there. 3924 03:26:32,162 --> 03:26:35,356 Yeah, they told me that too, I checked with the nurse. 3925 03:26:35,356 --> 03:26:38,106 Okay good, thanks a lot, bye-bye. 3926 03:26:41,678 --> 03:26:45,327 - I just came from talking with the wife 3927 03:26:45,327 --> 03:26:47,347 and she doesn't want any of that done. 3928 03:26:47,347 --> 03:26:49,750 Take away the antibiotics, keep him on 3929 03:26:49,750 --> 03:26:53,823 as much morphine and Valium as he needs 3930 03:26:53,823 --> 03:26:58,103 and you know, not deal with his fence sittings. 3931 03:26:58,103 --> 03:26:59,431 - No more gases? 3932 03:26:59,431 --> 03:27:03,215 - I wouldn't do any more gases or any more blood work. 3933 03:27:03,215 --> 03:27:05,288 She's very comfortable with that and I think 3934 03:27:05,288 --> 03:27:06,991 we're all comfortable with the fact that 3935 03:27:06,991 --> 03:27:09,244 he's just not gonna turn around at this point. 3936 03:27:09,244 --> 03:27:11,848 He's been intubated for four and a half weeks 3937 03:27:11,848 --> 03:27:16,691 and he's had his ups and downs but it's basically been down. 3938 03:27:16,691 --> 03:27:19,510 It's really pretty inconceivable to me 3939 03:27:19,510 --> 03:27:22,541 that he's gonna get any better. 3940 03:27:22,541 --> 03:27:24,624 And inconceivable to her. 3941 03:27:26,196 --> 03:27:28,363 - Has she gone out? - Yeah. 3942 03:27:29,545 --> 03:27:32,359 Yeah, she's out in the waiting area. 3943 03:27:32,359 --> 03:27:34,012 - That's good. 3944 03:27:34,012 --> 03:27:35,012 - All right? 3945 03:27:36,194 --> 03:27:38,046 So I'll write a brief note 3946 03:27:38,046 --> 03:27:39,723 and I'll talk to whoever's around. 3947 03:27:39,723 --> 03:27:40,997 - Okay. 3948 03:27:40,997 --> 03:27:43,065 - Okay, do you have any objections 3949 03:27:43,065 --> 03:27:46,456 or any problems with that? - Not at all. 3950 03:27:46,456 --> 03:27:49,023 - [Doctor] You did a good job helping her, I'll tell you. 3951 03:27:49,023 --> 03:27:50,640 Because she's come a long way. 3952 03:27:50,640 --> 03:27:52,346 - Yeah, well you guys did a good job too. 3953 03:27:52,346 --> 03:27:54,583 I know you spent a lot of time with her. 3954 03:27:54,583 --> 03:27:56,239 She appreciates it. - She's so wonderful. 3955 03:27:56,239 --> 03:27:58,734 - Yeah, she really is. 3956 03:27:58,734 --> 03:28:02,487 She really is and she's comfortable with the decision. 3957 03:28:02,487 --> 03:28:04,739 She doesn't feel like she's been pushed at all. 3958 03:28:04,739 --> 03:28:07,434 - [Doctor] That's good. 3959 03:28:07,434 --> 03:28:08,880 All right. 3960 03:28:08,880 --> 03:28:11,968 So maybe I could just borrow this for one second. 3961 03:28:11,968 --> 03:28:13,702 - Thank you. 3962 03:28:13,702 --> 03:28:15,869 - All right, so that's it. 3963 03:28:21,709 --> 03:28:23,959 (chattering) 3964 03:28:23,959 --> 03:28:26,545 - DC antibiotics? - Why don't we-- 3965 03:28:26,545 --> 03:28:30,521 - [Doctor] Yeah, DC antibiotics, no procedures. 3966 03:28:30,521 --> 03:28:32,354 - Well obviously, wow. 3967 03:28:34,006 --> 03:28:36,182 What, how'd that come about? 3968 03:28:36,182 --> 03:28:38,835 - I think that it's just, 3969 03:28:38,835 --> 03:28:40,533 I think he's just been kind of gradually 3970 03:28:40,533 --> 03:28:44,116 bringing her around to the realization that 3971 03:28:45,003 --> 03:28:47,559 he's not getting better and I think it's 3972 03:28:47,559 --> 03:28:50,084 one of those things where he's been telling her 3973 03:28:50,084 --> 03:28:52,392 that and she hasn't been hearing it and finally 3974 03:28:52,392 --> 03:28:55,947 she's started to hear it, yeah, she's started to hear it. 3975 03:28:55,947 --> 03:28:56,780 And so, 3976 03:28:57,933 --> 03:29:00,183 we're just gonna, you know, 3977 03:29:01,044 --> 03:29:05,107 stop the antibiotics and stop lab work. 3978 03:29:05,107 --> 03:29:07,752 - Good, no labs. - I think no labs, yeah. 3979 03:29:07,752 --> 03:29:09,613 I think no blood gases and no labs. 3980 03:29:09,613 --> 03:29:11,432 - No vent setting changes, no-- 3981 03:29:11,432 --> 03:29:12,265 - Yeah. 3982 03:29:14,332 --> 03:29:15,165 - Wow. 3983 03:29:16,280 --> 03:29:19,602 - It's appropriate in my mind. 3984 03:29:19,602 --> 03:29:23,685 - Oh yeah, it's just tragic. - Yeah, it really is. 3985 03:29:34,692 --> 03:29:36,834 Okay Mr. Cabra, I'll start by telling you 3986 03:29:36,834 --> 03:29:38,897 his status because that was the most significant 3987 03:29:38,897 --> 03:29:41,887 event of yesterday and that is that after 3988 03:29:41,887 --> 03:29:45,508 a long talk yesterday between Dr. Shuleman and Mrs. Cabra, 3989 03:29:45,508 --> 03:29:47,675 it was decided to actually 3990 03:29:48,680 --> 03:29:51,929 withdraw antibiotics from Mr. Cabra 3991 03:29:51,929 --> 03:29:53,846 and to not use pressers 3992 03:29:54,790 --> 03:29:57,778 to eliminate any blood drawing 3993 03:29:57,778 --> 03:30:01,945 and actually just maintain him on a ventilator and 3994 03:30:03,205 --> 03:30:07,884 continue to give him his TPN, give him nutrition. 3995 03:30:07,884 --> 03:30:09,717 But that was about it. 3996 03:30:12,695 --> 03:30:15,195 So that's his new disposition. 3997 03:30:16,645 --> 03:30:18,890 Basically comfort measures only, 3998 03:30:18,890 --> 03:30:21,258 he's on morphine as required. 3999 03:30:21,258 --> 03:30:22,951 - [Scott] I think Leonard made the right decision. 4000 03:30:22,951 --> 03:30:26,890 I think that it's been hopeless for a long time and 4001 03:30:26,890 --> 03:30:28,925 nothing we could really do here. 4002 03:30:28,925 --> 03:30:33,008 It's a tragedy but I mean that's the way it goes. 4003 03:30:46,434 --> 03:30:49,012 - If she is competent to make a decision, 4004 03:30:49,012 --> 03:30:51,549 then her decision has to be respected, 4005 03:30:51,549 --> 03:30:53,851 whatever her private physician or her 4006 03:30:53,851 --> 03:30:56,649 husband or what anyone else wants to do. 4007 03:30:56,649 --> 03:30:59,232 Those wishes become essentially 4008 03:31:00,161 --> 03:31:03,328 irrelevant both legally and ethically. 4009 03:31:04,746 --> 03:31:07,861 It's hospital policy, there's no question about it. 4010 03:31:07,861 --> 03:31:12,454 Her wishes get respected if there is agreement that 4011 03:31:12,454 --> 03:31:16,998 she can understand her situation and make a decision. 4012 03:31:16,998 --> 03:31:19,863 There may be disagreement about that, I don't know but-- 4013 03:31:19,863 --> 03:31:21,354 - There wasn't this morning but I guess 4014 03:31:21,354 --> 03:31:23,223 if you ever look back at the past notes 4015 03:31:23,223 --> 03:31:25,596 and you read under her neurological status, 4016 03:31:25,596 --> 03:31:27,461 that not everybody always agrees that she 4017 03:31:27,461 --> 03:31:30,218 has been alert or awake or-- - But the question is-- 4018 03:31:30,218 --> 03:31:31,340 - To even ask her. 4019 03:31:31,340 --> 03:31:32,809 - [Male Doctor] Now when she makes the decision, 4020 03:31:32,809 --> 03:31:34,796 she has now made the decision or expressed 4021 03:31:34,796 --> 03:31:36,512 a decision and if everybody agrees that 4022 03:31:36,512 --> 03:31:39,929 she was with it to make it sufficiently-- 4023 03:31:40,835 --> 03:31:43,116 - Then there's no dilemma. - Yeah, there's no dilemma. 4024 03:31:43,116 --> 03:31:44,572 - [Female Doctor] All right. 4025 03:31:44,572 --> 03:31:46,299 - [Anne-Louise] Well then let's think of another one 4026 03:31:46,299 --> 03:31:48,192 because we gotta come up with something, right? 4027 03:31:48,192 --> 03:31:50,223 - There should be no dilemma. - Right. 4028 03:31:50,223 --> 03:31:51,969 - Have people ever sat down in the room 4029 03:31:51,969 --> 03:31:53,751 with her and with her husband and with 4030 03:31:53,751 --> 03:31:55,785 the attending together and discussed this? 4031 03:31:55,785 --> 03:31:57,032 Because that sounds like the problem. 4032 03:31:57,032 --> 03:31:58,778 - That's today's issue. - That's the next issue. 4033 03:31:58,778 --> 03:32:00,375 - [Anne-Louise] That's what I've been dealing with today. 4034 03:32:00,375 --> 03:32:02,158 - But that sounds like that's, no matter what 4035 03:32:02,158 --> 03:32:03,814 you're gonna decide if you haven't gotten all 4036 03:32:03,814 --> 03:32:08,042 the people together but this is a very different kind of 4037 03:32:08,042 --> 03:32:10,530 tone of a discussion than the Ethics Advisory Board 4038 03:32:10,530 --> 03:32:12,704 is sort of set up for which isn't supposed to be 4039 03:32:12,704 --> 03:32:14,351 complaining about whether one person 4040 03:32:14,351 --> 03:32:16,300 or another has handled this right. 4041 03:32:16,300 --> 03:32:18,039 - [Male Doctor] This is political rather than ethical. 4042 03:32:18,039 --> 03:32:21,288 - [Anne-Louise] I see what you mean. 4043 03:32:21,288 --> 03:32:23,163 - Ethical would be you know, 4044 03:32:23,163 --> 03:32:24,687 some more question as to whether 4045 03:32:24,687 --> 03:32:26,865 or not we really can do this 4046 03:32:26,865 --> 03:32:27,698 and 4047 03:32:28,637 --> 03:32:30,340 I don't think at this point 4048 03:32:30,340 --> 03:32:33,340 in time in our hospital and with our 4049 03:32:35,510 --> 03:32:38,291 counsel from the hospital lawyer and all, 4050 03:32:38,291 --> 03:32:40,473 there's no question that we can do it. 4051 03:32:40,473 --> 03:32:42,475 We not only can do it, we have to do it. 4052 03:32:42,475 --> 03:32:43,814 - [Anne-Louise] Right, right, all right. 4053 03:32:43,814 --> 03:32:45,846 Well then we gotta think of another one. 4054 03:32:45,846 --> 03:32:47,580 - What about the woman with 4055 03:32:47,580 --> 03:32:49,500 breast cancer that we were talking about? 4056 03:32:49,500 --> 03:32:50,786 - Do you remember her, Kim? 4057 03:32:50,786 --> 03:32:54,262 She was the woman that had the tumor growing on the outside 4058 03:32:54,262 --> 03:32:58,017 and I used to put that bark liquid stuff, 4059 03:32:58,017 --> 03:33:00,742 some herbal, I don't know what it was but anyway. 4060 03:33:00,742 --> 03:33:02,889 Yeah and she didn't want to be extubated. 4061 03:33:02,889 --> 03:33:04,841 Meanwhile there was nothing-- - Oh yes. 4062 03:33:04,841 --> 03:33:06,007 - Do you remember her? 4063 03:33:06,007 --> 03:33:07,869 She was in room six. - She was my primary, yeah. 4064 03:33:07,869 --> 03:33:09,828 - Young woman, had never gone to a physician 4065 03:33:09,828 --> 03:33:12,515 until her tumor was growing outwards. 4066 03:33:12,515 --> 03:33:13,920 - And she refused chemo. 4067 03:33:13,920 --> 03:33:16,747 - and she refused chemo and then she was on the vent 4068 03:33:16,747 --> 03:33:19,786 and was probably ready to start to do something 4069 03:33:19,786 --> 03:33:22,157 with the vent and she didn't want anything 4070 03:33:22,157 --> 03:33:24,692 different to be supported. - And her family-- 4071 03:33:24,692 --> 03:33:25,889 - [Male Doctor] She didn't want to be extubated. 4072 03:33:25,889 --> 03:33:28,424 - Right, she wanted to stay as she was. 4073 03:33:28,424 --> 03:33:29,757 - That to me is, 4074 03:33:30,653 --> 03:33:32,399 that's an ethical issue. 4075 03:33:32,399 --> 03:33:36,387 That actually with maybe that other woman, do you remember? 4076 03:33:36,387 --> 03:33:38,055 - That woman a couple of months ago, 4077 03:33:38,055 --> 03:33:41,133 the one who said she wanted to live as long 4078 03:33:41,133 --> 03:33:42,880 as she could but the minute she went into 4079 03:33:42,880 --> 03:33:45,117 pulmonary edema and needed to be intubated 4080 03:33:45,117 --> 03:33:47,063 would scream "Leave me alone, leave me alone." 4081 03:33:47,063 --> 03:33:51,450 She had a mental status score of 13 out of like 130 4082 03:33:51,450 --> 03:33:55,065 and the family wanted to make her a DNR but every time 4083 03:33:55,065 --> 03:33:57,769 we would go in to talk to her... 4084 03:33:57,769 --> 03:34:00,494 - That's kinda getting more, this to me is actually, 4085 03:34:00,494 --> 03:34:04,019 this is still a sticky point for me as to 4086 03:34:04,019 --> 03:34:07,374 there was another woman down in bed 11 4087 03:34:07,374 --> 03:34:11,659 back in July who had disseminated endometrial cancer 4088 03:34:11,659 --> 03:34:14,891 or something that, it wasn't traditional endometrial 4089 03:34:14,891 --> 03:34:17,514 cancer but it was some sarcomatous cancer 4090 03:34:17,514 --> 03:34:19,502 that was totally untreatable and everybody 4091 03:34:19,502 --> 03:34:22,419 decided that it was untreatable and 4092 03:34:23,734 --> 03:34:28,475 she was gonna be sent to a chronic care hospital 4093 03:34:28,475 --> 03:34:33,076 from Five South and then arrested unexpectedly 4094 03:34:33,076 --> 03:34:34,409 and came up here 4095 03:34:35,637 --> 03:34:38,266 and was intubated briefly, 4096 03:34:38,266 --> 03:34:41,130 actually got extubated fairly quickly and then 4097 03:34:41,130 --> 03:34:43,153 there was a big discussion about what should be done 4098 03:34:43,153 --> 03:34:47,320 and her, she said "I don't want to die" basically. 4099 03:34:49,152 --> 03:34:51,400 And when people went in and asked her if she 4100 03:34:51,400 --> 03:34:53,889 wanted to be resuscitated, she said "I don't wanna die." 4101 03:34:53,889 --> 03:34:56,285 But in fact, she had a bowel obstruction and nobody 4102 03:34:56,285 --> 03:34:59,681 was proposing to operate on the bowel obstruction 4103 03:34:59,681 --> 03:35:02,672 and the issue was what can you do in that situation? 4104 03:35:02,672 --> 03:35:05,412 What are you obligated to do? 4105 03:35:05,412 --> 03:35:07,769 And it kind of strikes at the same question 4106 03:35:07,769 --> 03:35:11,260 as the woman with breast cancer which is 4107 03:35:11,260 --> 03:35:13,299 in the situation when we kind of decide 4108 03:35:13,299 --> 03:35:16,303 that someone is terminal in a sense, even if they 4109 03:35:16,303 --> 03:35:20,115 wish to keep on going, how much further do you go? 4110 03:35:20,115 --> 03:35:22,402 And the question is what is terminal? 4111 03:35:22,402 --> 03:35:26,267 If someone can live for two months on a ventilator 4112 03:35:26,267 --> 03:35:31,017 even with no therapy, no chemotherapy, are they terminal? 4113 03:35:32,070 --> 03:35:35,237 The woman with the endometrial cancer, 4114 03:35:36,710 --> 03:35:40,627 when I went in and said you're dying basically, 4115 03:35:41,506 --> 03:35:43,896 she was aware of that and really 4116 03:35:43,896 --> 03:35:46,407 what she wanted was to be kept comfortable. 4117 03:35:46,407 --> 03:35:49,471 We essentially told her that there was nothing more that we 4118 03:35:49,471 --> 03:35:54,471 could do for her and therefore resuscitation was irrelevant. 4119 03:35:55,445 --> 03:35:58,883 How can you resuscitate somebody if there is no therapy? 4120 03:35:58,883 --> 03:36:02,466 And this is actually a more kind of naughty 4121 03:36:03,721 --> 03:36:07,861 ethical dilemma to me is everybody talks about care of the 4122 03:36:07,861 --> 03:36:11,758 terminally ill but there's no blood test for terminality. 4123 03:36:11,758 --> 03:36:13,925 What is, what is terminal? 4124 03:36:15,253 --> 03:36:18,765 And you read all these things, it's kinda like competence. 4125 03:36:18,765 --> 03:36:20,684 Everybody says determine competence 4126 03:36:20,684 --> 03:36:24,172 and there's no litmus test for competence. 4127 03:36:24,172 --> 03:36:27,089 - All these articles talk about the 4128 03:36:28,494 --> 03:36:31,075 medical care decisions for the hopelessly ill 4129 03:36:31,075 --> 03:36:34,387 or the terminally ill and they never define what it is. 4130 03:36:34,387 --> 03:36:36,637 So you don't know whether-- 4131 03:36:38,526 --> 03:36:40,350 - What is hopeless or terminal? 4132 03:36:40,350 --> 03:36:44,996 Because in a sense if you decide that it's hopeless, 4133 03:36:44,996 --> 03:36:47,680 the issue is moot, I mean resuscitation 4134 03:36:47,680 --> 03:36:50,967 becomes an irrelevant concept almost. 4135 03:36:50,967 --> 03:36:52,415 But at what point? 4136 03:36:52,415 --> 03:36:55,110 Given the fact that with a lot of these diseases, 4137 03:36:55,110 --> 03:36:58,261 we're talking about a one in 100 chance of surviving anyway, 4138 03:36:58,261 --> 03:36:59,800 what is hopeless? 4139 03:36:59,800 --> 03:37:03,991 - So what if the title for the session next week is 4140 03:37:03,991 --> 03:37:08,436 something along the lines of when is a terminal illness 4141 03:37:08,436 --> 03:37:12,716 really terminal or something, some question along 4142 03:37:12,716 --> 03:37:16,497 those lines and then we can maybe even have both, 4143 03:37:16,497 --> 03:37:20,830 when does a terminal illness really become terminal? 4144 03:37:43,393 --> 03:37:45,552 - Andy, I said "How is he?" 4145 03:37:45,552 --> 03:37:49,238 And Andy said "Well, he says things like 4146 03:37:49,238 --> 03:37:50,808 "she never should've had the chemo, 4147 03:37:50,808 --> 03:37:52,721 "she never should've had the portecab. 4148 03:37:52,721 --> 03:37:57,721 "If she hadn't had any of that, this wouldn't be happening." 4149 03:37:59,609 --> 03:38:00,859 - [Scott] Well, 4150 03:38:02,723 --> 03:38:03,556 you know, 4151 03:38:04,511 --> 03:38:07,386 is five good months better than-- 4152 03:38:07,386 --> 03:38:09,588 - [Doctor] I don't know. 4153 03:38:09,588 --> 03:38:10,662 - Eight months of hell, 4154 03:38:10,662 --> 03:38:14,220 that's what it boils down to a lot of the time. 4155 03:38:14,220 --> 03:38:16,007 - [Doctor] What we're planning to do right now 4156 03:38:16,007 --> 03:38:18,554 is a sub-max ETT valve in the echo-- 4157 03:38:18,554 --> 03:38:20,583 - You can't blame him for being, 4158 03:38:20,583 --> 03:38:24,069 it's a lot healthier to be angry at the doctors. 4159 03:38:24,069 --> 03:38:25,569 - [Doctor] Oh yes. 4160 03:38:27,577 --> 03:38:30,261 - I mean who else can you be angry at? 4161 03:38:30,261 --> 03:38:31,707 You can't blame it on the kids. 4162 03:38:31,707 --> 03:38:33,108 - There isn't anybody tangible 4163 03:38:33,108 --> 03:38:36,190 to be angry at other than the doctor. 4164 03:38:38,447 --> 03:38:40,030 Better us than her. 4165 03:38:42,998 --> 03:38:46,665 - [Scott] I'm sure he's plenty angry at her. 4166 03:38:52,368 --> 03:38:53,777 - [Doctor] Well I hope that 4167 03:38:53,777 --> 03:38:57,074 this is fast one way or the other. 4168 03:38:57,074 --> 03:38:58,730 But I have a feeling it won't be fast. 4169 03:38:58,730 --> 03:39:00,681 - God decides. 4170 03:39:00,681 --> 03:39:03,098 God decides, we don't decide. 4171 03:39:05,127 --> 03:39:07,790 These things have a life of their own. 4172 03:39:07,790 --> 03:39:09,940 They really do you know, I mean they really do. 4173 03:39:09,940 --> 03:39:12,440 They have a life of their own. 4174 03:39:17,628 --> 03:39:18,904 He could go for two, 4175 03:39:18,904 --> 03:39:20,580 three days like that easy. - They all ask that question. 4176 03:39:20,580 --> 03:39:22,262 If we had done it earlier, 4177 03:39:22,262 --> 03:39:23,833 if we had found, caught it earlier. 4178 03:39:23,833 --> 03:39:25,641 - Sure, because it's guilt you know? 4179 03:39:25,641 --> 03:39:28,147 That's guilt, that's saying it's my fault. 4180 03:39:28,147 --> 03:39:32,642 If I had done this, if I had been a good patient. 4181 03:39:32,642 --> 03:39:35,170 If I had known what to do, 4182 03:39:35,170 --> 03:39:38,003 would it have made any difference? 4183 03:39:40,145 --> 03:39:42,172 And the answer is always the same. 4184 03:39:42,172 --> 03:39:45,180 Even if it's true that they should've come in earlier, 4185 03:39:45,180 --> 03:39:48,004 the answer that you give the patient is always the same. 4186 03:39:48,004 --> 03:39:51,132 No, you did everything you could. 4187 03:39:51,132 --> 03:39:54,215 The families already feel so bad that 4188 03:39:56,530 --> 03:40:00,114 what's the point of making them feel worse? 4189 03:40:02,431 --> 03:40:03,922 - I hope the swan goes all right. 4190 03:40:03,922 --> 03:40:05,447 I mean that was the scary thing, 4191 03:40:05,447 --> 03:40:07,096 when he said "Do you know her history? 4192 03:40:07,096 --> 03:40:10,803 "She has complications with everything." 4193 03:40:10,803 --> 03:40:14,326 - [Scott] Well it may not go all right. 4194 03:40:14,326 --> 03:40:16,438 But you see that's why, I mean-- 4195 03:40:16,438 --> 03:40:19,096 - I think you spelled it out exactly right. 4196 03:40:19,096 --> 03:40:20,627 - Knowing that is helpful though 4197 03:40:20,627 --> 03:40:23,990 in terms of the way you view the procedure. 4198 03:40:23,990 --> 03:40:27,490 Knowing that, that influences the way you, 4199 03:40:28,978 --> 03:40:32,389 you get a little bit less enthusiastic for it. 4200 03:40:32,389 --> 03:40:35,627 - Well you can't go cavalierly putting them in but if 4201 03:40:35,627 --> 03:40:40,127 anybody needs one, she needs one, that's what I think. 4202 03:40:41,041 --> 03:40:43,951 Because I think we are gonna be managing her 4203 03:40:43,951 --> 03:40:46,542 for awhile and its numbers might be helpful. 4204 03:40:46,542 --> 03:40:48,645 - I guess the question is 4205 03:40:48,645 --> 03:40:51,171 are we managing a chance to live 4206 03:40:51,171 --> 03:40:53,823 or are we managing her death? 4207 03:40:53,823 --> 03:40:55,901 If we're managing her death, I'm not sure we need it. 4208 03:40:55,901 --> 03:40:58,118 If we're managing her 4209 03:40:58,118 --> 03:41:00,769 with a chance to live, then maybe we need it. 4210 03:41:00,769 --> 03:41:02,716 - [Doctor] I'm managing her chance to live. 4211 03:41:02,716 --> 03:41:05,299 - Right but I'm not sure he is. 4212 03:41:08,958 --> 03:41:11,341 - That may be. (phone ringing) 4213 03:41:11,341 --> 03:41:13,211 - I think he's on the fence about that. 4214 03:41:13,211 --> 03:41:15,390 - He's trying very hard, well I think he's trying. 4215 03:41:15,390 --> 03:41:17,294 He's on one side and I think he's 4216 03:41:17,294 --> 03:41:21,535 trying very hard to prepare himself for it. 4217 03:41:21,535 --> 03:41:24,234 Andy said he was already talking about 4218 03:41:24,234 --> 03:41:26,851 how am I gonna raise the kids, what am I gonna do with them? 4219 03:41:26,851 --> 03:41:30,797 What is this gonna mean to me, do I have to quit my job? 4220 03:41:30,797 --> 03:41:32,833 He was already, you know, 4221 03:41:32,833 --> 03:41:35,917 Andy said 10 pages ahead of the book. 4222 03:41:38,408 --> 03:41:39,825 You may be right. 4223 03:41:41,536 --> 03:41:42,369 But... 4224 03:41:48,490 --> 03:41:51,137 - I don't know but I know one thing, 4225 03:41:51,137 --> 03:41:54,529 I'm glad I only do this one month a year. 4226 03:41:54,529 --> 03:41:56,429 - [Doctor] I don't know how nurses stay here all the time. 4227 03:41:56,429 --> 03:42:00,262 - I don't either, I don't know how they do it. 4228 03:42:02,909 --> 03:42:04,489 - I think it's the pregnancy part 4229 03:42:04,489 --> 03:42:07,716 that makes it the horrifying thing. 4230 03:42:07,716 --> 03:42:10,716 I mean aged it's awful and you know, 4231 03:42:12,369 --> 03:42:15,608 healthy its awful and then to do this while you're pregnant. 4232 03:42:15,608 --> 03:42:18,508 - [Scott] Certainly the circumstances of it are 4233 03:42:18,508 --> 03:42:19,925 far worse than... 4234 03:42:23,360 --> 03:42:28,277 Incredible kind of nightmare scenarios that get played out. 4235 03:42:36,134 --> 03:42:39,551 (distant sirens blaring) 4236 03:42:59,970 --> 03:43:03,140 - Is he gonna make it? - No, I don't think. 4237 03:43:03,140 --> 03:43:06,890 - It's white coat day, I see your white coat. 4238 03:43:07,782 --> 03:43:09,991 - What's a white coat? 4239 03:43:09,991 --> 03:43:12,324 - White sweater, white coat. 4240 03:43:13,304 --> 03:43:16,856 - By the way, Mr. Cabra died yesterday at about five p.m. 4241 03:43:16,856 --> 03:43:20,107 - Was his wife here? - Yes, very close. 4242 03:43:20,107 --> 03:43:22,937 - Was his wife here? - Yes, she was here 4243 03:43:22,937 --> 03:43:24,937 and actually it was her, 4244 03:43:26,050 --> 03:43:27,983 the feeling of the family was that this was 4245 03:43:27,983 --> 03:43:31,283 going much too long and it was really hard for them 4246 03:43:31,283 --> 03:43:34,063 and they talked to Dr. Shuleman about turning 4247 03:43:34,063 --> 03:43:38,473 his FIO2 down, so we turned it down to 40% 4248 03:43:38,473 --> 03:43:42,537 and he flat-lined a little while after that. 4249 03:43:42,537 --> 03:43:46,113 - [Scott] It probably wasn't related to that, but... 4250 03:43:46,113 --> 03:43:47,186 Who knows? 4251 03:43:47,186 --> 03:43:50,519 - There was like 10 family members here. 4252 03:43:52,276 --> 03:43:53,810 So, 4253 03:43:53,810 --> 03:43:55,175 and she was really-- 4254 03:43:55,175 --> 03:43:56,770 - [Scott] They don't get any tougher than that one. 4255 03:43:56,770 --> 03:43:57,603 - Yeah. 4256 03:43:59,089 --> 03:44:02,672 She said you know, if there's anything that 4257 03:44:03,685 --> 03:44:05,705 can be learned out of this, then that's 4258 03:44:05,705 --> 03:44:07,869 what he would want and that's what I want. 4259 03:44:07,869 --> 03:44:11,530 - She was very mature. - She was very cooperative. 4260 03:44:11,530 --> 03:44:13,030 So anyways. - Okay. 4261 03:44:24,838 --> 03:44:27,838 (metallic clanking) 4262 03:44:40,696 --> 03:44:44,183 - Let me do it, you release here. 4263 03:44:44,183 --> 03:44:46,455 No I can get it, move your hands, I got it. 4264 03:44:46,455 --> 03:44:48,859 Is this low enough, guys? 4265 03:44:48,859 --> 03:44:50,653 We cuddly? - Yes. 4266 03:44:50,653 --> 03:44:53,246 - You want to go on three? - Yeah. 4267 03:44:53,246 --> 03:44:54,579 One, two, three. 4268 03:44:56,900 --> 03:44:57,936 - One, 4269 03:44:57,936 --> 03:44:58,969 two. 4270 03:44:58,969 --> 03:44:59,802 - Three. 4271 03:45:06,033 --> 03:45:08,518 Who would like to come down with me? 4272 03:45:08,518 --> 03:45:11,935 - [Nurse] Are these the personal effects? 4273 03:45:14,692 --> 03:45:17,928 - Do you have a thing for me outside? 4274 03:45:17,928 --> 03:45:20,345 Are they outside of the door? 4275 03:47:44,083 --> 03:47:47,309 - All right, usually what we do is just put the legs there. 4276 03:47:47,309 --> 03:47:50,021 The head or the legs come first. 4277 03:47:50,021 --> 03:47:51,588 - Okay. 4278 03:47:51,588 --> 03:47:53,505 - Just hold this. - Yep. 4279 03:47:56,895 --> 03:47:57,978 - He's heavy. 4280 03:48:01,218 --> 03:48:02,655 - Do we need a fourth person? - Yeah. 4281 03:48:02,655 --> 03:48:04,348 - [Mortician] Can we have a fourth person to help us? 4282 03:48:04,348 --> 03:48:05,303 - You need help? - Yeah. 4283 03:48:05,303 --> 03:48:06,970 - Or a fifth. - Yeah. 4284 03:48:10,318 --> 03:48:12,216 - Which side you want me to help, this one? 4285 03:48:12,216 --> 03:48:13,429 - Yeah. - Yeah. 4286 03:48:13,429 --> 03:48:15,333 We wanna go in there. 4287 03:48:15,333 --> 03:48:16,699 No, no, no, no. 4288 03:48:16,699 --> 03:48:19,866 We want to move him in there. - I know. 4289 03:48:22,545 --> 03:48:24,295 - Help her out there. 4290 03:48:26,545 --> 03:48:27,833 - We'll be okay. 4291 03:48:27,833 --> 03:48:28,986 - [Mortician] One, 4292 03:48:28,986 --> 03:48:29,903 two, three. 4293 03:48:37,217 --> 03:48:40,384 Thank you very much. - You are welcome. 4294 03:49:08,614 --> 03:49:11,447 - What? Sorry. - Just string it on. 4295 03:49:16,693 --> 03:49:17,526 Yeah. 4296 03:49:20,129 --> 03:49:23,080 - [Mortician] We need to sign that? 4297 03:49:23,080 --> 03:49:26,734 - I think just leave it. - Oh, okay. 4298 03:49:26,734 --> 03:49:28,331 - We're gonna get everything out of here? 4299 03:49:28,331 --> 03:49:31,248 - [Mortician] Yep, we're gonna try. 4300 03:49:41,863 --> 03:49:43,530 - He's a 33 year old 4301 03:49:45,024 --> 03:49:48,639 white male who presented in December with aortitis 4302 03:49:48,639 --> 03:49:51,461 and had a course of antibiotics and subsequent to that 4303 03:49:51,461 --> 03:49:55,364 course of antibiotics was found to have a testicular mass. 4304 03:49:55,364 --> 03:49:59,435 He underwent a biopsy which showed embryonal cell CA 4305 03:49:59,435 --> 03:50:02,748 and he had a retroperitoneale lymph node dissection which 4306 03:50:02,748 --> 03:50:06,167 showed five out of seven nodes positive for embryonal CA. 4307 03:50:06,167 --> 03:50:08,907 - He had a biopsy? - He had an orchiectomy 4308 03:50:08,907 --> 03:50:10,843 with biopsy showing it. - A biopsy. 4309 03:50:10,843 --> 03:50:12,293 - Yeah. 4310 03:50:12,293 --> 03:50:15,101 Yeah right, he had the orchiectomy and it was documented 4311 03:50:15,101 --> 03:50:17,272 then and then he had the retroperitoneale 4312 03:50:17,272 --> 03:50:19,476 lymph dissection at the same time. 4313 03:50:19,476 --> 03:50:23,366 Five out of seven nodes positive and he received 4314 03:50:23,366 --> 03:50:26,963 four courses of chemotherapy including Bleomycin, 4315 03:50:26,963 --> 03:50:29,318 was considered to have an excellent response. 4316 03:50:29,318 --> 03:50:32,164 However a month later presented with shortness of breath. 4317 03:50:32,164 --> 03:50:36,380 Had a lung biopsy which showed pulmonary fibrosis 4318 03:50:36,380 --> 03:50:39,749 and his course from there was of 4319 03:50:39,749 --> 03:50:42,082 deteriorating lung function. 4320 03:50:42,916 --> 03:50:46,166 He presented to another hospital about, 4321 03:50:48,077 --> 03:50:51,059 let's see, it must have been, 4322 03:50:51,059 --> 03:50:52,926 it was September, 4323 03:50:52,926 --> 03:50:55,139 he presented at another hospital with acute 4324 03:50:55,139 --> 03:50:57,088 shortness of breath, had a respiratory arrest. 4325 03:50:57,088 --> 03:50:59,412 Was found to have tension pneumothorax. 4326 03:50:59,412 --> 03:51:01,317 A chest tube was placed, he was transferred 4327 03:51:01,317 --> 03:51:03,394 to this hospital to the Intensive Care Unit 4328 03:51:03,394 --> 03:51:05,815 where he remained for a month and his course 4329 03:51:05,815 --> 03:51:09,795 there was of slow degeneration of pulmonary function. 4330 03:51:09,795 --> 03:51:13,636 He remained on a respirator, required very high settings. 4331 03:51:13,636 --> 03:51:17,542 Loss of sedation, his peak pressures were often in the 70s. 4332 03:51:17,542 --> 03:51:21,231 He had lots of barotrauma besides the one pneumothorax. 4333 03:51:21,231 --> 03:51:23,637 He had a pneumoperitoneum. 4334 03:51:23,637 --> 03:51:25,463 He had some infectious complications 4335 03:51:25,463 --> 03:51:29,380 with very resistant gram-negative organisms and 4336 03:51:31,119 --> 03:51:34,190 he required high oxygen FIO2s 4337 03:51:34,190 --> 03:51:36,271 in the 50 to 70% range for 4338 03:51:36,271 --> 03:51:39,271 most of the time he was in the unit. 4339 03:51:40,126 --> 03:51:43,126 His family and his wife specifically 4340 03:51:45,390 --> 03:51:49,188 followed his course over all this time and eventually 4341 03:51:49,188 --> 03:51:51,188 she made the decision to 4342 03:51:52,585 --> 03:51:55,695 not have CPR performed if that was the case 4343 03:51:55,695 --> 03:51:57,525 and following that decision, 4344 03:51:57,525 --> 03:52:01,725 about a week later she came to the decision to 4345 03:52:01,725 --> 03:52:05,038 decrease his FIO2 and he expired shortly after that. 4346 03:52:05,038 --> 03:52:07,766 - So the questions for the autopsy were 4347 03:52:07,766 --> 03:52:09,625 going back to the original process, 4348 03:52:09,625 --> 03:52:13,357 what is the extent of the tumor with that autopsy? 4349 03:52:13,357 --> 03:52:16,176 Of course, 10 or 20 years ago he 4350 03:52:16,176 --> 03:52:19,993 would've died of metastatic and embryonal carcinoma. 4351 03:52:19,993 --> 03:52:23,101 Another question is to document the nature 4352 03:52:23,101 --> 03:52:25,672 of the pulmonary process to determine if 4353 03:52:25,672 --> 03:52:29,226 in fact it was an irreversible process 4354 03:52:29,226 --> 03:52:32,682 likely related to the Bleomycin treatment 4355 03:52:32,682 --> 03:52:35,140 and the subsequent treatment and finally 4356 03:52:35,140 --> 03:52:38,315 to look for unexpected processes that might've 4357 03:52:38,315 --> 03:52:41,780 helped to explain some of his clinical course. 4358 03:52:41,780 --> 03:52:42,614 Go ahead. 4359 03:52:42,614 --> 03:52:45,411 - So the autopsy is a large gentleman 4360 03:52:45,411 --> 03:52:49,902 and on careful dissection of the retroperitoneum, 4361 03:52:49,902 --> 03:52:52,472 we revealed multiple adhesions but 4362 03:52:52,472 --> 03:52:56,609 no gross evidence of tumor in the lymph nodes. 4363 03:52:56,609 --> 03:53:01,609 He also had a history apparently of a congenital absence of 4364 03:53:01,705 --> 03:53:05,811 a left testis or atrophy and there was no evidence of that. 4365 03:53:05,811 --> 03:53:08,724 He had had a right orchiectomy, 4366 03:53:08,724 --> 03:53:11,639 so the right testis was also gone. 4367 03:53:11,639 --> 03:53:13,299 - [Male Doctor] Basically there was no 4368 03:53:13,299 --> 03:53:16,257 evidence in the gross of any residual tumor. 4369 03:53:16,257 --> 03:53:18,900 - [Female Doctor] No microscopic evidence. 4370 03:53:18,900 --> 03:53:20,934 The most remarkable evidence 4371 03:53:20,934 --> 03:53:23,622 was found in the thoracic cavity. 4372 03:53:23,622 --> 03:53:25,039 He had 100 CCs of 4373 03:53:26,104 --> 03:53:28,687 serosanguinous plural effusions 4374 03:53:29,546 --> 03:53:34,379 bilaterally and both of his lungs weighed about 800 grams. 4375 03:53:36,612 --> 03:53:39,061 - [Bill] You really should feel these, put on gloves. 4376 03:53:39,061 --> 03:53:41,062 - Three times normal. - Important to feel it. 4377 03:53:41,062 --> 03:53:42,846 - [Doctor] Virtually no homeostasis in here. 4378 03:53:42,846 --> 03:53:44,510 - [Bill] Yeah, looking at them it isn't 4379 03:53:44,510 --> 03:53:47,166 evident how fibrotic they are but to touch, 4380 03:53:47,166 --> 03:53:49,616 it's a very woody consistency. 4381 03:53:49,616 --> 03:53:51,397 - [Female Doctor] I think too there was extensive 4382 03:53:51,397 --> 03:53:55,359 fibrosis and there seemed to be a superimposed-- 4383 03:53:55,359 --> 03:53:58,319 - [Scott] There's a band of fibrosis right there. 4384 03:53:58,319 --> 03:54:01,873 - [Female Doctor] Abscesses, small focus abscesses 4385 03:54:01,873 --> 03:54:04,159 and post-mortem cultures were positive 4386 03:54:04,159 --> 03:54:07,792 for gram-negatives and staph epidermis. 4387 03:54:07,792 --> 03:54:11,701 - Some seminiferous change. - Bronchiectasis. 4388 03:54:11,701 --> 03:54:14,490 - Plural on the other side. - A little. 4389 03:54:14,490 --> 03:54:17,036 I think that fits in with the fibrosis. 4390 03:54:17,036 --> 03:54:19,879 Of course at this stage, any of a number 4391 03:54:19,879 --> 03:54:22,868 of things can present a picture like this but 4392 03:54:22,868 --> 03:54:25,783 it is completely consistent with Bleomycin- 4393 03:54:25,783 --> 03:54:30,471 induced fibrosis perhaps with a component of ARDS as well. 4394 03:54:30,471 --> 03:54:32,554 Diffused cellular damage. 4395 03:54:34,451 --> 03:54:36,567 I think when the clinicians come, we'll take 4396 03:54:36,567 --> 03:54:39,224 the opportunity to mention how posts were 4397 03:54:39,224 --> 03:54:43,577 important in characterizing this form of toxicity. 4398 03:54:43,577 --> 03:54:46,780 So there really were no surprises at autopsy. 4399 03:54:46,780 --> 03:54:51,613 - This is an example of curing the tumor but that the cure 4400 03:54:52,789 --> 03:54:53,706 was deadly. 4401 03:54:55,074 --> 03:54:58,404 The therapeutic index is very low. 4402 03:54:58,404 --> 03:55:01,458 - Unfortunately we only see these patients at this point 4403 03:55:01,458 --> 03:55:04,792 but I think it's significant to mention that only 4404 03:55:04,792 --> 03:55:08,654 a real small percentage of the patients have toxicity 4405 03:55:08,654 --> 03:55:12,052 to Bleomycin and this kind of a cancer has an 80 4406 03:55:12,052 --> 03:55:16,412 to 90% cure rate and unfortunately there's 1% 4407 03:55:16,412 --> 03:55:21,412 or a small percentage of patients that get drug toxicity. 4408 03:55:21,964 --> 03:55:24,714 - Okay, why don't we do the next? 4409 03:55:55,472 --> 03:55:58,222 (sirens blaring) 4410 03:56:42,657 --> 03:56:45,740 (electronic beeping) 4411 03:56:56,718 --> 03:57:00,635 - He's going under right now. - Full anesthesia? 4412 03:57:01,866 --> 03:57:04,149 - One set. - Just one set. 4413 03:57:04,149 --> 03:57:06,718 - Is that his vital signs? - Mr. Sporiza? 4414 03:57:06,718 --> 03:57:11,145 - Finish his blood pressure. - Has anesthesia been called? 4415 03:57:11,145 --> 03:57:13,039 Call 'em, he needs to be intubated. 4416 03:57:13,039 --> 03:57:15,456 - [Nurse] Does anybody have a 4417 03:57:16,405 --> 03:57:17,988 tourniquet on them? 4418 03:57:21,792 --> 03:57:25,695 - The other way around. - Do you have a tourniquet? 4419 03:57:25,695 --> 03:57:27,862 - Check the second drawer. 4420 03:57:34,674 --> 03:57:37,818 - [Nurse] Gonna try and get a line in. 4421 03:57:37,818 --> 03:57:39,345 Do you need any drugs, Suzanne? 4422 03:57:39,345 --> 03:57:41,176 - Yeah, can you get me the intubation, 4423 03:57:41,176 --> 03:57:43,207 get me all the drugs from the kit. 4424 03:57:43,207 --> 03:57:45,940 I don't have anything in here. 4425 03:57:45,940 --> 03:57:48,764 - He's on the wrong one. 4426 03:57:48,764 --> 03:57:50,456 - He's just like not breathing. 4427 03:57:50,456 --> 03:57:51,905 - He just suddenly stop breathing. 4428 03:57:51,905 --> 03:57:53,317 - Were you in the room or what? 4429 03:57:53,317 --> 03:57:55,136 - [Suzanne] Yeah, he went into a weird rhythm 4430 03:57:55,136 --> 03:57:57,516 so I went to get an EKG and just started 4431 03:57:57,516 --> 03:58:01,404 dropping his pressure and turning blue. 4432 03:58:01,404 --> 03:58:03,571 Neo, single strength tube. 4433 03:58:08,601 --> 03:58:11,510 (chattering, overlapping voices) 4434 03:58:11,510 --> 03:58:14,956 - [Technician] Get the MG tube with the suction, please. 4435 03:58:14,956 --> 03:58:16,527 - [Nurse] Over on that side, 4436 03:58:16,527 --> 03:58:18,725 can somebody turn on the MG tube? 4437 03:58:18,725 --> 03:58:21,012 The suction over there. 4438 03:58:21,012 --> 03:58:25,096 Okay, I'll get over there. - It's around the back. 4439 03:58:28,176 --> 03:58:31,176 Can I have a needle for this? - Okay. 4440 03:58:33,674 --> 03:58:36,007 - [Nurse] Saline's going in. 4441 03:58:36,929 --> 03:58:40,012 Gloves, here's gloves, big and small. 4442 03:58:43,282 --> 03:58:45,104 Got it? - Nope. 4443 03:58:45,104 --> 03:58:47,604 - No? - Blood pressure's at 70. 4444 03:58:48,815 --> 03:58:51,315 - Can we put him under? - Yeah. 4445 03:58:52,541 --> 03:58:54,949 - [Nurse] You know what, brush him off. 4446 03:58:54,949 --> 03:58:56,985 - [Nurse] Can someone mix up his dopamine please? 4447 03:58:56,985 --> 03:58:58,542 Dopamine. 4448 03:58:58,542 --> 03:59:01,274 - [Nurse] I'm just gonna try this one. 4449 03:59:01,274 --> 03:59:04,094 (electronic beeping) 4450 03:59:04,094 --> 03:59:05,669 - You get it? - Yeah, we'll go again. 4451 03:59:05,669 --> 03:59:07,726 - I'm moving the head down. - Okay. 4452 03:59:07,726 --> 03:59:09,095 - Take care of him. 4453 03:59:09,095 --> 03:59:13,233 - [Nurse] Just trying to put a line in here. 4454 03:59:13,233 --> 03:59:15,228 Don't, no, just wait a minute. 4455 03:59:15,228 --> 03:59:18,132 - [Nurse] He had a tube right here. 4456 03:59:18,132 --> 03:59:19,579 - [Nurse] Can you just 4457 03:59:19,579 --> 03:59:22,764 unplug that amidone to top it out, Josh? 4458 03:59:22,764 --> 03:59:24,042 It's about seven. 4459 03:59:24,042 --> 03:59:25,856 - [Doctor] Rachel's taking care of him 4460 03:59:25,856 --> 03:59:27,665 and I'm gonna go finish rounds. 4461 03:59:27,665 --> 03:59:29,849 - [Nurse] Well that's gonna look good in about five minutes. 4462 03:59:29,849 --> 03:59:31,845 Do we have a triple bowman thing? 4463 03:59:31,845 --> 03:59:33,753 - Yeah, right here. - Oh good. 4464 03:59:33,753 --> 03:59:36,670 Just open it up, place it on there. 4465 03:59:39,287 --> 03:59:40,204 Looks good. 4466 03:59:41,486 --> 03:59:42,319 Gas? 4467 03:59:47,268 --> 03:59:50,768 - Do you want a quarter, what do you want? 4468 03:59:52,413 --> 03:59:56,397 - Do we still want this fluid running wide open? 4469 03:59:56,397 --> 03:59:58,565 - Neo, please. - What, Karen? 4470 03:59:58,565 --> 03:59:59,933 - Neo. - Neo. 4471 03:59:59,933 --> 04:00:01,874 - Did we get any back the other day at all? 4472 04:00:01,874 --> 04:00:03,204 - [Nurse] Nothing. 4473 04:00:03,204 --> 04:00:04,540 That suction draws up his tube to the back. 4474 04:00:04,540 --> 04:00:06,114 - [Nurse] Use this to push through here, 4475 04:00:06,114 --> 04:00:07,665 where is the dopamine? 4476 04:00:07,665 --> 04:00:09,921 - It's the central line. - Dopamine flowing. 4477 04:00:09,921 --> 04:00:12,421 - Yep, wide open, 500 an hour. 4478 04:00:15,584 --> 04:00:19,136 Saline is wide open. - We have some more saline? 4479 04:00:19,136 --> 04:00:22,727 - Blood pressure is 60. - We have an atropine ready? 4480 04:00:22,727 --> 04:00:25,144 - [Nurse] Atropine is coming. 4481 04:00:27,199 --> 04:00:29,242 - Put that on wide open neo. - Wide open neo. 4482 04:00:29,242 --> 04:00:30,572 - [Nurse] Wide open neo, 4483 04:00:30,572 --> 04:00:31,771 wide open dope and wide open fluids. 4484 04:00:31,771 --> 04:00:33,878 Is that correct? - That's correct. 4485 04:00:33,878 --> 04:00:38,238 - Obliterate 50. - Pulse is definitely better. 4486 04:00:38,238 --> 04:00:41,905 - Just gonna turn it on. - Who's got the neo? 4487 04:00:43,956 --> 04:00:45,539 - [Nurse] Dopamine. 4488 04:00:46,456 --> 04:00:47,577 No. 4489 04:00:47,577 --> 04:00:49,028 The two port is saline. 4490 04:00:49,028 --> 04:00:52,881 - [Nurse] All right good, we need saline. 4491 04:00:52,881 --> 04:00:55,381 (overlapping voices) 4492 04:00:55,381 --> 04:00:57,750 - [Nurse] I can do it, I can do it. 4493 04:00:57,750 --> 04:01:00,000 - I'm the one who'll do it. 4494 04:01:02,241 --> 04:01:05,195 Please? - Okay doctor, go to it. 4495 04:01:05,195 --> 04:01:08,995 - Bags 302, seven. - 100 more grams of lido. 4496 04:01:08,995 --> 04:01:11,495 - Okay. - 100 of lido going in. 4497 04:01:12,605 --> 04:01:14,724 - There's one. - I got it. 4498 04:01:14,724 --> 04:01:18,759 - [Nurse] So you wanna put him in sync mode at 50. 4499 04:01:18,759 --> 04:01:20,745 - [Suzanne] You wanna zap him out of this? 4500 04:01:20,745 --> 04:01:21,812 [Nurse] All right, here we go. 4501 04:01:21,812 --> 04:01:23,576 - Is it charged at all? - You can charge there. 4502 04:01:23,576 --> 04:01:25,649 - Consistent blood pressure. - Clear. 4503 04:01:25,649 --> 04:01:27,315 - Clear. - Clear. 4504 04:01:27,315 --> 04:01:29,184 - [Nurse] Jeff, you're still touching the metal bed. 4505 04:01:29,184 --> 04:01:32,065 - Yeah, charged. - Right leg back. 4506 04:01:32,065 --> 04:01:33,518 - [Jeff] Clear. 4507 04:01:33,518 --> 04:01:35,595 - [Nurse] You gotta hold it 'cause it's sinking. 4508 04:01:35,595 --> 04:01:37,678 - Okay. - Flow right away. 4509 04:01:38,832 --> 04:01:41,655 Now you've got-- - Something... 4510 04:01:41,655 --> 04:01:44,115 - Now we've got-- - We've got the-- 4511 04:01:44,115 --> 04:01:46,389 - Kind of ventricular-- - Ventricular. 4512 04:01:46,389 --> 04:01:49,503 - No, it's awful slow. - I know. 4513 04:01:49,503 --> 04:01:52,196 - We have a good blood pressure. 4514 04:01:52,196 --> 04:01:54,600 - [Nurse] He's got a better blood pressure with it, 4515 04:01:54,600 --> 04:01:56,350 he is to 70, hold on. 4516 04:01:57,414 --> 04:01:58,414 Don't shock. 4517 04:01:59,733 --> 04:02:03,566 - [Nurse] Looks like a flutter almost up here. 4518 04:02:04,648 --> 04:02:06,595 There you go, that's better. 4519 04:02:06,595 --> 04:02:09,881 - [Jeff] You've got a blood pressure of 80. 4520 04:02:09,881 --> 04:02:13,821 - It's a narrow complex now. - Yeah and it's a long, yeah. 4521 04:02:13,821 --> 04:02:16,739 - [Jeff] Narrow complex with inverted teeth. 4522 04:02:16,739 --> 04:02:18,441 - [Nurse] It looks like he's switching 4523 04:02:18,441 --> 04:02:20,636 bundles or something, can you tell up there? 4524 04:02:20,636 --> 04:02:23,421 - [Nurse] Some bundle and a little pacer. 4525 04:02:23,421 --> 04:02:26,432 - The P-waves aren't much. - Blood pressure's better. 4526 04:02:26,432 --> 04:02:29,027 - [Jeff] That looks like P-waves with a bundle. 4527 04:02:29,027 --> 04:02:31,483 - Just turn the amplitude up a little bit, Sue. 4528 04:02:31,483 --> 04:02:33,039 So that it picks up the heart rate. 4529 04:02:33,039 --> 04:02:35,579 Thanks. (electronic beeping) 4530 04:02:35,579 --> 04:02:38,246 - [Nurse] Did it flutter, three? 4531 04:02:39,148 --> 04:02:41,448 - I think it might be sinus. - Sinus. 4532 04:02:41,448 --> 04:02:43,064 - [Nurse] See those spikes you're seeing? 4533 04:02:43,064 --> 04:02:44,550 That's the offender. 4534 04:02:44,550 --> 04:02:45,633 - [Nurse] 62. 4535 04:02:49,631 --> 04:02:51,862 (overlapping voices) 4536 04:02:51,862 --> 04:02:54,913 That neo and dopamine's still wide open. 4537 04:02:54,913 --> 04:02:58,649 - Why don't you start that? - He's 70 systolic right now. 4538 04:02:58,649 --> 04:03:00,515 - That's better. - You know why he's 4539 04:03:00,515 --> 04:03:02,478 probably hypotensive now or 4540 04:03:02,478 --> 04:03:04,096 one of the reasons he may be-- - His bladder. 4541 04:03:04,096 --> 04:03:06,591 - No, I think that one of the major reasons 4542 04:03:06,591 --> 04:03:09,121 is that we may have blown off his CO2 too much 4543 04:03:09,121 --> 04:03:10,938 and I think it would be a good idea before 4544 04:03:10,938 --> 04:03:13,463 we start pouring a lot of drugs into the guy 4545 04:03:13,463 --> 04:03:18,063 to get another gas and see where you are because 4546 04:03:18,063 --> 04:03:20,480 his baseline PCO2 is like 60, 4547 04:03:21,512 --> 04:03:25,623 70 and I'd slow down actually a little bit, Frank. 4548 04:03:25,623 --> 04:03:27,494 Because oxygenation was the main, 4549 04:03:27,494 --> 04:03:31,525 and I think that just his pH could be 755, 76 4550 04:03:31,525 --> 04:03:34,794 and that could be all that's going on here. 4551 04:03:34,794 --> 04:03:36,167 So-- - Okay. 4552 04:03:36,167 --> 04:03:39,121 - I just, I can take responsibility for this one guys. 4553 04:03:39,121 --> 04:03:41,618 When I saw him this morning, I should've 4554 04:03:41,618 --> 04:03:44,474 told you to go ahead and intubate him right then. 4555 04:03:44,474 --> 04:03:49,391 That's the, no he was not breathing this morning very well. 4556 04:03:50,665 --> 04:03:52,787 - [Doctor] He wasn't moving a lot of air. 4557 04:03:52,787 --> 04:03:56,507 - I think the problem is that he was so down 4558 04:03:56,507 --> 04:03:59,888 mentally because he's been that way, you know? 4559 04:03:59,888 --> 04:04:02,971 But I think that, I would not make a big thing 4560 04:04:02,971 --> 04:04:05,623 about not putting a central line in him like last night. 4561 04:04:05,623 --> 04:04:07,787 I mean a central line is not the answer to the guy's 4562 04:04:07,787 --> 04:04:10,001 problems but if anybody made a mistake, I made 4563 04:04:10,001 --> 04:04:12,531 the mistake this morning in not suggesting 4564 04:04:12,531 --> 04:04:14,601 that we go ahead and intubate him electively. 4565 04:04:14,601 --> 04:04:16,752 So I think that's where the error was. 4566 04:04:16,752 --> 04:04:18,783 - [Doctor] I think something happened between the time-- 4567 04:04:18,783 --> 04:04:22,185 - I don't know, I don't think, I'm not sure. 4568 04:04:22,185 --> 04:04:23,881 - He's just quit breathing. - He's just out. 4569 04:04:23,881 --> 04:04:26,055 - [Scott] He just pooped out, I mean he was pooping, 4570 04:04:26,055 --> 04:04:29,791 he was pooping over 24 hours. - Within 15 minutes. 4571 04:04:29,791 --> 04:04:32,542 - He was pooping out over 24 hours, know what I mean? 4572 04:04:32,542 --> 04:04:34,748 He didn't look good yesterday in the evening 4573 04:04:34,748 --> 04:04:37,704 and he sorta gradually didn't look good 4574 04:04:37,704 --> 04:04:40,434 all night, so I think that's basically 4575 04:04:40,434 --> 04:04:42,505 what happened and I think it's just 4576 04:04:42,505 --> 04:04:45,005 a question of a guy being dry, 4577 04:04:46,005 --> 04:04:47,005 infected and 4578 04:04:48,672 --> 04:04:50,836 not waking up from the ad van 4579 04:04:50,836 --> 04:04:52,866 and not having a great respiratory drive. 4580 04:04:52,866 --> 04:04:54,936 - Charlie, can you hear me? 4581 04:04:54,936 --> 04:04:55,769 Charlie? 4582 04:04:56,835 --> 04:04:59,404 He's not very responsive. 4583 04:04:59,404 --> 04:05:01,311 Thank you, you guys. 4584 04:05:01,311 --> 04:05:02,644 Thanks everyone. 4585 04:05:03,704 --> 04:05:06,537 - You wanna keep this on? - No, go. 4586 04:05:07,406 --> 04:05:10,479 - I think that now pretty clearly he's 4587 04:05:10,479 --> 04:05:12,977 gonna go down to a valvuloplasty on a ventilator 4588 04:05:12,977 --> 04:05:15,006 and maybe it'll make him better and maybe 4589 04:05:15,006 --> 04:05:17,339 it won't but we don't even know after all 4590 04:05:17,339 --> 04:05:19,783 is said and done what sort of a brain 4591 04:05:19,783 --> 04:05:22,475 we've got here after all of this stuff. 4592 04:05:22,475 --> 04:05:24,309 We're gonna have to reevaluate the whole 4593 04:05:24,309 --> 04:05:28,564 situation after we sorta get him stabilized. 4594 04:05:28,564 --> 04:05:31,713 The thing that's tough is you get a case like that 4595 04:05:31,713 --> 04:05:35,365 and you've got a one in 100 chance of pulling 4596 04:05:35,365 --> 04:05:37,277 the guy through and you work like hell and you 4597 04:05:37,277 --> 04:05:39,902 stay up all night and you're almost there, 4598 04:05:39,902 --> 04:05:42,091 you think like he's gonna make it 4599 04:05:42,091 --> 04:05:44,466 and then he goes down the tubes again. 4600 04:05:44,466 --> 04:05:47,048 But like I say, you do your best and that's 4601 04:05:47,048 --> 04:05:50,631 all you can do and I think that aside from, 4602 04:05:51,907 --> 04:05:54,482 I mean everything would've been fine if Scott 4603 04:05:54,482 --> 04:05:56,800 Weiss had said look, we gotta call anesthesia 4604 04:05:56,800 --> 04:05:59,739 and get them over here and intubate him electively. 4605 04:05:59,739 --> 04:06:02,389 I think that was a mistake on my part. 4606 04:06:02,389 --> 04:06:03,635 I don't think that anything that you 4607 04:06:03,635 --> 04:06:05,486 guys did last night did or didn't matter. 4608 04:06:05,486 --> 04:06:07,103 If you look at the course of events, 4609 04:06:07,103 --> 04:06:11,131 he was sorta dribbling a little bit as we went along. 4610 04:06:11,131 --> 04:06:13,200 Let's finish up and see the rest of these people real quick. 4611 04:06:13,200 --> 04:06:15,882 There's enough stuff to do here to 4612 04:06:15,882 --> 04:06:18,549 keep everybody going for awhile. 4613 04:06:20,638 --> 04:06:21,971 - [Doctor] Okay. 4614 04:06:25,239 --> 04:06:26,989 - I mean the tendency 4615 04:06:28,263 --> 04:06:30,838 here is for all of us, 4616 04:06:30,838 --> 04:06:32,984 I mean certainly for Woody and for me, 4617 04:06:32,984 --> 04:06:36,234 the tendency is in general to say stop. 4618 04:06:37,209 --> 04:06:38,986 - [Nurse] We have a warped sense of looking at things. 4619 04:06:38,986 --> 04:06:40,867 - That's right. 4620 04:06:40,867 --> 04:06:43,763 That's right, I mean that's exactly it. 4621 04:06:43,763 --> 04:06:45,420 That's right and that's why I think 4622 04:06:45,420 --> 04:06:48,170 that because that's the tendency, 4623 04:06:50,159 --> 04:06:55,159 it's very important to give 'em the benefit of the doubt. 4624 04:06:55,312 --> 04:06:58,385 So Mr. Cabra got an extra 10 days on 4625 04:06:58,385 --> 04:07:01,006 the ventilator before he died. - I agree with you. 4626 04:07:01,006 --> 04:07:03,737 I am a big believer that everybody deserves a chance. 4627 04:07:03,737 --> 04:07:06,280 I don't care what you have, go great guns. 4628 04:07:06,280 --> 04:07:08,263 But then when you're working on the month, 4629 04:07:08,263 --> 04:07:10,122 the two month, the three month, 4630 04:07:10,122 --> 04:07:12,288 there comes a time when you gotta realize 4631 04:07:12,288 --> 04:07:14,448 we've offered everything we can. 4632 04:07:14,448 --> 04:07:19,031 - I think the other thing is I have never had a problem 4633 04:07:20,047 --> 04:07:24,274 ever in dealing with a family about any of this stuff. 4634 04:07:24,274 --> 04:07:26,150 No, no, no, I've had plenty of problems with families. 4635 04:07:26,150 --> 04:07:28,805 As long as I was able to establish 4636 04:07:28,805 --> 04:07:30,840 a relationship, we'd get there. 4637 04:07:30,840 --> 04:07:34,986 The problem is you get into the situation where-- 4638 04:07:34,986 --> 04:07:37,516 - You guys switch around. - Certain, you know, 4639 04:07:37,516 --> 04:07:39,712 stuff has been done before they come here. 4640 04:07:39,712 --> 04:07:41,041 - [Nurse] They come with a lot of 4641 04:07:41,041 --> 04:07:42,861 baggage already, I know what you're saying. 4642 04:07:42,861 --> 04:07:44,808 - There have been a few situations, really crazy 4643 04:07:44,808 --> 04:07:49,543 families where no matter what you did, you could never-- 4644 04:07:49,543 --> 04:07:51,872 - [Nurse] Gypsies and stuff like that. 4645 04:07:51,872 --> 04:07:56,101 - I don't know about gypsies but I think in general 4646 04:07:56,101 --> 04:07:58,166 if you have a good relationship with them and you 4647 04:07:58,166 --> 04:07:59,902 sort of are honest with them about what's going on 4648 04:07:59,902 --> 04:08:02,586 and say look you know, your father or whatever is dying-- 4649 04:08:02,586 --> 04:08:03,950 - But that's why I think we have 4650 04:08:03,950 --> 04:08:05,767 more problems with asking people here. 4651 04:08:05,767 --> 04:08:07,504 It's house staff, it's changing 4652 04:08:07,504 --> 04:08:10,114 and we want to keep getting to know the family. 4653 04:08:10,114 --> 04:08:11,692 How do you feel, what do you think? 4654 04:08:11,692 --> 04:08:13,307 Have you ever talked about this? 4655 04:08:13,307 --> 04:08:15,609 Where in community hospitals, other hospitals, 4656 04:08:15,609 --> 04:08:17,515 there's an attending and there's a family whose probably 4657 04:08:17,515 --> 04:08:19,913 taken care of 'em for years or knows the situation-- 4658 04:08:19,913 --> 04:08:22,145 - Where my sister practices-- - Right. 4659 04:08:22,145 --> 04:08:24,495 - She's taking care of these people, 4660 04:08:24,495 --> 04:08:26,428 yeah and she doesn't, she doesn't, 4661 04:08:26,428 --> 04:08:31,145 I can tell you, if somebody comes into a hospital there, 4662 04:08:31,145 --> 04:08:32,395 she doesn't say 4663 04:08:34,295 --> 04:08:35,701 "What do you think?" 4664 04:08:35,701 --> 04:08:37,601 She say-- - This is it. 4665 04:08:37,601 --> 04:08:40,479 - Your father's dying. - Right. 4666 04:08:40,479 --> 04:08:42,518 - If you don't know somebody and you've 4667 04:08:42,518 --> 04:08:45,458 never seen 'em before, it's very cavalier to say-- 4668 04:08:45,458 --> 04:08:48,405 - [Nurse] To say oh, well I know more than you do. 4669 04:08:48,405 --> 04:08:52,501 - Check out, I'm sorry but-- - It's all over. 4670 04:08:52,501 --> 04:08:55,864 - You end up, and clearly I mean, 4671 04:08:55,864 --> 04:08:58,780 clearly the house staff's sense of, 4672 04:09:02,476 --> 04:09:04,845 if you haven't seen 10,000 patients, 4673 04:09:04,845 --> 04:09:06,961 even if you have seen 10,000 patients, 4674 04:09:06,961 --> 04:09:09,908 I'm not ever sure, you know what I mean? 4675 04:09:09,908 --> 04:09:12,744 I'll tell you, Mrs. Pergolin, there is a good example. 4676 04:09:12,744 --> 04:09:15,491 I'd never seen that lady before, she shows up here. 4677 04:09:15,491 --> 04:09:18,278 All the stuff that went through my mind was 4678 04:09:18,278 --> 04:09:20,347 you know, has she, 4679 04:09:20,347 --> 04:09:22,923 have they really established a diagnosis? 4680 04:09:22,923 --> 04:09:25,968 What else could she possibly have? 4681 04:09:25,968 --> 04:09:28,521 And I started asking myself all these questions. 4682 04:09:28,521 --> 04:09:31,653 You still get uncomfortable about, 4683 04:09:31,653 --> 04:09:34,258 I mean I'd never seen her before 4684 04:09:34,258 --> 04:09:37,280 and yes, they say she refused chemotherapy in New York. 4685 04:09:37,280 --> 04:09:39,125 But did she really and what were 4686 04:09:39,125 --> 04:09:42,547 the circumstances and what was she told? 4687 04:09:42,547 --> 04:09:44,130 So I mean you know, 4688 04:09:45,401 --> 04:09:47,700 if you're cavalier about somebody like that, 4689 04:09:47,700 --> 04:09:49,561 then you oughta get outta the business. 4690 04:09:49,561 --> 04:09:51,559 - [Nurse] Did your best friend get diagnosed with 4691 04:09:51,559 --> 04:09:54,341 similar things and die two weeks after chemo, you know? 4692 04:09:54,341 --> 04:09:56,291 - [Nurse] Part of the job is unfortunately 4693 04:09:56,291 --> 04:09:58,830 like you said to take responsibility for it. 4694 04:09:58,830 --> 04:10:00,487 To also ignore that. 4695 04:10:00,487 --> 04:10:03,008 I think a lot of people because they have difficulty with it 4696 04:10:03,008 --> 04:10:06,100 almost like, especially certain, like an attending physician 4697 04:10:06,100 --> 04:10:09,011 almost puts it onto say the attending of the unit 4698 04:10:09,011 --> 04:10:12,035 or they have the relationship with the patient because-- 4699 04:10:12,035 --> 04:10:13,979 - [Nurse] In her case that wasn't true. 4700 04:10:13,979 --> 04:10:17,602 I think you're right, what you're saying is that-- 4701 04:10:17,602 --> 04:10:19,133 - [Nurse] Because it's a hard thing to deal with. 4702 04:10:19,133 --> 04:10:21,426 - In a situation like her, 4703 04:10:21,426 --> 04:10:24,377 they would take all of those uncertainties and it 4704 04:10:24,377 --> 04:10:26,038 would make them very nervous and then they would 4705 04:10:26,038 --> 04:10:28,644 just abdicate and say "You gotta make a decision." 4706 04:10:28,644 --> 04:10:31,265 But I think you gotta be very, very sure. 4707 04:10:31,265 --> 04:10:35,015 There are few situations though in life where 4708 04:10:36,016 --> 04:10:38,504 the critical meaning of what you say and how you say it 4709 04:10:38,504 --> 04:10:42,032 has as much ramifications as it does around this issue. 4710 04:10:42,032 --> 04:10:43,365 - How you doing? 4711 04:10:45,653 --> 04:10:47,718 More bad news. - What? 4712 04:10:47,718 --> 04:10:49,246 - I said there's more bad news, 4713 04:10:49,246 --> 04:10:53,586 one thing after another with what's been going on. 4714 04:10:53,586 --> 04:10:58,586 Right now there's no change since I spoke with you but 4715 04:10:58,774 --> 04:11:01,524 this latest set of episodes has-- 4716 04:11:02,737 --> 04:11:04,689 - It's not different? 4717 04:11:04,689 --> 04:11:08,000 - Not from when we spoke on the telephone but 4718 04:11:08,000 --> 04:11:10,484 he hasn't shown any recovery from that. 4719 04:11:10,484 --> 04:11:12,304 They're giving him some other medication now 4720 04:11:12,304 --> 04:11:14,843 to try to help his heart pump a little more 4721 04:11:14,843 --> 04:11:18,843 effectively and to see if that could be helpful. 4722 04:11:20,361 --> 04:11:23,947 - There's been a whole series of one problem after another. 4723 04:11:23,947 --> 04:11:25,818 - Why, he's been coming here so long. 4724 04:11:25,818 --> 04:11:28,480 He never had these problems. 4725 04:11:28,480 --> 04:11:29,647 What happened? 4726 04:11:30,511 --> 04:11:32,757 - I'm not sure we have the complete answer to that. 4727 04:11:32,757 --> 04:11:35,367 But you know the attempt to see how we'd do 4728 04:11:35,367 --> 04:11:39,151 in getting him off the breathing machine, 4729 04:11:39,151 --> 04:11:41,362 it looked like things were getting better and better 4730 04:11:41,362 --> 04:11:43,390 and he was remaining stable. - He was good. 4731 04:11:43,390 --> 04:11:48,037 - But he was in such a precarious situation that 4732 04:11:48,037 --> 04:11:51,650 we've seen some of the things that can happen from that. 4733 04:11:51,650 --> 04:11:53,302 I don't have an answer for you as 4734 04:11:53,302 --> 04:11:55,261 to why it was that it happened now. 4735 04:11:55,261 --> 04:11:57,300 It's possible that there may have been some 4736 04:11:57,300 --> 04:11:59,581 additional injury that happened either to his 4737 04:11:59,581 --> 04:12:01,663 heart or elsewhere that we haven't detected yet 4738 04:12:01,663 --> 04:12:05,580 and that may be the thing that caused all this. 4739 04:12:06,694 --> 04:12:08,915 - Is he holding his own now? 4740 04:12:08,915 --> 04:12:12,186 - Well, I guess it's fair to say barely. 4741 04:12:12,186 --> 04:12:13,842 I think in the last hour or two, 4742 04:12:13,842 --> 04:12:16,322 his blood pressure has been a little better 4743 04:12:16,322 --> 04:12:19,676 and his heart rhythm had gotten a little bit stronger. 4744 04:12:19,676 --> 04:12:21,826 His heart rhythm had been irregular 4745 04:12:21,826 --> 04:12:24,159 and it's now more stable but 4746 04:12:25,857 --> 04:12:30,366 I think the big picture still looks very grave. 4747 04:12:30,366 --> 04:12:31,199 Excuse me. 4748 04:12:36,357 --> 04:12:39,896 - Are you telling me that he doesn't have too much hope? 4749 04:12:39,896 --> 04:12:42,748 - Well I think there's always hope. 4750 04:12:42,748 --> 04:12:46,448 We don't know for sure how to predict the future but 4751 04:12:46,448 --> 04:12:49,553 I think these things all make us concerned about 4752 04:12:49,553 --> 04:12:52,044 and make us wonder, we don't know. 4753 04:12:52,044 --> 04:12:55,949 But each one of these things that happens is more 4754 04:12:55,949 --> 04:12:59,321 bad news and more for him to contend with if 4755 04:12:59,321 --> 04:13:01,811 he's gonna have any sort of meaningful recovery. 4756 04:13:01,811 --> 04:13:04,414 - Didn't he respond at all? - No. 4757 04:13:04,414 --> 04:13:06,728 But we don't know if that's because there's an 4758 04:13:06,728 --> 04:13:10,360 underlying problem that's causing him not to respond or 4759 04:13:10,360 --> 04:13:13,683 whether it's still a lingering effect from the sedatives. 4760 04:13:13,683 --> 04:13:16,293 Even off of it for a couple of days, 4761 04:13:16,293 --> 04:13:18,666 his kidneys have been not doing well 4762 04:13:18,666 --> 04:13:20,578 and his liver has been not doing well 4763 04:13:20,578 --> 04:13:21,953 and those are the things which 4764 04:13:21,953 --> 04:13:23,994 get rid of the sedative from his body. 4765 04:13:23,994 --> 04:13:27,258 So then it's possible that some of the effect 4766 04:13:27,258 --> 04:13:31,014 of him not waking up was from the medication. 4767 04:13:31,014 --> 04:13:33,576 But I think we also have to consider the possibility 4768 04:13:33,576 --> 04:13:37,523 that even once the medication's gone that we may find an 4769 04:13:37,523 --> 04:13:41,675 underlying problem that's responsible for him not waking up. 4770 04:13:41,675 --> 04:13:45,508 - He was always complaining about his kidneys. 4771 04:13:52,164 --> 04:13:54,164 I just feel so terrible. 4772 04:13:57,592 --> 04:13:59,092 He was so unhappy. 4773 04:14:01,853 --> 04:14:04,271 He was so sure he was gonna die 4774 04:14:04,271 --> 04:14:08,104 and I think that that's uppermost in his mind. 4775 04:14:09,155 --> 04:14:11,240 - That he was sure he was gonna die? 4776 04:14:11,240 --> 04:14:13,407 - Yes, that's all he said. 4777 04:14:19,864 --> 04:14:21,913 Of course I said "Gee darling, 4778 04:14:21,913 --> 04:14:25,185 "you've been doing pretty good." 4779 04:14:25,185 --> 04:14:27,711 He managed around the house but 4780 04:14:27,711 --> 04:14:30,423 the last week before we came in here, 4781 04:14:30,423 --> 04:14:34,840 he couldn't even go from the bedroom to the bathroom. 4782 04:14:37,761 --> 04:14:38,594 Well, 4783 04:14:39,674 --> 04:14:42,095 I'll put it in the hands of God. 4784 04:14:42,095 --> 04:14:45,762 There's nothing I can say or do except pray. 4785 04:14:50,567 --> 04:14:52,224 Can we go in the room? 4786 04:14:52,224 --> 04:14:53,843 - [Bill] Let me check with the nurse 4787 04:14:53,843 --> 04:14:56,270 to make sure that it's okay. 4788 04:14:56,270 --> 04:14:58,437 I'll be right back. - Okay. 4789 04:15:05,900 --> 04:15:08,983 - [Dr. Brisol] The technique is poor. 4790 04:15:18,532 --> 04:15:21,782 - She really feeling it? - Yeah, she is. 4791 04:15:53,353 --> 04:15:57,520 - [Suzanne] That's probably the smart thing to do. 4792 04:15:59,562 --> 04:16:01,224 - Has he talked to you at all? 4793 04:16:01,224 --> 04:16:02,961 - A little bit. 4794 04:16:02,961 --> 04:16:05,413 A little bit, not much but I had to give him some 4795 04:16:05,413 --> 04:16:10,063 medicine to put him to sleep again to keep him comfortable. 4796 04:16:10,063 --> 04:16:11,925 - Can we sit here quietly? 4797 04:16:11,925 --> 04:16:12,758 Okay. 4798 04:16:17,201 --> 04:16:20,742 - We have chairs here, we have chairs. 4799 04:16:20,742 --> 04:16:23,694 You can talk to him if you want. 4800 04:16:23,694 --> 04:16:26,527 You never know, he might hear you. 4801 04:16:30,588 --> 04:16:31,755 Way down here. 4802 04:16:38,540 --> 04:16:39,373 - Charlie. 4803 04:16:40,393 --> 04:16:41,226 Charlie. 4804 04:16:43,744 --> 04:16:46,313 Why have you got the tape on his eyes? 4805 04:16:46,313 --> 04:16:48,337 - Because his eyes were wide open, 4806 04:16:48,337 --> 04:16:50,618 he wasn't keeping 'em closed by himself. 4807 04:16:50,618 --> 04:16:52,509 So I didn't want them to get dried out. 4808 04:16:52,509 --> 04:16:55,092 It's more comfortable this way. 4809 04:17:19,644 --> 04:17:23,144 Hi Charlie, Charlie, do you hear me honey? 4810 04:17:25,062 --> 04:17:26,343 Do you hear me? 4811 04:17:26,343 --> 04:17:27,994 - [Suzanne] Do you understand what happened today? 4812 04:17:27,994 --> 04:17:29,665 - [Mrs. Sperazza] No. 4813 04:17:29,665 --> 04:17:32,855 - Well he was doing about the same as usual 4814 04:17:32,855 --> 04:17:36,092 and then he just got pooped out from breathing. 4815 04:17:36,092 --> 04:17:41,092 He just suddenly tired out completely and stopped breathing. 4816 04:17:41,295 --> 04:17:43,984 - He stopped breathing? - He stopped breathing, 4817 04:17:43,984 --> 04:17:44,901 completely. 4818 04:17:46,569 --> 04:17:48,580 So we had to put him back on the ventilator 4819 04:17:48,580 --> 04:17:50,774 but his heart at the same time had 4820 04:17:50,774 --> 04:17:53,180 started to go into a funny rhythm 4821 04:17:53,180 --> 04:17:55,282 and he dropped his blood pressure too. 4822 04:17:55,282 --> 04:17:56,775 He's on a lot of medications 4823 04:17:56,775 --> 04:17:59,525 for his blood pressure right now. 4824 04:18:02,076 --> 04:18:06,243 - I don't understand, he wasn't this sick at home. 4825 04:18:07,402 --> 04:18:09,683 Do you suppose it was coming on? 4826 04:18:09,683 --> 04:18:11,266 - It was coming on. 4827 04:18:13,134 --> 04:18:16,134 It might just be his time, you know? 4828 04:18:18,557 --> 04:18:22,127 He has a sick heart, he has a pretty sick heart. 4829 04:18:22,127 --> 04:18:23,294 - Yeah? - Yeah. 4830 04:18:24,808 --> 04:18:29,088 - He never got treated for that or had any problems or-- 4831 04:18:29,088 --> 04:18:32,803 - Well he was on Keptakrel, that was for his heart. 4832 04:18:32,803 --> 04:18:34,125 - Oh was it? - Yeah. 4833 04:18:34,125 --> 04:18:36,786 He was on a couple heart medications at home 4834 04:18:36,786 --> 04:18:40,424 and that's why his lungs kept getting bad this year. 4835 04:18:40,424 --> 04:18:42,327 It's because his heart wasn't pumping right, 4836 04:18:42,327 --> 04:18:45,902 so the fluid was backing up into his lungs. 4837 04:18:45,902 --> 04:18:46,735 Yeah. 4838 04:18:58,884 --> 04:19:00,241 - [Mrs. Sperazza] How can you tell 4839 04:19:00,241 --> 04:19:02,598 if he's doing better or not? 4840 04:19:02,598 --> 04:19:07,367 - [Suzanne] We watch his blood pressure and his heart rate. 4841 04:19:07,367 --> 04:19:09,683 - That lets you know, that's good. 4842 04:19:09,683 --> 04:19:11,296 - [Suzanne] Just his numbers, 4843 04:19:11,296 --> 04:19:14,129 that's all we can go by right now. 4844 04:19:17,606 --> 04:19:20,182 He has gotten better over the last hour. 4845 04:19:20,182 --> 04:19:21,055 - Really? 4846 04:19:21,055 --> 04:19:22,876 - He's gotten a little bit better. 4847 04:19:22,876 --> 04:19:24,708 His blood pressure's gotten better, 4848 04:19:24,708 --> 04:19:26,360 his heart rate's come down. 4849 04:19:26,360 --> 04:19:28,223 We've taken him off some of the medication, 4850 04:19:28,223 --> 04:19:30,591 so he's getting better. 4851 04:19:30,591 --> 04:19:33,617 But he had a pretty touch-and-go-morning. 4852 04:19:33,617 --> 04:19:36,284 - I called last night about 8:30 4853 04:19:37,556 --> 04:19:39,473 and Allison said to me, 4854 04:19:40,885 --> 04:19:44,550 "He's had a little trouble breathing." 4855 04:19:44,550 --> 04:19:47,205 So he must've started getting bad last night. 4856 04:19:47,205 --> 04:19:49,365 - He started getting bad last night. 4857 04:19:49,365 --> 04:19:51,061 His breathing was okay but his heart 4858 04:19:51,061 --> 04:19:54,024 went into a real fast rhythm. - Oh. 4859 04:19:54,024 --> 04:19:56,558 And they had to zap him, cardiovert him around 4860 04:19:56,558 --> 04:19:59,012 five in the morning to get him out of the rhythm. 4861 04:19:59,012 --> 04:20:00,619 - Oh. 4862 04:20:00,619 --> 04:20:04,372 - He was stable for about four hours and then his 4863 04:20:04,372 --> 04:20:08,149 heart just kinda slowed down and he stopped breathing. 4864 04:20:08,149 --> 04:20:09,436 So we had to put him back on 4865 04:20:09,436 --> 04:20:12,769 the machine and we had to zap him again. 4866 04:20:18,845 --> 04:20:21,875 - I don't believe it, he was a tiger. 4867 04:20:21,875 --> 04:20:26,625 If you knew how I used to beg him about those cigarettes. 4868 04:20:29,289 --> 04:20:31,956 Can't blame it on any one thing. 4869 04:20:43,880 --> 04:20:46,377 We're gonna stay around if you don't mind. 4870 04:20:46,377 --> 04:20:47,210 We won't, 4871 04:20:48,200 --> 04:20:50,700 you know-- - Come on over here. 4872 04:20:52,819 --> 04:20:55,565 Did Dr. Taylor talk to you? 4873 04:20:55,565 --> 04:20:59,390 Well at this point if his heart were to go 4874 04:20:59,390 --> 04:21:03,408 into a bad rhythm or if it was to stop again, 4875 04:21:03,408 --> 04:21:06,222 we can give him drugs and we can shock him, 4876 04:21:06,222 --> 04:21:09,583 we can try to save him or if you think that he's gone 4877 04:21:09,583 --> 04:21:12,457 through enough, you can decided for us to not do that. 4878 04:21:12,457 --> 04:21:14,202 To just keep everything we're doing 4879 04:21:14,202 --> 04:21:17,722 right now but not start anything else. 4880 04:21:17,722 --> 04:21:20,381 If you think you've been through enough with him-- 4881 04:21:20,381 --> 04:21:22,577 - [Mrs. Sperazza] Oh no, I'd want him to have every chance. 4882 04:21:22,577 --> 04:21:24,989 - [Suzanne] You want him to have every chance, okay, okay. 4883 04:21:24,989 --> 04:21:29,236 We have to ask you that and that's very reasonable for you. 4884 04:21:29,236 --> 04:21:32,583 Okay so we can pass along, I'll tell Dr. Taylor that 4885 04:21:32,583 --> 04:21:34,999 or if he doesn't ask you, I'll pass that along. 4886 04:21:34,999 --> 04:21:36,193 - Okay, thank you. 4887 04:21:36,193 --> 04:21:38,050 - [Suzanne] That we'll do everything for him, okay? 4888 04:21:38,050 --> 04:21:40,159 - Everything, every conceivable thing. 4889 04:21:40,159 --> 04:21:42,076 - [Suzanne] Okay, okay. 4890 04:21:43,280 --> 04:21:45,398 - You've been so good, Suzanne. 4891 04:21:45,398 --> 04:21:48,300 - [Suzanne] I know this is difficult for you. 4892 04:21:48,300 --> 04:21:51,444 - I don't know what else they can do. 4893 04:21:51,444 --> 04:21:53,694 He's my life, he's my life. 4894 04:22:10,856 --> 04:22:14,439 I was so afraid I'd go and leave him alone. 4895 04:22:34,740 --> 04:22:36,157 - [Nurse] Really? 4896 04:22:49,258 --> 04:22:51,926 - [Doctor] So you can come in any time. 4897 04:22:51,926 --> 04:22:52,836 All right? 4898 04:22:52,836 --> 04:22:54,003 Okay, bye-bye. 4899 04:23:19,008 --> 04:23:23,520 - I didn't even drive in today because I was afraid. 4900 04:23:23,520 --> 04:23:27,770 We had to wait three quarters of an hour for a cab. 4901 04:23:32,090 --> 04:23:35,178 I don't think I should be driving when I feel like this. 4902 04:23:35,178 --> 04:23:38,011 - [Bill] Yeah, I think it's smart. 4903 04:23:39,258 --> 04:23:41,665 When's your next appointment to come in and see me? 4904 04:23:41,665 --> 04:23:42,498 - 23rd. 4905 04:23:44,284 --> 04:23:46,635 Charlie had an appointment with you too. 4906 04:23:46,635 --> 04:23:48,540 - [Bill] Yeah I remember, we set that up. 4907 04:23:48,540 --> 04:23:49,582 - Yeah. 4908 04:23:49,582 --> 04:23:50,903 - [Bill] I'll see you sooner 4909 04:23:50,903 --> 04:23:53,673 if you think that would be useful. 4910 04:23:53,673 --> 04:23:58,590 - While Charlie's still here, I'm not thinking of anything. 4911 04:24:01,260 --> 04:24:02,667 - [Bill] What's your sense with 4912 04:24:02,667 --> 04:24:04,789 what's going on with him now? - My son? 4913 04:24:04,789 --> 04:24:06,112 - [Dr Taylor] What's your sense 4914 04:24:06,112 --> 04:24:07,673 of what's going on with him now? 4915 04:24:07,673 --> 04:24:10,340 - I think he's in bad condition. 4916 04:24:12,040 --> 04:24:13,609 - [Bill] Do you feel like you have an understanding 4917 04:24:13,609 --> 04:24:17,894 of what's happening to him as much as you want to have? 4918 04:24:17,894 --> 04:24:22,061 - Not really, I can't understand why he's so sick. 4919 04:24:23,171 --> 04:24:26,754 I mean you're mentioning liver and kidneys. 4920 04:24:27,949 --> 04:24:30,276 How did they all enter the picture? 4921 04:24:30,276 --> 04:24:32,897 - [Bill] Well what happens from whatever 4922 04:24:32,897 --> 04:24:35,468 the original cause is, when the heart is not pumping 4923 04:24:35,468 --> 04:24:38,868 efficiently and the blood pressure goes down, 4924 04:24:38,868 --> 04:24:41,577 the circulation to every organ is affected. 4925 04:24:41,577 --> 04:24:44,182 Part of what the heart does is supply 4926 04:24:44,182 --> 04:24:46,786 every organ with oxygen. 4927 04:24:46,786 --> 04:24:48,575 When the lungs aren't working well, 4928 04:24:48,575 --> 04:24:51,244 not as much oxygen gets in and then when the heart 4929 04:24:51,244 --> 04:24:54,650 is not pumping well, every organ can be affected 4930 04:24:54,650 --> 04:24:57,686 by the poor circulation and I'm afraid that's what 4931 04:24:57,686 --> 04:25:00,914 he's been through is that the heart problems and the 4932 04:25:00,914 --> 04:25:05,596 lung problems have probably set everything else off. 4933 04:25:05,596 --> 04:25:08,365 His kidneys are not working well at all. 4934 04:25:08,365 --> 04:25:10,599 His liver is not working well. 4935 04:25:10,599 --> 04:25:12,838 His blood sugar is out of control. 4936 04:25:12,838 --> 04:25:14,831 As we discussed on the phone, we have questions 4937 04:25:14,831 --> 04:25:17,168 about whether he might've had any brain damage 4938 04:25:17,168 --> 04:25:19,365 from what had gone on in the few days before 4939 04:25:19,365 --> 04:25:21,623 and we were hoping that once we could stop 4940 04:25:21,623 --> 04:25:24,110 the sedatives when he was off the machine 4941 04:25:24,110 --> 04:25:25,885 that we could see if he would wake up 4942 04:25:25,885 --> 04:25:28,461 at all as a sign that his brain was doing okay. 4943 04:25:28,461 --> 04:25:31,490 So we have, everywhere we turn-- 4944 04:25:31,490 --> 04:25:33,323 - There's an obstacle. 4945 04:25:38,217 --> 04:25:41,884 You know he said all week before he came in, 4946 04:25:42,898 --> 04:25:46,065 he screamed, he said "I'm going crazy. 4947 04:25:46,915 --> 04:25:48,415 "I'm going crazy." 4948 04:25:51,182 --> 04:25:53,244 It's just like you know, the girl that 4949 04:25:53,244 --> 04:25:56,448 used to take care of him that went to California, 4950 04:25:56,448 --> 04:25:59,768 he said "I feel worse than when she was here." 4951 04:25:59,768 --> 04:26:01,827 - When Dr. Gartol left? - Yeah. 4952 04:26:01,827 --> 04:26:03,441 - Yeah, that was a big loss for him. 4953 04:26:03,441 --> 04:26:05,774 - It was a big loss for him. 4954 04:26:06,814 --> 04:26:08,931 He didn't particularly take to 4955 04:26:08,931 --> 04:26:10,907 the doctor that took her place. 4956 04:26:10,907 --> 04:26:12,690 - Well I think any time there's a close 4957 04:26:12,690 --> 04:26:16,007 relationship as he had with that psychiatrist, 4958 04:26:16,007 --> 04:26:18,183 finding a replacement is very difficult. 4959 04:26:18,183 --> 04:26:19,016 - I know. 4960 04:26:22,820 --> 04:26:24,989 What can I do, Dr. Taylor? 4961 04:26:24,989 --> 04:26:26,466 - Well I think to be here the way 4962 04:26:26,466 --> 04:26:28,893 you are is probably the most important thing. 4963 04:26:28,893 --> 04:26:31,855 We don't think that he's able to sense much 4964 04:26:31,855 --> 04:26:33,719 in terms of what's going on around him. 4965 04:26:33,719 --> 04:26:36,481 But we never know and I think your presence, 4966 04:26:36,481 --> 04:26:40,363 your visits are probably the most important thing. 4967 04:26:40,363 --> 04:26:43,761 - My son came in last night, much against his will. 4968 04:26:43,761 --> 04:26:45,344 He just can't bear, 4969 04:26:46,527 --> 04:26:51,527 and he's so good but sickness just does something to him, 4970 04:26:51,936 --> 04:26:54,910 to just see somebody under these conditions. 4971 04:26:54,910 --> 04:26:58,887 - [Bill] Would it be useful for him to talk with me? 4972 04:26:58,887 --> 04:27:01,055 - I don't think so because 4973 04:27:03,548 --> 04:27:05,422 I'd say almost he was a Christian 4974 04:27:05,422 --> 04:27:08,554 Scientist if I didn't know better. 4975 04:27:08,554 --> 04:27:12,303 He won't go to a doc himself, he has the Harvard plan. 4976 04:27:12,303 --> 04:27:14,094 If he hurts himself someway, 4977 04:27:14,094 --> 04:27:17,511 he'll go to a doctor but other than that, 4978 04:27:18,381 --> 04:27:20,199 he heals himself. 4979 04:27:20,199 --> 04:27:22,075 - You might mention to him if you would that I'm 4980 04:27:22,075 --> 04:27:25,473 available if he thinks it might be useful for us to talk. 4981 04:27:25,473 --> 04:27:27,000 Even if it doesn't mean coming in, 4982 04:27:27,000 --> 04:27:29,294 we can even speak on the phone. 4983 04:27:29,294 --> 04:27:32,333 - I will if you don't mind because 4984 04:27:32,333 --> 04:27:34,612 I kinda talk to him about breaking down 4985 04:27:34,612 --> 04:27:36,930 and then he gets upset when I break down 4986 04:27:36,930 --> 04:27:41,512 and I don't want to do it, I don't do it intentionally. 4987 04:27:45,372 --> 04:27:46,895 - Well it's not necessarily a bad 4988 04:27:46,895 --> 04:27:50,312 thing for him to know how you're feeling. 4989 04:27:58,976 --> 04:28:01,678 One of the big questions from a medical point 4990 04:28:01,678 --> 04:28:05,716 of view is whether we should go ahead with this 4991 04:28:05,716 --> 04:28:08,118 procedure that we've talked about doing 4992 04:28:08,118 --> 04:28:09,819 where they put the balloon in and try to 4993 04:28:09,819 --> 04:28:13,176 open up the blockage in the heart valve. 4994 04:28:13,176 --> 04:28:16,769 It's a very, very difficult issue because 4995 04:28:16,769 --> 04:28:21,061 on the one hand with all the difficulty that he's having, 4996 04:28:21,061 --> 04:28:23,828 we don't want to subject him to the further difficulty that 4997 04:28:23,828 --> 04:28:27,145 could come if there were a complication from the procedure. 4998 04:28:27,145 --> 04:28:30,587 Because on the one hand, if it would offer him something 4999 04:28:30,587 --> 04:28:34,199 and the chance of a more meaningful opportunity to recover, 5000 04:28:34,199 --> 04:28:36,405 we certainly don't want to withhold that from him. 5001 04:28:36,405 --> 04:28:38,150 - No. - On the other hand, 5002 04:28:38,150 --> 04:28:40,973 if it means putting him through one more procedure 5003 04:28:40,973 --> 04:28:42,929 for no purpose, if it's not gonna help him 5004 04:28:42,929 --> 04:28:44,889 have a more meaningful chance of recovery, 5005 04:28:44,889 --> 04:28:47,113 we hate to subject him to it. 5006 04:28:47,113 --> 04:28:49,109 Not only from what the procedure does 5007 04:28:49,109 --> 04:28:51,179 but in case there could be any 5008 04:28:51,179 --> 04:28:54,129 complications from it or any problems because 5009 04:28:54,129 --> 04:28:57,151 although it's a relatively safe procedure, 5010 04:28:57,151 --> 04:29:00,684 there are complications-- - You explained it to me. 5011 04:29:00,684 --> 04:29:02,467 - And in his condition, 5012 04:29:02,467 --> 04:29:05,867 the possibility of complications always goes up. 5013 04:29:05,867 --> 04:29:07,823 When there are so many things-- 5014 04:29:07,823 --> 04:29:10,679 - [Mrs. Sperazza] What does that leave you with, nothing? 5015 04:29:10,679 --> 04:29:13,035 - Well I don't know, I think it leaves watching, 5016 04:29:13,035 --> 04:29:15,481 trying to do the best we can to stabilize him 5017 04:29:15,481 --> 04:29:17,425 and then to keep making this judgment as 5018 04:29:17,425 --> 04:29:19,943 best we can with the best input we can get. 5019 04:29:19,943 --> 04:29:21,840 Dr. Morgan has known him for awhile. 5020 04:29:21,840 --> 04:29:22,877 - Oh yes. 5021 04:29:22,877 --> 04:29:24,860 - [Bill] He's very thoughtful and careful 5022 04:29:24,860 --> 04:29:26,848 about giving advice about these things 5023 04:29:26,848 --> 04:29:28,580 and I think his opinion is gonna be 5024 04:29:28,580 --> 04:29:30,826 a real important one in terms of 5025 04:29:30,826 --> 04:29:33,071 whether he thinks this might be helpful. 5026 04:29:33,071 --> 04:29:35,012 Because you know back when he was evaluated, 5027 04:29:35,012 --> 04:29:37,410 when Charlie was evaluated in July, 5028 04:29:37,410 --> 04:29:39,641 it didn't look like the heart valve 5029 04:29:39,641 --> 04:29:41,894 was causing the primary problem. 5030 04:29:41,894 --> 04:29:44,864 - I know, that's why I don't understand this. 5031 04:29:44,864 --> 04:29:46,562 - [Bill] Well one of the things 5032 04:29:46,562 --> 04:29:50,535 that that says to me is that we have to be 5033 04:29:50,535 --> 04:29:52,864 careful, we don't want to rush ahead 5034 04:29:52,864 --> 04:29:55,306 and subject him to something unless we're 5035 04:29:55,306 --> 04:29:58,877 pretty sure that he's likely to stand to gain from it. 5036 04:29:58,877 --> 04:30:01,830 In the meantime, every additional problem 5037 04:30:01,830 --> 04:30:05,308 that develops is another strike against him 5038 04:30:05,308 --> 04:30:08,756 in terms of what we're all hoping for. 5039 04:30:08,756 --> 04:30:13,723 The possibility of some meaningful recovery from this. 5040 04:30:13,723 --> 04:30:18,127 - Is it possible that medication will help him? 5041 04:30:18,127 --> 04:30:20,023 - Well he's on medication. - Yes, I know. 5042 04:30:20,023 --> 04:30:21,632 - We're trying different ones to see 5043 04:30:21,632 --> 04:30:24,243 if we can find the best combination for him. 5044 04:30:24,243 --> 04:30:28,453 So we're doing what can be done with that 5045 04:30:28,453 --> 04:30:32,142 and not giving up in terms of trying to be helpful. 5046 04:30:32,142 --> 04:30:35,038 But I think to try to be realistic at the same time, 5047 04:30:35,038 --> 04:30:38,720 the more this goes on, the more complications that develop 5048 04:30:38,720 --> 04:30:42,194 in spite of doing everything that's being done, 5049 04:30:42,194 --> 04:30:43,938 the worse it looks. 5050 04:30:43,938 --> 04:30:45,856 - He's not suffering, is he? - No. 5051 04:30:45,856 --> 04:30:47,615 To the best of our knowledge, he's not. 5052 04:30:47,615 --> 04:30:50,094 When he's been resisting the tube or 5053 04:30:50,094 --> 04:30:52,470 looking like he's at all uncomfortable, 5054 04:30:52,470 --> 04:30:54,889 he has gotten the sedative medication to 5055 04:30:54,889 --> 04:30:58,427 try to take the edge off of that and try to make sure, 5056 04:30:58,427 --> 04:31:01,319 I believe since this tube has had to go back in 5057 04:31:01,319 --> 04:31:04,543 that he hasn't required much in the way of the sedative 5058 04:31:04,543 --> 04:31:07,362 either because there's still some in his bloodstream 5059 04:31:07,362 --> 04:31:11,509 or because he's so sick that he's not able to-- 5060 04:31:11,509 --> 04:31:13,244 - To fight. - To fight it or to 5061 04:31:13,244 --> 04:31:14,775 experience it. 5062 04:31:14,775 --> 04:31:17,940 - So what do you think, wait and see? 5063 04:31:17,940 --> 04:31:19,844 - [Bill] That's all we can do. 5064 04:31:19,844 --> 04:31:23,718 I think in the meantime we have to keep assessing 5065 04:31:23,718 --> 04:31:25,582 what's our goal for all this? 5066 04:31:25,582 --> 04:31:27,276 - Yeah, that's what I want to know. 5067 04:31:27,276 --> 04:31:29,485 - If there is some hope for some meaningful recovery, 5068 04:31:29,485 --> 04:31:33,261 we want to do everything to help him to achieve that. 5069 04:31:33,261 --> 04:31:35,739 If it reaches the point where that 5070 04:31:35,739 --> 04:31:38,539 isn't really possible, then we're gonna 5071 04:31:38,539 --> 04:31:41,276 have to reassess and say is it the right 5072 04:31:41,276 --> 04:31:43,878 thing to do to subject him to all this, 5073 04:31:43,878 --> 04:31:46,405 to all the tubes and the machines and the medications 5074 04:31:46,405 --> 04:31:49,470 and everything that goes on here in Intensive Care 5075 04:31:49,470 --> 04:31:51,678 if it's not gonna be for some purpose 5076 04:31:51,678 --> 04:31:55,348 in terms of him being able to recover from this? 5077 04:31:55,348 --> 04:31:57,960 And at this point I think we don't know, 5078 04:31:57,960 --> 04:32:01,123 we never know for sure but the longer it goes 5079 04:32:01,123 --> 04:32:03,492 with more and more complications, the less he 5080 04:32:03,492 --> 04:32:06,703 responds to all the different things that are being done. 5081 04:32:06,703 --> 04:32:08,310 - Couldn't it be just the opposite, 5082 04:32:08,310 --> 04:32:10,549 that he will start responding? 5083 04:32:10,549 --> 04:32:12,632 - [Bill] That's the hope. 5084 04:32:18,186 --> 04:32:19,603 - Oh, Dr. Taylor. 5085 04:32:35,897 --> 04:32:36,730 Well, 5086 04:32:38,773 --> 04:32:41,440 I'm gonna go along with the hope 5087 04:32:45,712 --> 04:32:48,379 that something will be resolved. 5088 04:32:50,403 --> 04:32:52,051 - [Bill] Let's stay in close touch. 5089 04:32:52,051 --> 04:32:53,227 You know how to reach me anytime. 5090 04:32:53,227 --> 04:32:55,405 - Oh yeah, I called you yesterday 5091 04:32:55,405 --> 04:32:58,360 and Paige had you on the line so long and then I 5092 04:32:58,360 --> 04:33:01,340 just hung up and I tried Dr. Morgan and I got him. 5093 04:33:01,340 --> 04:33:03,953 - [Bill] Good, sometimes when they 5094 04:33:03,953 --> 04:33:06,320 page me, the beeper doesn't go off. 5095 04:33:06,320 --> 04:33:07,271 - Oh yeah? 5096 04:33:07,271 --> 04:33:09,822 - Call and page again when that happens. 5097 04:33:09,822 --> 04:33:11,196 - Oh. - Okay? 5098 04:33:11,196 --> 04:33:13,846 - I thought maybe you weren't on page, you know? 5099 04:33:13,846 --> 04:33:15,794 - [Bill] No, they'll know that if they tell you 5100 04:33:15,794 --> 04:33:18,294 that I'm not on page, ask them for a number where you 5101 04:33:18,294 --> 04:33:20,752 can leave a message for me and then I can call you back. 5102 04:33:20,752 --> 04:33:22,533 There's always, if I can't be paged, 5103 04:33:22,533 --> 04:33:24,180 there's always a place where you can leave a message. 5104 04:33:24,180 --> 04:33:26,347 - Oh, I didn't know that, thank you. 5105 04:33:26,347 --> 04:33:27,379 - [Bill] Tomorrow I'll be 5106 04:33:27,379 --> 04:33:29,289 here all day and on page all day. 5107 04:33:29,289 --> 04:33:31,077 So you can speak to me later today through 5108 04:33:31,077 --> 04:33:33,783 the page operator or tomorrow, I'll be here. 5109 04:33:33,783 --> 04:33:38,651 - [Mrs. Sperazza] Dr. Morgan was very nice, he spoke to me. 5110 04:33:38,651 --> 04:33:41,831 I don't know what that doctor's name was. 5111 04:33:41,831 --> 04:33:44,207 He told me the most horrifying things 5112 04:33:44,207 --> 04:33:46,572 that can happen with that procedure. 5113 04:33:46,572 --> 04:33:49,145 - Yeah. - But of course I, 5114 04:33:49,145 --> 04:33:52,308 I imagine that they have to do that, you know? 5115 04:33:52,308 --> 04:33:53,847 - That they have to do which? 5116 04:33:53,847 --> 04:33:55,105 - [Mrs. Sperazza] Tell you all 5117 04:33:55,105 --> 04:33:56,597 the bad things that can happen. 5118 04:33:56,597 --> 04:33:58,414 - Yeah, I'm afraid they do. 5119 04:33:58,414 --> 04:34:01,448 Because the last thing that you'd want to have happen 5120 04:34:01,448 --> 04:34:03,103 is to have him go through it and have something 5121 04:34:03,103 --> 04:34:06,053 happen that you never even realized could occur. 5122 04:34:06,053 --> 04:34:07,910 So they want you to sort of have your eyes open. 5123 04:34:07,910 --> 04:34:09,855 - They've only done 140 of these. 5124 04:34:09,855 --> 04:34:11,338 - [Bill] It's a brand new procedure. 5125 04:34:11,338 --> 04:34:12,952 Most hospitals, my understanding is 5126 04:34:12,952 --> 04:34:14,756 most hospitals don't have it available. 5127 04:34:14,756 --> 04:34:17,126 We're fortunate to have people here who 5128 04:34:17,126 --> 04:34:19,819 are skilled in it but it's brand new, so 5129 04:34:19,819 --> 04:34:22,306 doing it has its hazards even though they 5130 04:34:22,306 --> 04:34:24,211 appear to be small and we also don't 5131 04:34:24,211 --> 04:34:28,010 really know about the long term effect. 5132 04:34:28,010 --> 04:34:30,080 - That's what he said and you also 5133 04:34:30,080 --> 04:34:31,983 don't know if that's what he really needs. 5134 04:34:31,983 --> 04:34:35,922 - That's the key, that's what we're trying to sort out. 5135 04:34:35,922 --> 04:34:38,627 My own view is that we need to hold off on that 5136 04:34:38,627 --> 04:34:41,121 right now and see if we can start to show some 5137 04:34:41,121 --> 04:34:44,188 signs of turning the corner, being stabilized, 5138 04:34:44,188 --> 04:34:47,339 looking like there's some chance of meaningful recovery. 5139 04:34:47,339 --> 04:34:49,655 Because I would hate to subject him to it 5140 04:34:49,655 --> 04:34:52,190 and have it be for no purpose or even worse, 5141 04:34:52,190 --> 04:34:55,378 to have it be something that causes him additional problems. 5142 04:34:55,378 --> 04:34:58,359 So if it looks like he's able to hold his own, 5143 04:34:58,359 --> 04:35:01,717 he is able to start to show some signs of recovery, 5144 04:35:01,717 --> 04:35:04,587 I think we'd have to assess whether it might be worth doing 5145 04:35:04,587 --> 04:35:07,462 and as I say, I'll depend very heavily on Dr. Morgan 5146 04:35:07,462 --> 04:35:10,234 and the rest of the cardiologists about whether-- 5147 04:35:10,234 --> 04:35:12,433 - [Mrs. Sperazza] Will Dr. McKay be in on this? 5148 04:35:12,433 --> 04:35:14,675 - Yeah, well Dr. McKay is the one with 5149 04:35:14,675 --> 04:35:17,750 Dr. Safien who are the experts on doing it. 5150 04:35:17,750 --> 04:35:18,949 - [Mrs. Sperazza] Oh, I see. 5151 04:35:18,949 --> 04:35:21,019 - Dr. Morgan's consulting with him all the time 5152 04:35:21,019 --> 04:35:24,589 about whether it's something that would be useful for him 5153 04:35:24,589 --> 04:35:28,455 or whether it should be done soon or we should hold off. 5154 04:35:28,455 --> 04:35:31,873 Just what would be the best sort of plan. 5155 04:35:34,487 --> 04:35:37,907 - I don't know what I'd do without her. 5156 04:35:37,907 --> 04:35:38,739 I mean, 5157 04:35:40,565 --> 04:35:43,877 she walks my dog in the morning. 5158 04:35:43,877 --> 04:35:46,592 Poor dog doesn't know where Charlie is. 5159 04:35:46,592 --> 04:35:51,092 He keeps going and looking at the bed and he's so sad. 5160 04:35:53,398 --> 04:35:56,262 He leaves a hole everywhere. 5161 04:35:56,262 --> 04:35:59,086 You know Charlie from here, 5162 04:35:59,086 --> 04:36:00,919 Charlie is one of the, 5163 04:36:02,057 --> 04:36:04,317 I mean greatest, that's all I can say. 5164 04:36:04,317 --> 04:36:07,932 The kids adore him when they see him coming down the street. 5165 04:36:07,932 --> 04:36:10,724 If your Daniel saw him, he'd fly in his arms. 5166 04:36:10,724 --> 04:36:13,491 That's the way he is. - I know that about him. 5167 04:36:13,491 --> 04:36:15,658 - Yeah, he loves children. 5168 04:36:19,012 --> 04:36:20,915 And the kids have all asked me, 5169 04:36:20,915 --> 04:36:23,773 yesterday they gave me drawings to put in his room. 5170 04:36:23,773 --> 04:36:25,974 They were horrible, I didn't dare 5171 04:36:25,974 --> 04:36:28,555 tell the little girl what I thought it was. 5172 04:36:28,555 --> 04:36:30,461 I thought it was a candle. 5173 04:36:30,461 --> 04:36:33,527 She said it was a Christmas tree. 5174 04:36:33,527 --> 04:36:37,695 - She's working on it. - She's working on it, yeah. 5175 04:36:39,154 --> 04:36:41,021 - [Bill] Maybe the spirit of what's behind that-- 5176 04:36:41,021 --> 04:36:42,271 - That's right. 5177 04:36:43,456 --> 04:36:45,661 - [Bill] Well I'll be around later today as I say 5178 04:36:45,661 --> 04:36:48,196 and tomorrow as well, so let's stay in close touch. 5179 04:36:48,196 --> 04:36:51,149 - Oh yes, I may go home for a little while, 5180 04:36:51,149 --> 04:36:54,152 straighten the dog out, lock up the house. 5181 04:36:54,152 --> 04:36:57,619 But I'll be back, I'll get a ride back, I won't drive. 5182 04:36:57,619 --> 04:37:00,464 - [Bill] Good, that's the right thing to do. 5183 04:37:00,464 --> 04:37:05,464 - Thank you so much for your time and your kindness. 5184 04:37:05,556 --> 04:37:07,556 - Thank you, Dr. Taylor. 5185 04:37:13,532 --> 04:37:15,190 - So, 5186 04:37:15,190 --> 04:37:18,874 I just you know tried to explain to the wife 5187 04:37:18,874 --> 04:37:21,186 in pretty simple terms the scenario of things. 5188 04:37:21,186 --> 04:37:25,249 She's aware that he is doing very poorly. 5189 04:37:25,249 --> 04:37:27,416 But she still very strongly feels 5190 04:37:27,416 --> 04:37:29,719 that she wants everything done for him. 5191 04:37:29,719 --> 04:37:32,897 - [Nurse] Did someone bring it up and she definitely said-- 5192 04:37:32,897 --> 04:37:35,675 - I said to her if his heart stops 5193 04:37:35,675 --> 04:37:39,383 or if he goes into a bad rhythm I said we can shock 5194 04:37:39,383 --> 04:37:42,004 him and we can give him drugs, is this what you want? 5195 04:37:42,004 --> 04:37:44,938 And she said "Oh God yes, I want everything done." 5196 04:37:44,938 --> 04:37:46,679 - [Nurse] Okay. 5197 04:37:46,679 --> 04:37:49,501 - But the sister I think has a little bit more realistic 5198 04:37:49,501 --> 04:37:52,983 view of the situation and she's not as emotionally involved. 5199 04:37:52,983 --> 04:37:56,587 - She might just need time to accept this. 5200 04:37:56,587 --> 04:37:59,726 - And that's what the sister said and I said to her, 5201 04:37:59,726 --> 04:38:01,895 I said I would not be surprised if something sudden 5202 04:38:01,895 --> 04:38:03,758 happened and I said I really don't want to mention 5203 04:38:03,758 --> 04:38:07,255 this to her but just don't leave her alone at home. 5204 04:38:07,255 --> 04:38:10,042 I said you know, just be prepared that something 5205 04:38:10,042 --> 04:38:13,792 could happen and that he's doing very poorly. 5206 04:38:15,322 --> 04:38:17,002 She seems a lot more reasonable. 5207 04:38:17,002 --> 04:38:19,049 - Go through the sister to approach. 5208 04:38:19,049 --> 04:38:21,078 - That's what I figured, you know? 5209 04:38:21,078 --> 04:38:24,155 The wife, she's really heartbroken. 5210 04:38:24,155 --> 04:38:25,890 She really loves Charlie. 5211 04:38:25,890 --> 04:38:27,501 She doesn't know what she's gonna do without him. 5212 04:38:27,501 --> 04:38:28,991 She knows now he's gonna die. 5213 04:38:28,991 --> 04:38:30,800 - She's very sick since he's been sick. 5214 04:38:30,800 --> 04:38:34,039 She comes in here and she's been dizzy. 5215 04:38:34,039 --> 04:38:35,728 - Has she really? - Yeah. 5216 04:38:35,728 --> 04:38:37,061 - Oh, wonderful. 5217 04:38:40,877 --> 04:38:43,205 Thanks for getting me lunch, Ken. 5218 04:38:43,205 --> 04:38:45,500 I haven't eaten yet either you know. 5219 04:38:45,500 --> 04:38:46,332 God. 5220 04:38:47,641 --> 04:38:49,336 - But you're going home. 5221 04:38:49,336 --> 04:38:51,250 You're going home now. - Absolutely. 5222 04:38:51,250 --> 04:38:54,757 - I'm going home now too. - I'm going to the bar now. 5223 04:38:54,757 --> 04:38:56,529 And that's all. 5224 04:38:56,529 --> 04:38:58,436 And who is it? 5225 04:38:58,436 --> 04:39:01,086 Taylor has spent time-- 5226 04:39:01,086 --> 04:39:03,866 - He's very good, he's very realistic. 5227 04:39:03,866 --> 04:39:06,713 He sees them every day and he was saying we shouldn't 5228 04:39:06,713 --> 04:39:11,012 valvoplasty if this man mentally is not with it. 5229 04:39:11,012 --> 04:39:12,591 If he's had a stroke or whatever 5230 04:39:12,591 --> 04:39:14,046 that we haven't discovered yet. 5231 04:39:14,046 --> 04:39:16,114 - He was on the list for valvoplasty tomorrow and they 5232 04:39:16,114 --> 04:39:18,967 canceled him and they're possibly gonna do it on Monday. 5233 04:39:18,967 --> 04:39:21,382 You know they're not gonna take him. 5234 04:39:21,382 --> 04:39:25,736 There's no way he's stable enough to go down for that. 5235 04:39:25,736 --> 04:39:26,569 So, 5236 04:39:27,775 --> 04:39:29,942 just have to wait and see. 5237 04:39:32,555 --> 04:39:34,481 I need that Blue Book big time, 5238 04:39:34,481 --> 04:39:36,683 you can go ahead and see it first. 5239 04:39:36,683 --> 04:39:40,704 I'm gonna go down and get something to eat. 5240 04:39:40,704 --> 04:39:42,371 - All right, thanks. 5241 04:39:44,763 --> 04:39:45,680 Okay, okay. 5242 04:39:47,081 --> 04:39:49,737 - He must be upset, his blood pressure's 153. 5243 04:39:49,737 --> 04:39:51,520 - That's good though. 5244 04:39:51,520 --> 04:39:56,103 At least it might mean his kidneys are a little better. 5245 04:39:58,413 --> 04:39:59,864 - The DC. 5246 04:39:59,864 --> 04:40:01,404 I think the real problem is we need to 5247 04:40:01,404 --> 04:40:03,554 get together with Jim again and sort of 5248 04:40:03,554 --> 04:40:06,099 thing about whether there's anything that, 5249 04:40:06,099 --> 04:40:09,016 I don't really know why he crumped. 5250 04:40:09,889 --> 04:40:12,040 The history of it is much more 5251 04:40:12,040 --> 04:40:14,925 consistent with a respiratory thing. 5252 04:40:14,925 --> 04:40:19,925 From his heart, he was as maximal as we could make him. 5253 04:40:20,228 --> 04:40:23,011 I think he was well diagnosed and he looked pretty good. 5254 04:40:23,011 --> 04:40:25,784 I think that he had a high white count and it may be that 5255 04:40:25,784 --> 04:40:29,563 just the combination of the sedation and whatever infection 5256 04:40:29,563 --> 04:40:33,596 he had, he just gradually went downhill over 36 hour period. 5257 04:40:33,596 --> 04:40:35,772 So it was more a respiratory decompensation 5258 04:40:35,772 --> 04:40:38,751 but what bothers me is his lungs are so bad 5259 04:40:38,751 --> 04:40:40,827 and his heart is so bad, we got his heart 5260 04:40:40,827 --> 04:40:42,652 to the best we could get it and we still 5261 04:40:42,652 --> 04:40:44,573 couldn't keep him off the ventilator and that 5262 04:40:44,573 --> 04:40:47,221 doesn't bode very well for a valvuloplasty. 5263 04:40:47,221 --> 04:40:49,499 What that says is even with a valvuloplasty, 5264 04:40:49,499 --> 04:40:51,238 I can't get him off the ventilator. 5265 04:40:51,238 --> 04:40:53,383 So I think we just need to sorta sit tight for 5266 04:40:53,383 --> 04:40:56,900 a day and see what happens because he's got some ATN. 5267 04:40:56,900 --> 04:40:59,348 He's non-oliguric probably and it looks 5268 04:40:59,348 --> 04:41:01,132 like he's starting to pee now that we've 5269 04:41:01,132 --> 04:41:02,788 got everything metabolically under control. 5270 04:41:02,788 --> 04:41:04,107 The guy's being ruled out, 5271 04:41:04,107 --> 04:41:05,639 there's a whole bunch of other things 5272 04:41:05,639 --> 04:41:07,216 but then I think we have to sorta sit down 5273 04:41:07,216 --> 04:41:09,432 with Jim and I mean I just, I'd be very 5274 04:41:09,432 --> 04:41:12,042 pessimistic that a valvuloplasty would do anything. 5275 04:41:12,042 --> 04:41:16,061 But I also don't think I'm gonna get him off the ventilator. 5276 04:41:16,061 --> 04:41:18,977 - But to do a valvuloplasty that's not gonna help, 5277 04:41:18,977 --> 04:41:22,644 there's not a reason-- - That's what I think. 5278 04:41:23,669 --> 04:41:25,242 - Well Jim knows him well, so-- 5279 04:41:25,242 --> 04:41:27,058 - I think we need to just sorta touch base with 5280 04:41:27,058 --> 04:41:30,524 him about that and say okay look, is there any, 5281 04:41:30,524 --> 04:41:34,857 because my feeling would be forget it at this point. 5282 04:41:35,751 --> 04:41:38,434 But then I think we'd both have to 5283 04:41:38,434 --> 04:41:41,208 talk to his wife and explain to her what the situation is. 5284 04:41:41,208 --> 04:41:43,814 I think we may get him to the point again 5285 04:41:43,814 --> 04:41:46,542 where we can try to extubate him but if we do that, 5286 04:41:46,542 --> 04:41:48,155 I'd be in favor of not putting him 5287 04:41:48,155 --> 04:41:49,863 back on if he didn't fly probably. 5288 04:41:49,863 --> 04:41:53,600 - Yeah, the question is also what-- 5289 04:41:53,600 --> 04:41:56,993 - Yeah, well I mean I think then it would be hopeless. 5290 04:41:56,993 --> 04:41:58,604 There wouldn't be any chance 5291 04:41:58,604 --> 04:42:00,529 except sort of prolonging his death. 5292 04:42:00,529 --> 04:42:02,212 - I'll talk to her some more today. 5293 04:42:02,212 --> 04:42:04,805 - Yeah, talk to Jim and then we'll see. 5294 04:42:04,805 --> 04:42:06,750 I don't think we have to make any sudden 5295 04:42:06,750 --> 04:42:10,109 moves over the next, you know the weekend. 5296 04:42:10,109 --> 04:42:12,859 See what happens. - Thanks, Scott. 5297 04:42:26,285 --> 04:42:27,746 The question is gonna come up if 5298 04:42:27,746 --> 04:42:30,413 we are able to take out the tube 5299 04:42:31,710 --> 04:42:34,204 and see how he does, 5300 04:42:34,204 --> 04:42:36,405 what happens if he does not do well? 5301 04:42:36,405 --> 04:42:38,348 Certainly if we take it out, it will be our 5302 04:42:38,348 --> 04:42:40,089 hope and we'll do everything we possibly 5303 04:42:40,089 --> 04:42:43,163 can to see that he does well without it. 5304 04:42:43,163 --> 04:42:48,068 But if his breathing becomes a problem off the tube again, 5305 04:42:48,068 --> 04:42:50,941 we're gonna have to face the issue of whether 5306 04:42:50,941 --> 04:42:53,524 to put the tube back in or not. 5307 04:42:58,828 --> 04:42:59,661 Excuse me? 5308 04:43:03,250 --> 04:43:04,695 Well that's the question, 5309 04:43:04,695 --> 04:43:07,945 I think it can only be used essentially 5310 04:43:10,291 --> 04:43:12,811 for the kind of support that he's getting now. 5311 04:43:12,811 --> 04:43:14,559 We would hope that in the long run 5312 04:43:14,559 --> 04:43:17,214 that he'd be able to manage without it. 5313 04:43:17,214 --> 04:43:18,832 If we have to put it back in again, 5314 04:43:18,832 --> 04:43:21,864 the question is for what, what sort of a recovery 5315 04:43:21,864 --> 04:43:25,036 might he have if he's unable to breathe 5316 04:43:25,036 --> 04:43:28,453 except to have the machine do it for him? 5317 04:43:32,155 --> 04:43:34,322 Are you gonna be in today? 5318 04:43:41,730 --> 04:43:42,563 Uh-huh. 5319 04:43:44,508 --> 04:43:45,341 Yes. 5320 04:43:48,386 --> 04:43:49,219 Uh-huh. 5321 04:43:51,614 --> 04:43:52,936 Yeah. 5322 04:43:52,936 --> 04:43:57,176 Well would you rather talk about this sorta stuff in person? 5323 04:43:57,176 --> 04:43:58,711 Yeah, all righty. 5324 04:43:58,711 --> 04:44:00,516 Well when you come in, why don't you ask 5325 04:44:00,516 --> 04:44:02,625 the Unit Coordinator up here in the Intensive Care 5326 04:44:02,625 --> 04:44:06,116 Unit to page me and I'll come and we'll speak then. 5327 04:44:06,116 --> 04:44:08,614 Because I think the issue that we started to talk 5328 04:44:08,614 --> 04:44:13,447 about is one that'll be important to talk about some more. 5329 04:44:17,010 --> 04:44:20,119 Well we'll talk about it together, I think 5330 04:44:20,119 --> 04:44:22,881 you have to understand as best you can 5331 04:44:22,881 --> 04:44:26,521 the medical situation and it's my job to try to 5332 04:44:26,521 --> 04:44:29,326 tell you as best I can about that and then together 5333 04:44:29,326 --> 04:44:34,321 we'll try to figure out what's the best plan and what to do. 5334 04:44:34,321 --> 04:44:37,738 Okay, I'll speak to you later, take care. 5335 04:44:53,800 --> 04:44:56,980 - [Scott] I think if we're gonna do a valvuloplasty, 5336 04:44:56,980 --> 04:44:58,807 we've gotta do it while he's intubated. 5337 04:44:58,807 --> 04:45:00,711 I don't think we oughta try to extubate him. 5338 04:45:00,711 --> 04:45:02,415 At the moment it's not clear at all to me 5339 04:45:02,415 --> 04:45:04,242 that he could come off the ventilator. 5340 04:45:04,242 --> 04:45:06,017 - It's also not clear either that he stands 5341 04:45:06,017 --> 04:45:08,168 to benefit a wit from the valvuloplasty. 5342 04:45:08,168 --> 04:45:09,900 - Right but those are the questions we gotta, 5343 04:45:09,900 --> 04:45:11,861 I guess the other question to put to Jim is 5344 04:45:11,861 --> 04:45:14,522 whether, what do you think is the right cardioversion 5345 04:45:14,522 --> 04:45:17,755 since we've got his rate controlled but you know, 5346 04:45:17,755 --> 04:45:20,712 he may not be able to hold cardioversion and obviously-- 5347 04:45:20,712 --> 04:45:23,406 - He's been repeatedly in rhythm, right? 5348 04:45:23,406 --> 04:45:24,936 - No, he's in AF. - He's in AF now. 5349 04:45:24,936 --> 04:45:26,927 - He hasn't been in and out of AF? 5350 04:45:26,927 --> 04:45:28,582 - [Nurse] Pretty much been in the last 5351 04:45:28,582 --> 04:45:30,406 couple days but he does go in and out. 5352 04:45:30,406 --> 04:45:32,834 - He's digitalized now, so his rate is controlled. 5353 04:45:32,834 --> 04:45:34,699 Anyway I'm not, 5354 04:45:34,699 --> 04:45:37,155 I'm not big on either one of those but-- 5355 04:45:37,155 --> 04:45:39,896 - We can do more and more technologically but 5356 04:45:39,896 --> 04:45:41,342 the question is for what? 5357 04:45:41,342 --> 04:45:44,439 Like if he can't be maintained off the respirator, 5358 04:45:44,439 --> 04:45:48,561 the big for what becomes sorta written in large letters. 5359 04:45:48,561 --> 04:45:51,873 - If we take him off and he doesn't fly, 5360 04:45:51,873 --> 04:45:55,147 I'm loath to put him back on. - Yeah, I agree with that. 5361 04:45:55,147 --> 04:45:57,086 She's coming in around three and I asked her 5362 04:45:57,086 --> 04:45:58,979 to give me a call, so maybe we'll keep the plan 5363 04:45:58,979 --> 04:46:01,657 as it is right now, speak to Jim and then 5364 04:46:01,657 --> 04:46:03,967 see if we can evolve something towards that. 5365 04:46:03,967 --> 04:46:05,588 - Good, okay. 5366 04:46:05,588 --> 04:46:06,838 - [Nurse] Okay? 5367 04:46:08,545 --> 04:46:11,242 - Can you close her door. - What did he say? 5368 04:46:11,242 --> 04:46:13,864 - He says he doesn't think it, it's not, 5369 04:46:13,864 --> 04:46:16,114 this is more technology for 5370 04:46:17,639 --> 04:46:19,556 unclear benefit. - Okay. 5371 04:46:20,554 --> 04:46:23,339 - [Mrs. Sperazza] What do you think? 5372 04:46:23,339 --> 04:46:24,882 - [Bill] Well I think that if that tube 5373 04:46:24,882 --> 04:46:28,607 could come out, it would be a big step forward. 5374 04:46:28,607 --> 04:46:30,959 There's still all the other problems 5375 04:46:30,959 --> 04:46:34,959 that haven't gone away since we spoke last time. 5376 04:46:36,153 --> 04:46:37,805 But 5377 04:46:37,805 --> 04:46:39,683 they've been relatively stable and 5378 04:46:39,683 --> 04:46:43,594 that gives us reason to be hopeful I think. 5379 04:46:43,594 --> 04:46:46,577 It's still an incredibly grave and difficult situation 5380 04:46:46,577 --> 04:46:49,790 but I think if he could come off of that tube, 5381 04:46:49,790 --> 04:46:51,572 it would be a big step forward 5382 04:46:51,572 --> 04:46:55,072 and clearly if he's gonna be alert at all, 5383 04:46:56,391 --> 04:46:59,255 it's gonna be hard for him with that tube in place. 5384 04:46:59,255 --> 04:47:00,910 He has to get sedated in order 5385 04:47:00,910 --> 04:47:03,140 to have it be tolerable for him. 5386 04:47:03,140 --> 04:47:05,899 So that's a difficult situation for him 5387 04:47:05,899 --> 04:47:08,625 either to be a little bit more alert but have 5388 04:47:08,625 --> 04:47:11,676 the discomfort of it or to be sedated 5389 04:47:11,676 --> 04:47:14,359 and not really be able to participate. 5390 04:47:14,359 --> 04:47:18,609 - I wouldn't want to see him go back into the sedation. 5391 04:47:18,609 --> 04:47:21,836 - No, I wouldn't either. - I really wouldn't. 5392 04:47:21,836 --> 04:47:24,297 Because he's not there at all. - Right. 5393 04:47:24,297 --> 04:47:27,359 And yet with the tube in place, without the sedation, 5394 04:47:27,359 --> 04:47:29,341 he appears to be quite uncomfortable. 5395 04:47:29,341 --> 04:47:30,174 So I think 5396 04:47:31,275 --> 04:47:33,144 if it can happen safely, 5397 04:47:33,144 --> 04:47:36,208 what we want to have happen is what we're making 5398 04:47:36,208 --> 04:47:39,438 progress toward again which is to try to get that tube 5399 04:47:39,438 --> 04:47:43,358 removed and to get him off of the breathing machine. 5400 04:47:43,358 --> 04:47:47,941 If that goes well, we'll have a lot to be thankful for. 5401 04:47:48,958 --> 04:47:52,508 We have to also plan if it does happen, 5402 04:47:52,508 --> 04:47:56,425 what if he has another breathing problem again? 5403 04:47:57,736 --> 04:48:00,385 Are we gonna subject him to the tube 5404 04:48:00,385 --> 04:48:03,135 and the machine for a third time? 5405 04:48:04,245 --> 04:48:05,939 And we'd have to ask ourselves 5406 04:48:05,939 --> 04:48:07,898 what would the purpose of that be? 5407 04:48:07,898 --> 04:48:10,438 Hopefully this isn't anything we're gonna face. 5408 04:48:10,438 --> 04:48:12,628 Hopefully he'll come off that tube 5409 04:48:12,628 --> 04:48:14,940 and we'll see some improvement. 5410 04:48:14,940 --> 04:48:17,688 But the fact that he's had so much difficulty, 5411 04:48:17,688 --> 04:48:19,843 that there's been so much trouble with 5412 04:48:19,843 --> 04:48:23,074 so many different things as we've talked about 5413 04:48:23,074 --> 04:48:25,353 makes us have to have our eyes open 5414 04:48:25,353 --> 04:48:27,686 even at the same time that we're hopeful 5415 04:48:27,686 --> 04:48:30,599 to the possibility that things aren't gonna go well 5416 04:48:30,599 --> 04:48:33,581 and I think we have to plan for that at the same time 5417 04:48:33,581 --> 04:48:36,664 that we're trying to do everything to 5418 04:48:37,681 --> 04:48:40,953 help him move in the right direction. 5419 04:48:40,953 --> 04:48:44,019 My own view would be, and hearing from you people 5420 04:48:44,019 --> 04:48:48,421 about this is gonna be crucial but my own view would be 5421 04:48:48,421 --> 04:48:51,787 that if we're able to get him off the tube successfully, 5422 04:48:51,787 --> 04:48:54,684 that gives him the maximum chance of seeing 5423 04:48:54,684 --> 04:48:58,938 whether there's any possibility for meaningful recovery. 5424 04:48:58,938 --> 04:49:01,053 That we do everything we possibly can 5425 04:49:01,053 --> 04:49:02,962 to get him off the tube, we do everything 5426 04:49:02,962 --> 04:49:04,797 once he's off the tube to try to keep him 5427 04:49:04,797 --> 04:49:07,880 off of it but that we make a decision 5428 04:49:08,973 --> 04:49:11,248 not to put the tube back in again if that's 5429 04:49:11,248 --> 04:49:13,692 something that you people are comfortable with 5430 04:49:13,692 --> 04:49:16,041 and the reason for that would be the notion 5431 04:49:16,041 --> 04:49:18,869 that putting the tube back in would be for 5432 04:49:18,869 --> 04:49:22,619 no purpose in the sense that if he deteriorates 5433 04:49:22,619 --> 04:49:25,036 to the point where he needs it again, 5434 04:49:25,036 --> 04:49:27,306 that the likelihood for any meaningful kind of 5435 04:49:27,306 --> 04:49:30,011 recovery would be so remote that we'd say 5436 04:49:30,011 --> 04:49:33,200 why are we putting him through all of this? 5437 04:49:33,200 --> 04:49:35,661 I don't know if, that's a lot to hear 5438 04:49:35,661 --> 04:49:37,403 and to think about, I don't know if that 5439 04:49:37,403 --> 04:49:39,310 makes sense to you or if you have questions 5440 04:49:39,310 --> 04:49:42,554 about it but I think that's the sense that I have. 5441 04:49:42,554 --> 04:49:45,160 I've spoken to Dr. Sands, the intern, 5442 04:49:45,160 --> 04:49:47,418 I've spoken Dr. Weiss, the attending in 5443 04:49:47,418 --> 04:49:49,533 the Medical Intensive Care Unit and I've 5444 04:49:49,533 --> 04:49:53,140 spoken to the nursing staff and to Dr. Morgan, 5445 04:49:53,140 --> 04:49:55,132 the cardiologist this morning, 5446 04:49:55,132 --> 04:49:57,706 I've spoken to all of those people 5447 04:49:57,706 --> 04:50:01,314 and they all believe that this would be 5448 04:50:01,314 --> 04:50:04,676 a reasonable way to try to maximize the chance for 5449 04:50:04,676 --> 04:50:08,532 a meaningful recovery and yet if things don't go well, 5450 04:50:08,532 --> 04:50:12,050 to minimize the chance that we're gonna be doing 5451 04:50:12,050 --> 04:50:14,040 needless things to him that are gonna be 5452 04:50:14,040 --> 04:50:16,947 difficult for him really for no purpose. 5453 04:50:16,947 --> 04:50:20,646 We're on the edges of that. - Did you ever have a case 5454 04:50:20,646 --> 04:50:22,646 where this was reversed? 5455 04:50:24,766 --> 04:50:25,599 - I... 5456 04:50:27,466 --> 04:50:30,919 I've been involved in cases where people have looked 5457 04:50:30,919 --> 04:50:35,624 desperately sick and where they fooled us and recovered. 5458 04:50:35,624 --> 04:50:37,801 But I have to tell you that that 5459 04:50:37,801 --> 04:50:40,219 is extremely rare and I don't think that 5460 04:50:40,219 --> 04:50:43,152 I've ever been involved with someone as sick 5461 04:50:43,152 --> 04:50:47,165 with as many strikes against him as Mr. Sperazza 5462 04:50:47,165 --> 04:50:50,347 has where I've seen a meaningful recovery. 5463 04:50:50,347 --> 04:50:52,383 But that doesn't mean it doesn't happen. 5464 04:50:52,383 --> 04:50:54,466 It's just extremely rare. 5465 04:50:55,322 --> 04:50:58,599 We have hope, we are doing what we can to try to see if 5466 04:50:58,599 --> 04:51:02,405 that's possible but I think it's at the level where if he 5467 04:51:02,405 --> 04:51:07,150 were to recover from this, it would be close to a miracle. 5468 04:51:07,150 --> 04:51:08,502 - Really? - Yeah. 5469 04:51:08,502 --> 04:51:10,402 - What is the extent of damage right now? 5470 04:51:10,402 --> 04:51:11,910 - Well some of that's hard to assess. 5471 04:51:11,910 --> 04:51:14,553 The most crucial thing of course is his brain 5472 04:51:14,553 --> 04:51:17,877 and how much he's able to recover in terms of 5473 04:51:17,877 --> 04:51:21,948 his mental functioning and with the medical complications 5474 04:51:21,948 --> 04:51:25,390 that he's had plus with the sedatives he's had to receive, 5475 04:51:25,390 --> 04:51:27,414 we can't tell for sure. - So you don't know. 5476 04:51:27,414 --> 04:51:28,489 - We don't know. 5477 04:51:28,489 --> 04:51:30,216 - What about the other vital organs? 5478 04:51:30,216 --> 04:51:33,624 - I could give you a list of the things that are in trouble. 5479 04:51:33,624 --> 04:51:36,033 The main things where the difficulty's been 5480 04:51:36,033 --> 04:51:38,978 have been his lungs with respiratory failure 5481 04:51:38,978 --> 04:51:42,284 which has required the machine and his heart with 5482 04:51:42,284 --> 04:51:46,798 congestive heart failure that has complicated the situation. 5483 04:51:46,798 --> 04:51:48,652 He's had irregular heart beating, 5484 04:51:48,652 --> 04:51:52,911 which has made the heart pump less effectively 5485 04:51:52,911 --> 04:51:56,944 and he's got this problem with a blocked heart valve which 5486 04:51:56,944 --> 04:51:58,980 we've been going round and round on 5487 04:51:58,980 --> 04:52:01,641 whether that may be contributing to this. 5488 04:52:01,641 --> 04:52:03,807 The best assessment we have currently is while 5489 04:52:03,807 --> 04:52:05,797 that's not good, that that's probably not making 5490 04:52:05,797 --> 04:52:09,288 a major contribution to how poorly he's doing. 5491 04:52:09,288 --> 04:52:14,218 The other big organ system difficulty is his kidneys. 5492 04:52:14,218 --> 04:52:16,507 He's been, his kidneys have been producing 5493 04:52:16,507 --> 04:52:19,394 very little urine over the last few days 5494 04:52:19,394 --> 04:52:21,394 and added to the list of 5495 04:52:22,775 --> 04:52:26,214 questionable failure related to his brain, 5496 04:52:26,214 --> 04:52:28,117 respiratory failure. 5497 04:52:28,117 --> 04:52:30,649 Heart failure, I think we have to 5498 04:52:30,649 --> 04:52:32,671 add kidney failure to the list. 5499 04:52:32,671 --> 04:52:36,441 So in that setting, the notion of some sort of 5500 04:52:36,441 --> 04:52:40,858 meaningful recovery is extremely remote but you know, 5501 04:52:42,915 --> 04:52:45,514 we don't know for sure and that's the reason to 5502 04:52:45,514 --> 04:52:48,065 continue to try to support him. 5503 04:52:48,065 --> 04:52:49,431 - So if you remove the tube, 5504 04:52:49,431 --> 04:52:52,439 that will allow you to do this surgical procedure? 5505 04:52:52,439 --> 04:52:54,774 - Well that's looking off to the future. 5506 04:52:54,774 --> 04:52:57,861 I think the first step is to see if he can manage 5507 04:52:57,861 --> 04:52:59,717 without the tube. - The removal of the tube. 5508 04:52:59,717 --> 04:53:01,832 So you're not taking it any further than that. 5509 04:53:01,832 --> 04:53:04,182 - No, we were wondering whether that, 5510 04:53:04,182 --> 04:53:05,828 what you call the surgical procedure where 5511 04:53:05,828 --> 04:53:07,903 they'd use the balloon to open up that heart valve, 5512 04:53:07,903 --> 04:53:11,017 whether that might help him to improve his heart function 5513 04:53:11,017 --> 04:53:13,520 because everything is so related to everything else 5514 04:53:13,520 --> 04:53:15,887 that if we can intervene in one place and make him 5515 04:53:15,887 --> 04:53:18,697 a little better, sometimes that can have implications. 5516 04:53:18,697 --> 04:53:21,682 But the current think is that that's probably not 5517 04:53:21,682 --> 04:53:24,175 a major contributor to how poorly he's doing. 5518 04:53:24,175 --> 04:53:27,470 - So the real question is all you want to do, 5519 04:53:27,470 --> 04:53:30,005 you want to see what removal of the tube will do 5520 04:53:30,005 --> 04:53:33,233 and the secondary question is if he can't survive 5521 04:53:33,233 --> 04:53:36,838 without that tube, should you re-insert the tube? 5522 04:53:36,838 --> 04:53:40,518 And that's a decision for the family to make, is that right? 5523 04:53:40,518 --> 04:53:41,915 - Well it's a decision that we 5524 04:53:41,915 --> 04:53:44,120 all have to participate in together. 5525 04:53:44,120 --> 04:53:46,813 In a sense you could say it's a medical decision. 5526 04:53:46,813 --> 04:53:49,590 If there's no medical hope or the hope is so 5527 04:53:49,590 --> 04:53:54,317 remote that it really is just ridiculously unlikely, 5528 04:53:54,317 --> 04:53:56,983 can we medically subject him to that? 5529 04:53:56,983 --> 04:53:58,970 On the other hand, you could say it's a decision for the 5530 04:53:58,970 --> 04:54:02,000 family because it's really making a decision to terminate 5531 04:54:02,000 --> 04:54:04,864 life-support because that's what that tube involves. 5532 04:54:04,864 --> 04:54:07,410 - It's a gray area here where both of those things 5533 04:54:07,410 --> 04:54:11,602 come into play and I think if medically we come to 5534 04:54:11,602 --> 04:54:15,096 a decision that from the point of view of your role 5535 04:54:15,096 --> 04:54:18,250 in the family looking out for his best interest, 5536 04:54:18,250 --> 04:54:21,087 you're comfortable with too, then I think we don't 5537 04:54:21,087 --> 04:54:24,608 have to sort out sort of what's on which side of it. 5538 04:54:24,608 --> 04:54:27,605 But if we don't see it exactly the same way, 5539 04:54:27,605 --> 04:54:29,590 then we can't really move forward with a plan. 5540 04:54:29,590 --> 04:54:32,033 We want a plan that everybody feels is 5541 04:54:32,033 --> 04:54:34,410 medically best for him but also looking at 5542 04:54:34,410 --> 04:54:37,820 the big picture of what he would want and what 5543 04:54:37,820 --> 04:54:40,370 you want for him that's consistent with your views. 5544 04:54:40,370 --> 04:54:42,650 - Charlie would want to live but 5545 04:54:42,650 --> 04:54:45,928 I wouldn't want to see him suffer. 5546 04:54:45,928 --> 04:54:46,761 You know? 5547 04:54:53,636 --> 04:54:57,469 - [Charlie] When would you need that decision? 5548 04:55:00,179 --> 04:55:01,666 - [Bill] It's possible that he may 5549 04:55:01,666 --> 04:55:03,684 be moving today or tomorrow towards a point 5550 04:55:03,684 --> 04:55:07,017 where we may be able to remove the tube. 5551 04:55:08,655 --> 04:55:09,488 I would 5552 04:55:11,725 --> 04:55:15,143 ideally like to have, by the time that tube can come out, 5553 04:55:15,143 --> 04:55:17,681 it would be nice if we were all at a place where we 5554 04:55:17,681 --> 04:55:21,119 were comfortable with a plan of what to do from there. 5555 04:55:21,119 --> 04:55:25,619 - If you take out the tube and you see he can make it, 5556 04:55:26,960 --> 04:55:29,594 every day is a good day that they live. 5557 04:55:29,594 --> 04:55:31,493 - [Bill] Yep, then there's no question. 5558 04:55:31,493 --> 04:55:33,951 Then I think there's no, we don't face this-- 5559 04:55:33,951 --> 04:55:35,201 - That's right. 5560 04:55:38,201 --> 04:55:39,976 You know I'll always go by your 5561 04:55:39,976 --> 04:55:43,324 decision on what's good for Charlie. 5562 04:55:43,324 --> 04:55:45,969 - He's asking you for it. - I know. 5563 04:55:45,969 --> 04:55:47,302 I say medically, 5564 04:55:50,258 --> 04:55:52,436 he wouldn't want Charlie to suffer. 5565 04:55:52,436 --> 04:55:54,769 - [Charlie] No, I know that. 5566 04:56:00,061 --> 04:56:02,500 - It's so hard. - It is hard. 5567 04:56:02,500 --> 04:56:04,167 - It really is hard. 5568 04:56:08,246 --> 04:56:12,629 Don't you think that we could make more of a commitment 5569 04:56:12,629 --> 04:56:15,521 once you take the tube out? 5570 04:56:15,521 --> 04:56:17,391 - [Bill] I'm not sure I understand. 5571 04:56:17,391 --> 04:56:18,224 - Well, 5572 04:56:19,385 --> 04:56:21,789 what if you take the tube out and you 5573 04:56:21,789 --> 04:56:25,206 find that he more or less rallies around, 5574 04:56:27,191 --> 04:56:30,358 anything I say doesn't mean, you know, 5575 04:56:31,720 --> 04:56:36,387 she's given me permission to say that's it but you know, 5576 04:56:37,435 --> 04:56:41,435 you're gonna do the best for him and I know that 5577 04:56:45,001 --> 04:56:48,317 and if there isn't any hope or if he's gonna, 5578 04:56:48,317 --> 04:56:49,900 medically you know, 5579 04:56:51,943 --> 04:56:55,275 I would never want him to suffer, never. 5580 04:56:57,372 --> 04:57:01,576 - I think that if the tube comes out and he shows 5581 04:57:01,576 --> 04:57:05,620 an ability to rally with the best that we can do for him, 5582 04:57:05,620 --> 04:57:08,779 then we're all comfortable that we'd do everything 5583 04:57:08,779 --> 04:57:12,712 to support that and I think if I hear you correctly, 5584 04:57:12,712 --> 04:57:17,116 that we're also at a point where if we are able to take 5585 04:57:17,116 --> 04:57:21,772 the tube out and yet things take a turn for the worse-- 5586 04:57:21,772 --> 04:57:26,065 - I don't want the tube back. - It doesn't do him any good. 5587 04:57:26,065 --> 04:57:29,898 - But you understand-- - I understand, Charlie. 5588 04:57:31,416 --> 04:57:33,278 The tube bothers him. 5589 04:57:33,278 --> 04:57:35,577 If he has the tube in him, 5590 04:57:35,577 --> 04:57:37,727 then he's gonna be sedated all over again 5591 04:57:37,727 --> 04:57:39,680 because he can't tolerate the tube. 5592 04:57:39,680 --> 04:57:41,677 - [Bill] If he has the tube in him, it's not living. 5593 04:57:41,677 --> 04:57:45,007 - [Mrs. Sperazza] It's not living, he's existing. 5594 04:57:45,007 --> 04:57:46,913 - We'd also face the issue then 5595 04:57:46,913 --> 04:57:48,701 of sort of where do we go from there? 5596 04:57:48,701 --> 04:57:50,436 Because then would we try again to 5597 04:57:50,436 --> 04:57:52,472 remove it and put him through that again? 5598 04:57:52,472 --> 04:57:55,464 Would we try to keep him on it on a long term basis which 5599 04:57:55,464 --> 04:57:58,438 would be miserable for him and as you say from a certain 5600 04:57:58,438 --> 04:58:01,380 point of view, right, it's not the kind of life that-- 5601 04:58:01,380 --> 04:58:04,569 - No, and he wouldn't want it that way either. 5602 04:58:04,569 --> 04:58:07,986 Charlie would never want to be like that. 5603 04:58:09,335 --> 04:58:13,000 I'm not thinking of me because me, 5604 04:58:13,000 --> 04:58:14,750 for me it's lonesome. 5605 04:58:19,560 --> 04:58:22,322 He's suffered terribly the last two months. 5606 04:58:22,322 --> 04:58:24,025 Maybe, would it have made 5607 04:58:24,025 --> 04:58:26,135 a difference if he'd come in sooner? 5608 04:58:26,135 --> 04:58:28,042 - [Bill] I don't think that it would have. 5609 04:58:28,042 --> 04:58:29,625 No, I really don't. 5610 04:58:36,595 --> 04:58:39,841 - He kept saying the last month, 5611 04:58:39,841 --> 04:58:43,466 Charlie was a bit of a crybaby, you know that. 5612 04:58:43,466 --> 04:58:47,466 He gets scared of everything, every little pain. 5613 04:58:48,775 --> 04:58:53,775 He's like the little boy that cried wolf once too often. 5614 04:58:54,096 --> 04:58:57,295 He kept saying "I'm gonna die. 5615 04:58:57,295 --> 04:58:59,795 "I feel like I'm going crazy." 5616 04:59:01,725 --> 04:59:04,746 When we came in here that Sunday morning 5617 04:59:04,746 --> 04:59:08,829 at four o'clock in the morning, he was screaming. 5618 04:59:13,662 --> 04:59:14,745 I don't know. 5619 04:59:24,292 --> 04:59:26,875 I want whatever's best for him. 5620 04:59:28,274 --> 04:59:29,860 - [Bill] I think we all want that and I think 5621 04:59:29,860 --> 04:59:31,866 we've done a little bit of work toward defining that 5622 04:59:31,866 --> 04:59:36,033 in a way that we're all comfortable with together. 5623 04:59:38,720 --> 04:59:41,175 I'm gonna be around for the rest of the day 5624 04:59:41,175 --> 04:59:44,309 and if you talk some more and want to be in touch again, 5625 04:59:44,309 --> 04:59:46,392 they know how to call me. 5626 04:59:47,493 --> 04:59:49,235 - [Charlie] The way you feel right now, 5627 04:59:49,235 --> 04:59:51,899 the tube has to be removed, we understand that right? 5628 04:59:51,899 --> 04:59:55,230 - They're gonna try to do that within the next day anyway. 5629 04:59:55,230 --> 04:59:57,057 - [Bill] If things go well in that regard, 5630 04:59:57,057 --> 04:59:59,307 we'll be able to remove it. 5631 05:00:00,934 --> 05:00:05,205 - In the event you can't remove it, then we'll have to-- 5632 05:00:05,205 --> 05:00:07,538 - We'll face a different set of issues then. 5633 05:00:07,538 --> 05:00:09,651 It's much more difficult, if we can see that 5634 05:00:09,651 --> 05:00:12,505 kind of improvement, there's a lot more reason 5635 05:00:12,505 --> 05:00:15,377 to be hopeful if he can manage without it. 5636 05:00:15,377 --> 05:00:17,365 That's really our hope for the next couple 5637 05:00:17,365 --> 05:00:19,238 of days is to move in that direction. 5638 05:00:19,238 --> 05:00:22,086 I think if a couple days from now 5639 05:00:22,086 --> 05:00:23,946 we're not able to do that, we'll have 5640 05:00:23,946 --> 05:00:26,126 to talk some more and take it from there. 5641 05:00:26,126 --> 05:00:29,126 But I think it's so complicated that 5642 05:00:29,972 --> 05:00:32,821 it's hard enough with the one step at a time approach. 5643 05:00:32,821 --> 05:00:34,981 - But you're moving towards the whole issue of 5644 05:00:34,981 --> 05:00:38,766 if there's any chance whatsoever, the tube has to be removed 5645 05:00:38,766 --> 05:00:43,258 and that hope is as slight as it may be and you can't even 5646 05:00:43,258 --> 05:00:46,299 move beyond what will happen once they remove the tube. 5647 05:00:46,299 --> 05:00:49,244 You just feel and I would agree with you by the way, 5648 05:00:49,244 --> 05:00:51,620 I understand what you're saying that if there's 5649 05:00:51,620 --> 05:00:54,236 to be any chance, the tube has to be removed. 5650 05:00:54,236 --> 05:00:55,486 - Right. - Okay. 5651 05:01:00,098 --> 05:01:01,181 - Dr. Taylor, 5652 05:01:02,620 --> 05:01:03,870 what can I say? 5653 05:01:11,821 --> 05:01:13,854 I wasn't gonna keep my appointment 5654 05:01:13,854 --> 05:01:16,161 Friday but I think I better come in. 5655 05:01:16,161 --> 05:01:19,828 - Yeah, I think it would be good to see you. 5656 05:01:20,841 --> 05:01:24,830 - He's my friend, he's not only a doctor, he's my friend. 5657 05:01:24,830 --> 05:01:26,146 - [Charlie] It's good that you have confidence. 5658 05:01:26,146 --> 05:01:28,479 That support. - I do, utmost. 5659 05:01:29,544 --> 05:01:34,087 Well thank you Dr. Taylor and I'm sorry I took so much time. 5660 05:01:34,087 --> 05:01:38,102 - I'm here for you. - Thank you for explaining. 5661 05:01:38,102 --> 05:01:39,313 - [Bill] I'll call you tomorrow 5662 05:01:39,313 --> 05:01:40,718 if I don't see you later today. 5663 05:01:40,718 --> 05:01:43,885 All right, thank you. - Just stay here. 5664 05:01:47,118 --> 05:01:49,106 While you're in the room with him. 5665 05:01:49,106 --> 05:01:52,773 - [Mrs. Sperazza] Why don't you ask him now? 5666 05:02:07,355 --> 05:02:11,184 - I think he's got anoxic brain damage personally 5667 05:02:11,184 --> 05:02:14,420 and I think he's had everything there. 5668 05:02:14,420 --> 05:02:16,587 But I mean there's no way to really assess that. 5669 05:02:16,587 --> 05:02:19,318 The neurology people wouldn't help us. 5670 05:02:19,318 --> 05:02:21,329 We did want to get a head CT to sort of rule 5671 05:02:21,329 --> 05:02:23,587 on any structural lesion but I think it's unlikely, 5672 05:02:23,587 --> 05:02:26,986 the chances that that's gonna show anything are 5673 05:02:26,986 --> 05:02:28,643 I would think one in 10,000. 5674 05:02:28,643 --> 05:02:30,756 I think it's mostly the guy with aortic stenosis 5675 05:02:30,756 --> 05:02:32,625 who dropped his blood pressure, had a sustained 5676 05:02:32,625 --> 05:02:35,629 episode when his blood pressure was running around 70, 5677 05:02:35,629 --> 05:02:38,510 had an episode of hypotension when he went on the ventilator 5678 05:02:38,510 --> 05:02:43,260 the first time and has a bad ticker and that's all taped. 5679 05:02:45,534 --> 05:02:48,586 So I mean, but you could also implicated the Fentanyl, 5680 05:02:48,586 --> 05:02:51,010 the Ativan, et cetera, et cetera, et cetera. 5681 05:02:51,010 --> 05:02:54,330 So I mean you never know but I mean 5682 05:02:54,330 --> 05:02:56,777 you don't breathe up here, you breathe down here. 5683 05:02:56,777 --> 05:02:59,538 So this can be all gone and you breathe fine, 5684 05:02:59,538 --> 05:03:01,568 so that's the experience up here. 5685 05:03:01,568 --> 05:03:03,038 - But he isn't. - But he isn't. 5686 05:03:03,038 --> 05:03:04,402 - He could've had an event. 5687 05:03:04,402 --> 05:03:06,565 - He could've had an event there but I doubt it. 5688 05:03:06,565 --> 05:03:09,583 I think the reason he's not breathing relates more 5689 05:03:09,583 --> 05:03:12,410 to the fact that his lungs and his heart are so terrible 5690 05:03:12,410 --> 05:03:13,942 and then I think we're gonna have to address 5691 05:03:13,942 --> 05:03:17,045 the issue with his wife, what do we do at that point? 5692 05:03:17,045 --> 05:03:18,319 - Yeah. 5693 05:03:18,319 --> 05:03:19,969 But you haven't give up on the idea that 5694 05:03:19,969 --> 05:03:22,733 he might be able to be weaned? - No, no, not yet. 5695 05:03:22,733 --> 05:03:25,387 But I think that I probably would still get him, 5696 05:03:25,387 --> 05:03:28,387 even if we, I would get him optimal. 5697 05:03:30,150 --> 05:03:32,070 The fact that he didn't wean with INB yesterday 5698 05:03:32,070 --> 05:03:33,896 doesn't mean that much either because there's increased 5699 05:03:33,896 --> 05:03:36,895 resistance to the tubing and the circuitry and so forth. 5700 05:03:36,895 --> 05:03:39,164 When we took him off the last time, 5701 05:03:39,164 --> 05:03:42,446 the sensorimotor force was only 50 to 100. 5702 05:03:42,446 --> 05:03:44,104 Now that may have been one of the reasons 5703 05:03:44,104 --> 05:03:46,018 that he failed with the weaning attempt but 5704 05:03:46,018 --> 05:03:47,842 on the other hand it's also true that he was 5705 05:03:47,842 --> 05:03:50,165 actually doing pretty well for a couple days there. 5706 05:03:50,165 --> 05:03:51,665 - Yeah, but now we're seeing 5707 05:03:51,665 --> 05:03:54,026 no spontaneous respiratory effort. 5708 05:03:54,026 --> 05:03:57,473 That puts it in a little different category maybe. 5709 05:03:57,473 --> 05:03:59,511 - Maybe, yeah. - All righty. 5710 05:03:59,511 --> 05:04:00,545 - Anyway, 5711 05:04:00,545 --> 05:04:04,487 we got a little fine-tuning to do first before we-- 5712 05:04:04,487 --> 05:04:06,102 - Before you can see. - Yep. 5713 05:04:06,102 --> 05:04:08,435 - All righty, thanks. - Okay. 5714 05:04:34,376 --> 05:04:35,745 So what's the long range plan, 5715 05:04:35,745 --> 05:04:38,147 what do you see as the long range plan? 5716 05:04:38,147 --> 05:04:41,375 - We're gonna diverse him back down to his weight of 75, 5717 05:04:41,375 --> 05:04:43,588 we're gonna pull out the tubes and give 5718 05:04:43,588 --> 05:04:47,088 it a try and it's probably not gonna work. 5719 05:04:48,565 --> 05:04:50,709 - [Scott] I agree, no that's exactly-- 5720 05:04:50,709 --> 05:04:52,278 - [Nurse] We're not gonna re-intubate him? 5721 05:04:52,278 --> 05:04:53,474 - Yeah. - We will not re-intubate him. 5722 05:04:53,474 --> 05:04:57,199 - I think that's the long range plan. 5723 05:04:57,199 --> 05:04:58,532 I mean you know, 5724 05:04:59,769 --> 05:05:02,288 it makes me angry, we worked so hard on this guy 5725 05:05:02,288 --> 05:05:06,564 and it looks so, so grim, I mean it's just 5726 05:05:06,564 --> 05:05:09,716 really discouraging but I don't see any, 5727 05:05:09,716 --> 05:05:11,915 we just gotta get him to the point where we optimize 5728 05:05:11,915 --> 05:05:16,106 everything and then see if we can get him to fly here. 5729 05:05:16,106 --> 05:05:17,596 We've got a few more days. 5730 05:05:17,596 --> 05:05:19,926 The big thing is if he doesn't, 5731 05:05:19,926 --> 05:05:23,356 if you can't keep him negative kilo, 5732 05:05:23,356 --> 05:05:27,001 don't hesitate to start to dobutamine and dopamine back up. 5733 05:05:27,001 --> 05:05:29,747 Because he's on a negative inotrope now he wasn't on before. 5734 05:05:29,747 --> 05:05:31,239 - His pressures have been real good. 5735 05:05:31,239 --> 05:05:32,769 Dopamine alone plus diuretics 5736 05:05:32,769 --> 05:05:34,765 will probably stand him in good stead. 5737 05:05:34,765 --> 05:05:36,681 The last couple of times he's gotten diuretics-- 5738 05:05:36,681 --> 05:05:38,342 - Go back and check on him after rounds, 5739 05:05:38,342 --> 05:05:40,412 check on his urine output-- - What is it makes him pee? 5740 05:05:40,412 --> 05:05:43,577 200 and 200? - Yeah, 200 or 250. 5741 05:05:43,577 --> 05:05:45,994 - 250 of diarol. - 250 diarol. 5742 05:05:47,075 --> 05:05:49,767 - [Nurse] So pretty much you just have to keep an eye 5743 05:05:49,767 --> 05:05:54,282 on his urine output and when it drops below like 160. 5744 05:05:54,282 --> 05:05:55,850 He was on a renal organotrope, 5745 05:05:55,850 --> 05:05:59,430 we'd like to reconstruct that again. 5746 05:05:59,430 --> 05:06:01,644 - [Scott] Keep an eye on his potassium, the other thing. 5747 05:06:01,644 --> 05:06:03,519 - [Nurse] And the other thing on the protein is 5748 05:06:03,519 --> 05:06:06,781 just the nap but he's got an elevated pattern in the nap. 5749 05:06:06,781 --> 05:06:08,936 So just keep an eye on that. - He may have too much, 5750 05:06:08,936 --> 05:06:13,531 be a little bit too much sort of where the levels are. 5751 05:06:13,531 --> 05:06:15,531 - Okay. - He's been fine. 5752 05:06:50,128 --> 05:06:52,719 - [Doctor] The goal is to wean him down, 5753 05:06:52,719 --> 05:06:55,619 maybe even drop his breaths one more tonight. 5754 05:06:55,619 --> 05:06:57,277 See how he does. - Tonight? 5755 05:06:57,277 --> 05:07:00,025 - Maybe, I kind of discouraged that. 5756 05:07:00,025 --> 05:07:02,486 And try and get him off tomorrow. 5757 05:07:02,486 --> 05:07:05,319 - He should rest overnight. - Yeah. 5758 05:07:07,402 --> 05:07:10,028 I talked to the intern, he says he wants to go 5759 05:07:10,028 --> 05:07:12,591 and talk to the wife and make sure that she 5760 05:07:12,591 --> 05:07:15,149 is really adamant about not re-intubating him. 5761 05:07:15,149 --> 05:07:18,839 - He's not to be re-intubated? - That's the plan as of now. 5762 05:07:18,839 --> 05:07:20,614 They feel that we've done everything 5763 05:07:20,614 --> 05:07:23,448 medically that can be done with this patient. 5764 05:07:23,448 --> 05:07:27,531 We dried him out, we buffed him up nutritionally. 5765 05:07:28,803 --> 05:07:32,082 He doesn't have an infection right now. 5766 05:07:32,082 --> 05:07:34,470 We've done everything we can and the aortic 5767 05:07:34,470 --> 05:07:37,983 stenosis may be so severe, we won't be able to-- 5768 05:07:37,983 --> 05:07:39,853 - [Nurse] You're not gonna take him for the valvuloplasty? 5769 05:07:39,853 --> 05:07:41,388 - No. - Why is that? 5770 05:07:41,388 --> 05:07:46,033 - I don't believe that he's a good risk at all right now. 5771 05:07:46,033 --> 05:07:48,291 - Is he DNR? - Yeah. 5772 05:07:48,291 --> 05:07:49,208 No pressers 5773 05:07:50,616 --> 05:07:53,023 and as it stands now, we will not re-intubate. 5774 05:07:53,023 --> 05:07:55,881 However he's waking up a little bit more 5775 05:07:55,881 --> 05:08:00,048 right now and the wife seems really very happy and 5776 05:08:02,391 --> 05:08:04,259 I'm just afraid that she'll say 5777 05:08:04,259 --> 05:08:07,676 "Well, I do want to re-intubate him now." 5778 05:08:08,882 --> 05:08:10,746 So whoever's gonna talk to her today, 5779 05:08:10,746 --> 05:08:14,236 Paul, he's gonna talk to her tonight and really 5780 05:08:14,236 --> 05:08:16,830 try to explain that we have done everything we could 5781 05:08:16,830 --> 05:08:19,648 and he's a 73 year old man with a very severe disease 5782 05:08:19,648 --> 05:08:22,799 and does she really want him to live on a ventilator? 5783 05:08:22,799 --> 05:08:24,297 Which I think has to be said too. 5784 05:08:24,297 --> 05:08:27,223 I think she has to be told in very plain language 5785 05:08:27,223 --> 05:08:28,962 what's going on because I'm afraid that 5786 05:08:28,962 --> 05:08:32,870 she's gonna see him a little bit more alert, 5787 05:08:32,870 --> 05:08:36,016 responding to her and will say "Oh, I do want him to live. 5788 05:08:36,016 --> 05:08:39,433 "I do want you to do everything you can." 5789 05:08:40,474 --> 05:08:42,256 That just, you know, 5790 05:08:42,256 --> 05:08:44,256 came up rather recently. 5791 05:08:46,068 --> 05:08:47,791 - [Nurse] Anne-Louise, you have a call on line five. 5792 05:08:47,791 --> 05:08:49,286 - [Doctor] She might look at this and say gee, 5793 05:08:49,286 --> 05:08:51,156 I want everything done again. - Uh-huh. 5794 05:08:51,156 --> 05:08:55,736 - [Nurse] So that, he went from 10 to 12 to 16. 5795 05:08:55,736 --> 05:08:57,063 - [Doctor] Do you feel like we 5796 05:08:57,063 --> 05:08:58,930 can do anything more for him right now? 5797 05:08:58,930 --> 05:09:01,868 - [Bill] No, I think the key is to see how he does and to-- 5798 05:09:01,868 --> 05:09:04,678 - Extubate him, yeah. - Yeah. 5799 05:09:04,678 --> 05:09:06,972 - [Doctor] Because that was definitely 5800 05:09:06,972 --> 05:09:09,389 what I got from rounds today. 5801 05:09:10,328 --> 05:09:11,732 - I can't imagine that there's much we 5802 05:09:11,732 --> 05:09:14,101 have to offer him by getting him weaned 5803 05:09:14,101 --> 05:09:16,345 and then having him back on the ventilator. 5804 05:09:16,345 --> 05:09:19,526 The question is can he fly? - He has normal looking urine. 5805 05:09:19,526 --> 05:09:22,013 So is his blood sugar. - Well he's buffed. 5806 05:09:22,013 --> 05:09:23,800 I don't think there's any question that he's dry, 5807 05:09:23,800 --> 05:09:25,873 he's almost a little bit too dry. 5808 05:09:25,873 --> 05:09:27,736 His blood pressure's been down today. 5809 05:09:27,736 --> 05:09:29,161 - How down? 5810 05:09:29,161 --> 05:09:32,004 - It's been down as low as 104 5811 05:09:32,004 --> 05:09:35,029 and it only goes up to 140 whereas 5812 05:09:35,029 --> 05:09:38,446 two days ago it was going up to 200, 180. 5813 05:09:39,413 --> 05:09:43,530 And his sodium's up a little bit too, 152. 5814 05:09:43,530 --> 05:09:45,069 - Well this may be as good as he 5815 05:09:45,069 --> 05:09:48,319 can be to see how he does off the tube. 5816 05:09:51,739 --> 05:09:54,770 He's having some spontaneous respirations up to about 10? 5817 05:09:54,770 --> 05:09:58,596 - Yeah, pretty poor quality but there's some. 5818 05:09:58,596 --> 05:10:00,962 Obviously they're oxygenating him well enough. 5819 05:10:00,962 --> 05:10:02,204 His gases have been good, 5820 05:10:02,204 --> 05:10:03,690 I don't know if you've seen the blue chart. 5821 05:10:03,690 --> 05:10:06,259 His gas is retaining a little bit more CO2 but 5822 05:10:06,259 --> 05:10:11,259 besides that the oxygenation's okay, the O2's at about 92%. 5823 05:10:12,303 --> 05:10:14,714 Can't get much better than that. 5824 05:10:14,714 --> 05:10:17,194 What's his baseline gas? 5825 05:10:17,194 --> 05:10:19,809 One of the nurses just asked me, I wasn't sure. 5826 05:10:19,809 --> 05:10:23,134 - [Bill] I'd have to check, I think it's around 50-50. 5827 05:10:23,134 --> 05:10:25,717 - What you'd expect then, okay. 5828 05:10:50,588 --> 05:10:51,918 - In here? - Yeah. 5829 05:10:51,918 --> 05:10:53,592 They may throw us out of the room. 5830 05:10:53,592 --> 05:10:55,788 - [Mrs. Sperazza] What about the brain scan? 5831 05:10:55,788 --> 05:10:59,020 - [Bill] Preliminary result on that scan is that it's okay. 5832 05:10:59,020 --> 05:11:00,489 The couldn't get as good a study as they'd 5833 05:11:00,489 --> 05:11:04,063 like to get because he was moving a little bit. 5834 05:11:04,063 --> 05:11:07,831 But with everything they could see, it looked fine. 5835 05:11:07,831 --> 05:11:10,038 As near as we could tell from that, 5836 05:11:10,038 --> 05:11:13,577 no problems apparent on that. - Thank God for that. 5837 05:11:13,577 --> 05:11:18,156 But the nurse said they're not sedating him as much 5838 05:11:18,156 --> 05:11:21,690 because are you thinking of doing the, 5839 05:11:21,690 --> 05:11:23,309 getting him off the respirator? 5840 05:11:23,309 --> 05:11:25,725 - That's the hope, we're hoping if things continue 5841 05:11:25,725 --> 05:11:28,592 to go the way they have been today that maybe by 5842 05:11:28,592 --> 05:11:32,842 tomorrow, he'll be able to come off the respirator. 5843 05:11:33,813 --> 05:11:36,274 - You think he'll be able to breathe on his own? 5844 05:11:36,274 --> 05:11:37,797 - We're not gonna take him off of it 5845 05:11:37,797 --> 05:11:39,545 unless there's a good sign that he can. 5846 05:11:39,545 --> 05:11:41,449 What'll happen after that, we don't know. 5847 05:11:41,449 --> 05:11:44,345 But right now things seem to be in the optimal 5848 05:11:44,345 --> 05:11:46,974 situation to maximize the chance that 5849 05:11:46,974 --> 05:11:50,325 he will be able to manage off of it 5850 05:11:50,325 --> 05:11:51,910 and that's clearly the best time 5851 05:11:51,910 --> 05:11:54,555 to work toward getting him off. 5852 05:11:54,555 --> 05:11:57,757 - You mean this doesn't mean that he's coming off? 5853 05:11:57,757 --> 05:12:00,049 - No, it means he's moving in that direction. 5854 05:12:00,049 --> 05:12:02,965 If he has continued improvement the way he has today 5855 05:12:02,965 --> 05:12:05,385 that he should be able to have the tube 5856 05:12:05,385 --> 05:12:07,792 come out and he off the respirator tomorrow. 5857 05:12:07,792 --> 05:12:11,023 But it's still critical enough that it's still 5858 05:12:11,023 --> 05:12:15,881 one of these one step at a time kinda situations. 5859 05:12:15,881 --> 05:12:18,372 - What does it actually do? 5860 05:12:18,372 --> 05:12:20,907 I mean if he comes off of it... 5861 05:12:20,907 --> 05:12:23,274 - The respirator is breathing for him. 5862 05:12:23,274 --> 05:12:26,524 It's doing the breathing and right now, 5863 05:12:27,371 --> 05:12:29,536 he's taking some breaths but 5864 05:12:29,536 --> 05:12:32,489 not enough to maintain enough oxygen. 5865 05:12:32,489 --> 05:12:33,811 - Oh, I see. 5866 05:12:33,811 --> 05:12:35,792 - But yesterday he was taking 5867 05:12:35,792 --> 05:12:39,073 virtually no breaths on his own. 5868 05:12:39,073 --> 05:12:41,523 So if he can take more and more as 5869 05:12:41,523 --> 05:12:43,763 we turn the respirator down and down, 5870 05:12:43,763 --> 05:12:46,775 if he takes more and more so that he can maintain 5871 05:12:46,775 --> 05:12:49,974 an adequate amount of oxygen in his blood, then we can 5872 05:12:49,974 --> 05:12:53,113 turn off the machine but we have to do one step at a time. 5873 05:12:53,113 --> 05:12:56,161 We turn the machine down and down and down and watch 5874 05:12:56,161 --> 05:12:59,137 and see if he can as it's being turned down respond 5875 05:12:59,137 --> 05:13:01,907 by breathing a little bit more and a little bit more. 5876 05:13:01,907 --> 05:13:04,793 He has to be able to breathe enough himself 5877 05:13:04,793 --> 05:13:07,261 to supply himself with enough oxygen. 5878 05:13:07,261 --> 05:13:10,170 - You know what puzzles me, Dr. Taylor? 5879 05:13:10,170 --> 05:13:14,837 - He was in here three weeks before that or around that. 5880 05:13:16,034 --> 05:13:18,989 Nothing of this could be detected. 5881 05:13:18,989 --> 05:13:21,720 - Well what was detected is what was known about 5882 05:13:21,720 --> 05:13:25,455 for years which is that he had very serious lung disease. 5883 05:13:25,455 --> 05:13:28,641 - Yeah but I mean I'm talking about the heart. 5884 05:13:28,641 --> 05:13:31,332 - No his heart actually, it seems that what's 5885 05:13:31,332 --> 05:13:34,400 happened is a combination of all these different things 5886 05:13:34,400 --> 05:13:38,030 that all together have pushed him to the side of 5887 05:13:38,030 --> 05:13:40,433 this critical illness that he's got. 5888 05:13:40,433 --> 05:13:43,463 The largest contribution is probably his lungs. 5889 05:13:43,463 --> 05:13:45,199 Another contribution is his heart, 5890 05:13:45,199 --> 05:13:47,305 another contribution is his kidneys. 5891 05:13:47,305 --> 05:13:49,581 All these different things that are in trouble 5892 05:13:49,581 --> 05:13:52,059 are all contributing to how poorly he's doing. 5893 05:13:52,059 --> 05:13:55,308 But his heart, you know in July just a few months ago, 5894 05:13:55,308 --> 05:13:58,539 he had the most sophisticated heart evaluation we know 5895 05:13:58,539 --> 05:14:01,948 how to do and at that time his heart did not look too bad. 5896 05:14:01,948 --> 05:14:03,842 I mean there were problems, we knew about them. 5897 05:14:03,842 --> 05:14:06,788 We needed to assess how bad were they? 5898 05:14:06,788 --> 05:14:08,466 But they weren't-- - And the kidneys. 5899 05:14:08,466 --> 05:14:10,034 He never had kidney trouble. 5900 05:14:10,034 --> 05:14:11,408 - That's really a complication 5901 05:14:11,408 --> 05:14:13,443 of everything else getting into trouble. 5902 05:14:13,443 --> 05:14:15,199 When the blood pressure goes down, 5903 05:14:15,199 --> 05:14:17,420 when the heart isn't pumping effectively, when the-- 5904 05:14:17,420 --> 05:14:20,001 - Oh you mean these things cause this? 5905 05:14:20,001 --> 05:14:22,168 - Yeah. - Oh, I understand. 5906 05:14:23,092 --> 05:14:26,829 It just puzzled me because I said if he had these, he's 5907 05:14:26,829 --> 05:14:30,203 always, you know how he is about coming for his check-ups. 5908 05:14:30,203 --> 05:14:32,071 - Yeah, I know. 5909 05:14:32,071 --> 05:14:35,738 - I know a couple times he had back trouble. 5910 05:14:36,704 --> 05:14:39,320 - Yeah, that was for the urinary tract infection. 5911 05:14:39,320 --> 05:14:41,180 - Nothing to do with his kidneys? 5912 05:14:41,180 --> 05:14:42,256 - No. - I see. 5913 05:14:42,256 --> 05:14:44,547 - Well I say no, probably that infection 5914 05:14:44,547 --> 05:14:46,717 was just in his bladder and certainly 5915 05:14:46,717 --> 05:14:48,583 he didn't have any kidney damage from that. 5916 05:14:48,583 --> 05:14:50,908 So that seems to be totally unrelated 5917 05:14:50,908 --> 05:14:55,678 to the kidneys not working that we've seen recently. 5918 05:14:55,678 --> 05:14:58,428 - If he comes off the respirator, 5919 05:14:59,918 --> 05:15:02,668 is it something that could recur? 5920 05:15:03,709 --> 05:15:06,363 - Could he need the respirator again in terms of-- 5921 05:15:06,363 --> 05:15:07,734 - In the future? 5922 05:15:07,734 --> 05:15:10,554 - Well we don't know, that's a real important question 5923 05:15:10,554 --> 05:15:12,420 and that's what we talked about a couple days ago 5924 05:15:12,420 --> 05:15:14,532 when we talked about if he comes off of it, 5925 05:15:14,532 --> 05:15:17,430 should we subject him to it again if he needs it? 5926 05:15:17,430 --> 05:15:20,263 He could be in the situation where 5927 05:15:21,859 --> 05:15:26,859 his breathing on his own is inadequate to support his life 5928 05:15:27,134 --> 05:15:30,574 and that's the issue that we have to be sure that we're 5929 05:15:30,574 --> 05:15:33,882 all comfortable with or as comfortable as you can be 5930 05:15:33,882 --> 05:15:37,685 in terms of a decision because the decision that 5931 05:15:37,685 --> 05:15:40,893 we talked about a couple days ago was that when he 5932 05:15:40,893 --> 05:15:43,870 comes off of that respirator as we hope that he will, 5933 05:15:43,870 --> 05:15:46,613 that we'll do everything to maximize the chance 5934 05:15:46,613 --> 05:15:50,190 that he can stay off it it and what we had come to together 5935 05:15:50,190 --> 05:15:55,059 before was that if he then takes a turn for the worse, 5936 05:15:55,059 --> 05:15:56,883 that we're not gonna subject him to the 5937 05:15:56,883 --> 05:15:59,425 tube and the respirator again. - I don't wanna do that. 5938 05:15:59,425 --> 05:16:01,584 - Well I think it's the right decision from 5939 05:16:01,584 --> 05:16:04,120 a medical point of view because I can't imagine 5940 05:16:04,120 --> 05:16:06,703 a situation if he did take that sort of a turn for 5941 05:16:06,703 --> 05:16:09,776 the worse from which he could have some sort of a recovery. 5942 05:16:09,776 --> 05:16:13,776 - No, Charlie wouldn't want that kind of a life. 5943 05:16:15,953 --> 05:16:18,018 - Well it's terrible to have to be facing 5944 05:16:18,018 --> 05:16:22,140 that issue at the same time that we have the hope 5945 05:16:22,140 --> 05:16:25,202 that comes from seeing him doing a little better. 5946 05:16:25,202 --> 05:16:27,851 He's taken one step forward. 5947 05:16:27,851 --> 05:16:30,456 There are many, many more steps to go in order 5948 05:16:30,456 --> 05:16:33,983 for him to have any sort of recovery from this but 5949 05:16:33,983 --> 05:16:36,094 it's a wonderful thing-- - But it could be? 5950 05:16:36,094 --> 05:16:38,111 - We don't know, that's right. 5951 05:16:38,111 --> 05:16:40,397 And before we were looking at even if he had 5952 05:16:40,397 --> 05:16:43,923 a day without further problems, that was a plus. 5953 05:16:43,923 --> 05:16:47,662 Now he's had a day where he's actually made progress. 5954 05:16:47,662 --> 05:16:52,162 Although the hope is as thin as a thread, there's hope 5955 05:16:54,671 --> 05:16:57,097 and we're doing everything that can be done to try 5956 05:16:57,097 --> 05:17:00,761 to maximize the chance for some sort of a recovery 5957 05:17:00,761 --> 05:17:04,320 and as you suggested with the question that you asked, 5958 05:17:04,320 --> 05:17:06,400 it's gonna be a critical time, 5959 05:17:06,400 --> 05:17:08,576 if we can get him off the machine, 5960 05:17:08,576 --> 05:17:11,037 it's a critical time to see if he can 5961 05:17:11,037 --> 05:17:13,918 maintain some sort of improvement because if he 5962 05:17:13,918 --> 05:17:16,521 takes a turn for the worse at that point, 5963 05:17:16,521 --> 05:17:20,593 there probably will be nothing that we can do. 5964 05:17:20,593 --> 05:17:21,426 - Well, 5965 05:17:22,502 --> 05:17:24,335 I can understand that. 5966 05:17:34,793 --> 05:17:38,293 I just don't know how these things happen. 5967 05:17:40,543 --> 05:17:44,361 He's like a boy that cried wolf once too often. 5968 05:17:44,361 --> 05:17:46,861 He was not a hypochondriac but 5969 05:17:48,235 --> 05:17:53,152 he always worried about little things, you know how he was. 5970 05:17:55,033 --> 05:17:55,866 But 5971 05:17:57,618 --> 05:18:00,974 I never saw him like this, never 5972 05:18:00,974 --> 05:18:03,832 and Charlie's been in and out of hospitals. 5973 05:18:03,832 --> 05:18:06,499 Never have I seen him like this. 5974 05:18:07,333 --> 05:18:09,414 - [Bill] This is the worst it's been, I'm afraid. 5975 05:18:09,414 --> 05:18:10,247 - Yeah. 5976 05:18:11,197 --> 05:18:14,191 What does Dr. Morgan think, the same as you? 5977 05:18:14,191 --> 05:18:15,759 - [Bill] Yeah well he's been very helpful 5978 05:18:15,759 --> 05:18:18,269 in terms of making suggestions about adjusting things 5979 05:18:18,269 --> 05:18:21,936 from the point of view of helping his heart. 5980 05:18:22,945 --> 05:18:27,528 - Well, thank you very much for answering my questions. 5981 05:18:29,294 --> 05:18:31,152 - [Bill] I'm gonna see you in the office tomorrow. 5982 05:18:31,152 --> 05:18:33,384 - Yeah, I canceled 5983 05:18:33,384 --> 05:18:35,618 Charlie's appointment and the 5984 05:18:35,618 --> 05:18:38,400 first time I laughed in a long time. 5985 05:18:38,400 --> 05:18:41,400 I don't know who the girl I got was. 5986 05:18:43,738 --> 05:18:47,480 But I said to her you know, I was gonna cancel. 5987 05:18:47,480 --> 05:18:50,198 He's in Intensive Care in the hospital there. 5988 05:18:50,198 --> 05:18:54,972 She says does that mean he wants to cancel his appointment? 5989 05:18:54,972 --> 05:18:57,043 Well that did me in, you know? 5990 05:18:57,043 --> 05:18:58,993 - I said "Yeah, I think it does." 5991 05:18:58,993 --> 05:19:00,733 - There's somebody new down in the desk there. 5992 05:19:00,733 --> 05:19:01,983 - Must've been. 5993 05:19:03,603 --> 05:19:05,258 I didn't think you'd roll him up from 5994 05:19:05,258 --> 05:19:07,348 here down there to give him an appointment. 5995 05:19:07,348 --> 05:19:09,292 - I roll myself up here to see him instead. 5996 05:19:09,292 --> 05:19:10,125 - Right. 5997 05:19:10,992 --> 05:19:14,492 Thank you, thank you very much Dr. Taylor. 5998 05:19:18,374 --> 05:19:19,903 - You need to go look at him. 5999 05:19:19,903 --> 05:19:21,821 I'm told that he's more awake 6000 05:19:21,821 --> 05:19:24,708 and indeed was responding to commands. 6001 05:19:24,708 --> 05:19:27,147 - Great. - That therapeutic head CT. 6002 05:19:27,147 --> 05:19:30,049 - That's right, that's all it takes 6003 05:19:30,049 --> 05:19:32,824 and Lorraine really lightened up on the-- 6004 05:19:32,824 --> 05:19:35,864 - Did you get any mechanics today, or? 6005 05:19:35,864 --> 05:19:38,141 - No, he's breathing a little bit. 6006 05:19:38,141 --> 05:19:39,569 I didn't ask him to try to do mechanics. 6007 05:19:39,569 --> 05:19:41,234 - So we'll do those first thing in the morning then. 6008 05:19:41,234 --> 05:19:42,983 - [Scott] I think we're gonna try to 6009 05:19:42,983 --> 05:19:44,967 pull his tooth tomorrow. 6010 05:19:44,967 --> 05:19:47,580 - Dr. Taylor was just talking to his wife, so. 6011 05:19:47,580 --> 05:19:49,621 Hi, Mr. Sperazza. 6012 05:19:49,621 --> 05:19:51,461 Good morning. 6013 05:19:51,461 --> 05:19:53,544 How are you this morning? 6014 05:19:56,859 --> 05:19:59,846 Mr. Sperazza, squeeze my hand. 6015 05:19:59,846 --> 05:20:02,679 Squeeze it again, can you squeeze? 6016 05:20:06,511 --> 05:20:10,594 Mr. Sperazza, squeeze my hand, squeeze over here. 6017 05:20:12,159 --> 05:20:13,482 Good. - Today's the day. 6018 05:20:13,482 --> 05:20:16,482 We're gonna get that tube out today. 6019 05:20:19,150 --> 05:20:20,317 Big day today. 6020 05:20:22,475 --> 05:20:27,058 We're gonna take a listen to your heart and your lungs. 6021 05:20:29,135 --> 05:20:33,498 - [Nurse] Administrative answering page on line five. 6022 05:20:33,498 --> 05:20:37,081 Administrating answering page on line five. 6023 05:20:40,183 --> 05:20:43,100 - [Scott] That really looks better. 6024 05:20:44,228 --> 05:20:46,145 It's okay rhythm. - Yes. 6025 05:20:51,445 --> 05:20:55,278 - [Nurse] That's what we discussed last night. 6026 05:21:03,890 --> 05:21:05,390 - Squeeze my hand. 6027 05:21:06,480 --> 05:21:08,544 You know it's me. 6028 05:21:08,544 --> 05:21:09,961 You know it's me. 6029 05:21:14,997 --> 05:21:18,914 Charlie, you're breathing on your own you know. 6030 05:21:20,729 --> 05:21:22,229 What's the matter? 6031 05:21:28,412 --> 05:21:31,162 I was downstairs with Dr. Taylor. 6032 05:21:59,481 --> 05:22:00,314 Charlie. 6033 05:22:02,596 --> 05:22:04,096 Julie's coming in. 6034 05:22:05,360 --> 05:22:07,277 Do you wanna see Julie? 6035 05:22:08,345 --> 05:22:10,428 Squeeze my hand, Charlie. 6036 05:22:23,176 --> 05:22:25,593 Wanna get up and take a walk? 6037 05:22:31,982 --> 05:22:34,337 Why is he breathing so heavy? 6038 05:22:34,337 --> 05:22:36,911 - He's got secretions in his throat after 6039 05:22:36,911 --> 05:22:39,734 we pulled out the tube, so it's gonna take awhile. 6040 05:22:39,734 --> 05:22:43,234 We've been suctioning him quite a bit, so. 6041 05:22:56,011 --> 05:22:58,428 - Here I am, here I am honey. 6042 05:23:02,073 --> 05:23:03,972 I didn't drive in, 6043 05:23:03,972 --> 05:23:08,183 Debbie drove me in and she's coming up here. 6044 05:23:08,183 --> 05:23:10,516 She was with you last night. 6045 05:23:19,653 --> 05:23:21,819 What's the matter, honey? 6046 05:23:21,819 --> 05:23:23,319 What's the matter? 6047 05:23:27,440 --> 05:23:30,773 I know you don't like that tube up there 6048 05:23:32,015 --> 05:23:36,265 but it's better than the one you had in your mouth. 6049 05:23:48,751 --> 05:23:50,405 Is he breathe, 6050 05:23:50,405 --> 05:23:51,905 breathe, you know? 6051 05:23:53,940 --> 05:23:55,391 - He's breathing all right, 6052 05:23:55,391 --> 05:24:00,291 he's breathing kind of rapidly, yeah but he's okay. 6053 05:24:00,291 --> 05:24:02,480 Taking nice big deep breaths, so. 6054 05:24:02,480 --> 05:24:03,730 - Is he? - Yeah. 6055 05:24:10,947 --> 05:24:15,697 Looks like I'll have to go on a diet to compete with you. 6056 05:24:17,943 --> 05:24:21,526 You wanted to lose weight, now you lost it. 6057 05:24:23,943 --> 05:24:25,360 Okay honey, okay. 6058 05:24:43,615 --> 05:24:46,068 - I had to go to a trustee dinner last night. 6059 05:24:46,068 --> 05:24:48,888 Mitch has these dinners with the trustees. 6060 05:24:48,888 --> 05:24:50,829 - Yeah, good eats or not? 6061 05:24:50,829 --> 05:24:52,361 - No. 6062 05:24:52,361 --> 05:24:57,028 - To show off the professor. - The rubber chicken, no no. 6063 05:24:57,993 --> 05:25:02,109 He does this to sorta get the trustees to 6064 05:25:02,109 --> 05:25:03,978 be more educated about the hospital but 6065 05:25:03,978 --> 05:25:06,450 the topic that we had to discuss was 6066 05:25:06,450 --> 05:25:09,729 how to cut the hospital budget three to 5% to 6067 05:25:09,729 --> 05:25:14,061 accommodate the decrease in revenues associated with 6068 05:25:16,359 --> 05:25:19,323 you know, the lack of healthcare legislation 6069 05:25:19,323 --> 05:25:23,433 and the state anticipate a $5 million deficit. 6070 05:25:23,433 --> 05:25:26,019 So basically I think the businessmen and I, 6071 05:25:26,019 --> 05:25:27,837 the trustees and I were the only 6072 05:25:27,837 --> 05:25:30,670 people who manage our own budgets. 6073 05:25:32,431 --> 05:25:34,511 I said three to 5%, no problem. 6074 05:25:34,511 --> 05:25:36,325 You can cut three to 5% out of virtually 6075 05:25:36,325 --> 05:25:38,606 any budget and you won't have any problem. 6076 05:25:38,606 --> 05:25:41,564 But that doesn't really solve the problem because 6077 05:25:41,564 --> 05:25:46,231 the problem is how do you explain to the American public 6078 05:25:47,189 --> 05:25:51,848 that if they want to have everything done for everybody 6079 05:25:51,848 --> 05:25:54,335 that it's not only gonna cost what it costs now but it's 6080 05:25:54,335 --> 05:25:58,416 gonna go up every year as the number of older people go up. 6081 05:25:58,416 --> 05:26:00,911 Two-thirds of all your healthcare costs 6082 05:26:00,911 --> 05:26:03,890 are incurred during the final 21 days of life 6083 05:26:03,890 --> 05:26:06,792 and I thought that it was two-thirds in the final, 6084 05:26:06,792 --> 05:26:08,917 or half in the final year, its even worse than that. 6085 05:26:08,917 --> 05:26:11,917 It's two-thirds in the final 21 days 6086 05:26:12,952 --> 05:26:15,153 and the problem is we can't tell 6087 05:26:15,153 --> 05:26:18,737 who's gonna make it and who's not. 6088 05:26:18,737 --> 05:26:19,820 All right so, 6089 05:26:21,999 --> 05:26:23,666 shoot. - Mr. Sperazza 6090 05:26:25,074 --> 05:26:27,396 had a relatively good day yesterday. 6091 05:26:27,396 --> 05:26:31,015 As I gather you heard, there was a period where he 6092 05:26:31,015 --> 05:26:33,834 apparently recognized his wife and would respond 6093 05:26:33,834 --> 05:26:36,231 to commands to nursing and indeed at one point when I 6094 05:26:36,231 --> 05:26:40,411 went in, he would squeeze and release my hand on command 6095 05:26:40,411 --> 05:26:41,828 and was attentive 6096 05:26:43,018 --> 05:26:44,018 to his name. 6097 05:26:44,875 --> 05:26:47,288 So some improvement. 6098 05:26:47,288 --> 05:26:49,538 Mr. Sperazza, good morning. 6099 05:26:50,417 --> 05:26:52,084 How are you feeling? 6100 05:26:54,237 --> 05:26:56,237 Can you squeeze my hand? 6101 05:26:57,366 --> 05:26:59,449 Come on, squeeze it hard. 6102 05:27:00,922 --> 05:27:02,672 - Did he do it? - Yep. 6103 05:27:04,800 --> 05:27:07,996 Can you wiggle your toes, Mr. Sperazza? 6104 05:27:07,996 --> 05:27:11,279 Let's see you wiggle your toes. 6105 05:27:11,279 --> 05:27:12,696 Great, good work. 6106 05:27:25,901 --> 05:27:30,068 - [Female Doctor] You're doing good, Mr. Sperazza. 6107 05:27:36,577 --> 05:27:38,795 - You get him out of bed at all? 6108 05:27:38,795 --> 05:27:40,327 - Pardon me? - He get out of bed at all? 6109 05:27:40,327 --> 05:27:42,744 - Yeah. - He sat in the chair. 6110 05:28:18,304 --> 05:28:21,711 - [Bill] Squeeze my hand, Mr. Sperazza. 6111 05:28:21,711 --> 05:28:22,794 Mr. Sperazza? 6112 05:28:25,986 --> 05:28:28,736 Squeeze my hand, can you do that? 6113 05:28:32,999 --> 05:28:35,377 Okay, I'm gonna let you get some rest 6114 05:28:35,377 --> 05:28:38,377 and I'll come back to see you again. 6115 05:28:45,942 --> 05:28:49,208 - See they're questioning pneumonia in the right bay. 6116 05:28:49,208 --> 05:28:51,405 - He should probably actually go on chest PT again 6117 05:28:51,405 --> 05:28:53,795 but I'm sure they'll have more to say about that. 6118 05:28:53,795 --> 05:28:55,125 - That's when he died last time. 6119 05:28:55,125 --> 05:28:55,958 - Yeah. 6120 05:28:56,994 --> 05:29:00,850 - Chest PT and he stopped breathing, okay. 6121 05:29:00,850 --> 05:29:04,446 - His rate's been a little higher than it was, 38 to 40. 6122 05:29:04,446 --> 05:29:06,433 He definitely looks labored. 6123 05:29:06,433 --> 05:29:07,843 He looks like he did before 6124 05:29:07,843 --> 05:29:09,572 he respiratory arrested last time. 6125 05:29:09,572 --> 05:29:11,006 - He's using his belly and stuff? 6126 05:29:11,006 --> 05:29:15,339 - Yeah, asynchronous breathing and that kinda stuff. 6127 05:29:18,202 --> 05:29:19,700 - So if he just stops breathing, 6128 05:29:19,700 --> 05:29:21,857 we just let him stop breathing? 6129 05:29:21,857 --> 05:29:24,107 - Mm hmm. - That's so weird. 6130 05:29:42,540 --> 05:29:44,290 - Can you squeeze it? 6131 05:29:45,240 --> 05:29:46,573 Squeeze my hand? 6132 05:30:07,272 --> 05:30:10,396 - I've seen people come back from this. 6133 05:30:10,396 --> 05:30:14,243 It's just that the odds are really against him 6134 05:30:14,243 --> 05:30:16,766 in terms of his coming back from it and there's still 6135 05:30:16,766 --> 05:30:19,014 a possibility that some of this could be metabolic things. 6136 05:30:19,014 --> 05:30:22,875 But I have seen some people come back from it. 6137 05:30:22,875 --> 05:30:23,792 I mean not, 6138 05:30:25,855 --> 05:30:29,706 the chances are with all of his problems, 6139 05:30:29,706 --> 05:30:32,212 you're looking at a less than 6140 05:30:32,212 --> 05:30:35,614 5% six month survival at the very best 6141 05:30:35,614 --> 05:30:39,177 and probably much worse than that. 6142 05:30:39,177 --> 05:30:40,335 (phone ringing) 6143 05:30:40,335 --> 05:30:43,085 - [Nurse] Medical Intensive Care. 6144 05:30:56,105 --> 05:30:59,105 - Okay, just gonna do this side now. 6145 05:30:59,993 --> 05:31:02,993 I'm gonna put your oxygen over here. 6146 05:31:03,882 --> 05:31:05,465 Can you look at me? 6147 05:31:08,842 --> 05:31:09,675 Sorry. 6148 05:31:15,094 --> 05:31:16,094 Cough it up. 6149 05:31:20,681 --> 05:31:21,882 There's your oxygen. 6150 05:31:21,882 --> 05:31:25,965 Now don't shake it off, just keep it right there. 6151 05:31:31,264 --> 05:31:34,316 No, don't taste it, it tastes gross. 6152 05:31:34,316 --> 05:31:36,899 Keep your tongue in your mouth. 6153 05:31:39,842 --> 05:31:40,842 - Ow. - What? 6154 05:31:41,963 --> 05:31:43,380 Put your chin up. 6155 05:31:49,968 --> 05:31:52,507 This tube hurts, huh? - Yeah. 6156 05:31:52,507 --> 05:31:54,243 - Yeah, I know. 6157 05:31:54,243 --> 05:31:55,076 Good. 6158 05:32:25,051 --> 05:32:25,968 - You know, 6159 05:32:27,084 --> 05:32:29,489 this is where sort of clinical epidemiology 6160 05:32:29,489 --> 05:32:31,616 and clinical medicine sorta don't intersect. 6161 05:32:31,616 --> 05:32:33,616 If you take 1,000 people 6162 05:32:34,682 --> 05:32:39,682 and you do these incredibly dangerous interventions to them, 6163 05:32:40,280 --> 05:32:43,105 statistically a rare one or two 6164 05:32:43,105 --> 05:32:45,938 or three end up with a bad outcome 6165 05:32:48,219 --> 05:32:51,464 without any apparent, because it's high risk. 6166 05:32:51,464 --> 05:32:54,831 Think about the stuff that we're doing. 6167 05:32:54,831 --> 05:32:57,593 Taking away somebody's bone marrow and then 6168 05:32:57,593 --> 05:33:00,664 giving them mega-doses of chemotherapy and then 6169 05:33:00,664 --> 05:33:04,811 infusing it back into them or giving them six 6170 05:33:04,811 --> 05:33:09,302 toxic chemotherapeutic agents in sequence and 6171 05:33:09,302 --> 05:33:11,660 watching their white count disappear and sure, 6172 05:33:11,660 --> 05:33:15,577 you may get away with it 900 times or 990 times 6173 05:33:16,528 --> 05:33:20,027 out of 1,000 but there are gonna be a few people 6174 05:33:20,027 --> 05:33:24,602 who are gonna have an incredibly, and the other thing, 6175 05:33:24,602 --> 05:33:27,424 the other thing is the way a lot of 6176 05:33:27,424 --> 05:33:30,412 chemotherapy is presented to people too. 6177 05:33:30,412 --> 05:33:32,906 Take a guy with cell carcinoma in the lungs, 6178 05:33:32,906 --> 05:33:35,579 you can say to that person well, 6179 05:33:35,579 --> 05:33:37,900 we can double your life expectancy. 6180 05:33:37,900 --> 05:33:40,380 We can take you from living three months 6181 05:33:40,380 --> 05:33:43,053 with no chemotherapy to living six months 6182 05:33:43,053 --> 05:33:46,123 with chemotherapy but for that six months, 6183 05:33:46,123 --> 05:33:47,993 you won't be able to swallow anything because your 6184 05:33:47,993 --> 05:33:51,543 mouth will be raw, you'll be constantly in the hospital 6185 05:33:51,543 --> 05:33:55,543 and infected and, but you'll live twice as long. 6186 05:33:56,966 --> 05:33:59,546 But that's not the way it's presented. 6187 05:33:59,546 --> 05:34:01,160 You don't present it to a person, 6188 05:34:01,160 --> 05:34:03,476 well yeah, we're gonna have you live twice 6189 05:34:03,476 --> 05:34:06,276 as long but there's a morbidity associated with 6190 05:34:06,276 --> 05:34:11,275 living twice as long or you can live short and sweet and-- 6191 05:34:11,686 --> 05:34:14,394 - That's a fallacy, it isn't short and sweet. 6192 05:34:14,394 --> 05:34:16,211 That man with cell carcinoma 6193 05:34:16,211 --> 05:34:18,372 is in marked respiratory distress. 6194 05:34:18,372 --> 05:34:20,544 I mean I buy your argument-- - Maybe he gets two months 6195 05:34:20,544 --> 05:34:22,206 and then you give him morphine but-- 6196 05:34:22,206 --> 05:34:23,860 - That may be. 6197 05:34:23,860 --> 05:34:25,390 - [Scott] You know-- 6198 05:34:25,390 --> 05:34:27,223 - But I mean you know, 6199 05:34:28,165 --> 05:34:30,111 it's not like you live well with 6200 05:34:30,111 --> 05:34:33,083 untreated cancer until the day you die. 6201 05:34:33,083 --> 05:34:38,083 You're in horrible pain and worsening respiratory status. 6202 05:34:38,576 --> 05:34:42,751 - There may be pain, maybe not, you can treat the pain. 6203 05:34:42,751 --> 05:34:43,584 But 6204 05:34:47,185 --> 05:34:50,852 no risk is zero, no risk in medicine is zero 6205 05:34:52,777 --> 05:34:56,694 and the problem you see is that the culture, 6206 05:34:56,694 --> 05:35:00,260 we blind ourselves to all of that stuff because we have to. 6207 05:35:00,260 --> 05:35:02,950 Because you have to be a true believer, 6208 05:35:02,950 --> 05:35:04,986 you have to believe in this stuff to do it. 6209 05:35:04,986 --> 05:35:08,531 If you didn't believe that this stuff would work, 6210 05:35:08,531 --> 05:35:10,891 why would you do it? 6211 05:35:10,891 --> 05:35:14,495 Faced with Larry Shuleman's dilemma, 6212 05:35:14,495 --> 05:35:17,275 a 38 year old woman with three kids, 6213 05:35:17,275 --> 05:35:19,907 well you have a choice of doing nothing and watching 6214 05:35:19,907 --> 05:35:24,212 her die over the course of a year or doing something-- 6215 05:35:24,212 --> 05:35:27,285 - [Doctor] For a small chance of survival. 6216 05:35:27,285 --> 05:35:29,273 - Right, I mean you know-- 6217 05:35:29,273 --> 05:35:32,095 - [Doctor] I agree with his choice. 6218 05:35:32,095 --> 05:35:34,565 - Well it's hard not to do the other thing 6219 05:35:34,565 --> 05:35:36,652 but I think the problem is when you do do that, 6220 05:35:36,652 --> 05:35:41,402 then you sometimes end up shortening some people's lives. 6221 05:35:44,940 --> 05:35:47,773 So it's a no-win because it's not, 6222 05:35:48,691 --> 05:35:50,217 it's manipulating things when you don't 6223 05:35:50,217 --> 05:35:52,929 really have an awful lot to manipulate. 6224 05:35:52,929 --> 05:35:55,213 In the short term-- - We always-- 6225 05:35:55,213 --> 05:35:58,446 - Who's got the better prognosis, Mrs. Factor or-- 6226 05:35:58,446 --> 05:36:00,817 - Or an AIDS patient? - No, this lady. 6227 05:36:00,817 --> 05:36:01,978 - [Doctor] In the short term, 6228 05:36:01,978 --> 05:36:04,010 Mrs. Factor has a better prognosis. 6229 05:36:04,010 --> 05:36:05,522 On the other hand I believe ICUs are 6230 05:36:05,522 --> 05:36:08,060 for this lady, not for Mrs. Factor frankly. 6231 05:36:08,060 --> 05:36:09,423 - [Scott] But why? 6232 05:36:09,423 --> 05:36:12,246 - It's an age-prejudice that I cannot beat. 6233 05:36:12,246 --> 05:36:15,531 - That's ageist. - It is ageist. 6234 05:36:15,531 --> 05:36:19,523 It isn't age though, it's just her disease. 6235 05:36:19,523 --> 05:36:22,177 - [Scott] Right it's an emotional response to the situation. 6236 05:36:22,177 --> 05:36:25,120 Here's this 38 year old lady, she's got three kids. 6237 05:36:25,120 --> 05:36:26,113 - [Doctor] No no no, 6238 05:36:26,113 --> 05:36:29,188 but I don't believe Mrs. Factor can never be cured. 6239 05:36:29,188 --> 05:36:32,736 I cannot fix hypertrophic cardiomyopathy and bad lungs. 6240 05:36:32,736 --> 05:36:35,554 - Pleural mesothelioma can never be cured either. 6241 05:36:35,554 --> 05:36:37,924 - Unless you believe as oncologists believe 6242 05:36:37,924 --> 05:36:41,300 that she has a one in a million chance of survival 6243 05:36:41,300 --> 05:36:45,215 with this chemo surgery plan for her. 6244 05:36:45,215 --> 05:36:47,243 - [Scott] But you see I think it's important-- 6245 05:36:47,243 --> 05:36:49,916 - You can't say that there's absolutely no hope for her. 6246 05:36:49,916 --> 05:36:52,044 - Yes, I would say that there is no hope for her. 6247 05:36:52,044 --> 05:36:54,525 In fact that her hope is less than Mrs. Factor 6248 05:36:54,525 --> 05:36:57,679 and in fact I think that borders on the same kind of 6249 05:36:57,679 --> 05:37:02,512 religious faith that you know, I happen to believe in God. 6250 05:37:03,861 --> 05:37:08,474 I have very strong faith in a Supreme Being and yet 6251 05:37:08,474 --> 05:37:10,141 I'd have to say that 6252 05:37:11,726 --> 05:37:16,393 belief in that is exactly the same sort of blind faith-- 6253 05:37:17,464 --> 05:37:20,303 - [Doctor] Some mesothelioma patients are cured. 6254 05:37:20,303 --> 05:37:23,886 - Yes but much more commonly pleural, sure. 6255 05:37:25,659 --> 05:37:28,054 But you have to think about what kind of cases. 6256 05:37:28,054 --> 05:37:30,050 They're not pleuro mesotheliomas like this. 6257 05:37:30,050 --> 05:37:33,692 - If you really believe that there's no hope, 6258 05:37:33,692 --> 05:37:37,051 then this chemo is a farce and cruel 6259 05:37:37,051 --> 05:37:39,534 and this ICU stay is a farce and cruel. 6260 05:37:39,534 --> 05:37:41,525 - [Scott] Well... 6261 05:37:41,525 --> 05:37:43,442 - I can't believe that. 6262 05:37:44,962 --> 05:37:46,502 - [Scott] Right, I mean I think-- 6263 05:37:46,502 --> 05:37:49,280 - I cannot stay up all night with this lady and plug her 6264 05:37:49,280 --> 05:37:51,774 and get excited about DIC improving and all this stuff-- 6265 05:37:51,774 --> 05:37:53,179 - [Scott] You cannot do what you have to do-- 6266 05:37:53,179 --> 05:37:54,524 - That's right. - If you believe that. 6267 05:37:54,524 --> 05:37:56,099 That's exactly what I'm saying, you have to believe in it. 6268 05:37:56,099 --> 05:38:00,429 - And I can't actually be a doctor for most of my patients 6269 05:38:00,429 --> 05:38:02,012 because you know... 6270 05:38:02,924 --> 05:38:05,341 - That's part of the problem. 6271 05:38:10,114 --> 05:38:11,984 I think that's part of the problem because 6272 05:38:11,984 --> 05:38:15,139 I really do believe that from the moment that diagnosis 6273 05:38:15,139 --> 05:38:19,749 was made, it's like in Treasure Island you know when 6274 05:38:19,749 --> 05:38:22,706 the old Captain gets handed the black spot, 6275 05:38:22,706 --> 05:38:25,206 she got handed the black spot. 6276 05:38:26,279 --> 05:38:29,971 She was called and we're minor actors-- 6277 05:38:29,971 --> 05:38:32,696 - So therefore we shouldn't put active-- 6278 05:38:32,696 --> 05:38:34,354 - [Scott] I don't say you shouldn't do it. 6279 05:38:34,354 --> 05:38:37,045 I think that it's important to recognize that look, 6280 05:38:37,045 --> 05:38:39,574 I said put in the swan. 6281 05:38:39,574 --> 05:38:42,682 But I think it's important to recognize the reality 6282 05:38:42,682 --> 05:38:46,020 of what the situation is. - Oh yeah. 6283 05:38:46,020 --> 05:38:49,603 When you first diagnose a patient like her, 6284 05:38:50,489 --> 05:38:51,945 you know-- 6285 05:38:51,945 --> 05:38:53,981 - I think that doctors-- - Your heart sinks. 6286 05:38:53,981 --> 05:38:56,399 But you can't just give up on her. 6287 05:38:56,399 --> 05:39:00,282 You aren't doing her a favor by giving up on her either. 6288 05:39:00,282 --> 05:39:04,610 - See you say it's giving up, you say it's giving up on her. 6289 05:39:04,610 --> 05:39:06,911 Well maybe it is giving up on her. 6290 05:39:06,911 --> 05:39:08,949 That's one view of it. 6291 05:39:08,949 --> 05:39:12,935 That view would suggest that we have something to offer. 6292 05:39:12,935 --> 05:39:15,508 But what I'm saying is that it's 6293 05:39:15,508 --> 05:39:18,425 not clear we have anything to offer 6294 05:39:19,422 --> 05:39:22,172 and in fact what, for the system, 6295 05:39:23,371 --> 05:39:26,708 because you know I think I very well might 6296 05:39:26,708 --> 05:39:28,902 have done the same thing that Larry did but 6297 05:39:28,902 --> 05:39:30,933 I think it's important to recognize 6298 05:39:30,933 --> 05:39:32,506 that the system probably shortened her life. 6299 05:39:32,506 --> 05:39:36,971 There are some things that are just bigger than us 6300 05:39:36,971 --> 05:39:40,881 and doctors in this day and age are extremely 6301 05:39:40,881 --> 05:39:44,275 reluctant to say "We can't do anything for that. 6302 05:39:44,275 --> 05:39:47,227 "We have no way to help that yet." 6303 05:39:47,227 --> 05:39:49,977 I don't know you know, it's hard. 6304 05:39:52,423 --> 05:39:55,340 But I mean so much of this stuff is 6305 05:39:59,025 --> 05:40:02,693 heavy flail for relatively small to no gain. 6306 05:40:06,970 --> 05:40:10,595 I mean a number of people, having built this thing, 6307 05:40:10,595 --> 05:40:14,178 I have serious questions as to its utility. 6308 05:40:15,282 --> 05:40:17,532 - Oh yeah, I mean you know, 6309 05:40:18,444 --> 05:40:21,305 in all the months that I've been here, 6310 05:40:21,305 --> 05:40:25,731 three years in a row, there aren't very many patients 6311 05:40:25,731 --> 05:40:29,582 who you actually sort of help save their life, 6312 05:40:29,582 --> 05:40:31,582 make a major difference. 6313 05:40:33,159 --> 05:40:35,022 - We know that everybody who rolls 6314 05:40:35,022 --> 05:40:38,154 through that door looks bad, they look bad. 6315 05:40:38,154 --> 05:40:41,978 They could go anytime but we can't tell you when. 6316 05:40:41,978 --> 05:40:43,561 That's the problem. 6317 05:40:45,441 --> 05:40:50,274 I don't know, there's nothing more discouraging than this. 6318 05:40:52,041 --> 05:40:56,541 The psychological toll on us and on the family is just 6319 05:41:00,183 --> 05:41:01,183 really grim. 6320 05:41:21,257 --> 05:41:24,790 - Wish I had somewhere to put this. 6321 05:41:24,790 --> 05:41:28,540 I'm gonna put this on top here, is that okay? 6322 05:41:32,257 --> 05:41:35,612 Yeah just, yeah can you hold onto that? 6323 05:41:35,612 --> 05:41:37,195 Yeah, okay hold it. 6324 05:41:47,779 --> 05:41:49,841 Now okay, I can put it up here. 6325 05:41:49,841 --> 05:41:52,581 We can take a table with us too. 6326 05:41:52,581 --> 05:41:53,498 Here we go. 6327 05:41:54,773 --> 05:41:55,606 Okay. 6328 05:42:03,436 --> 05:42:05,436 Can you get that? - Yeah. 6329 05:42:09,530 --> 05:42:12,780 (patient moans) - What? 6330 05:42:31,587 --> 05:42:32,825 Okay. 6331 05:42:32,825 --> 05:42:35,408 (loud buzzing) 6332 05:42:51,323 --> 05:42:53,739 (chattering) 6333 05:43:02,573 --> 05:43:05,845 - [Doctor] Otherwise it's a pretty simple situation. 6334 05:43:05,845 --> 05:43:10,684 - [Scott] Right but as with everything you do, there's 6335 05:43:10,684 --> 05:43:15,267 the potential that this is gonna be counter-beneficial. 6336 05:43:20,028 --> 05:43:24,361 - [Doctor] But then I would settle more on an x-ray. 6337 05:43:25,541 --> 05:43:27,708 - [Scott] Agree with that. 6338 05:43:37,179 --> 05:43:40,717 - Other issues, substantial metabolic alkalies have 6339 05:43:40,717 --> 05:43:45,384 switched, it seemed to be reaching and well-compensated. 6340 05:43:46,676 --> 05:43:50,759 - [Nurse] Medical Intensive Care, can I help you? 6341 05:44:12,543 --> 05:44:13,876 - Open this bag. 6342 05:44:20,012 --> 05:44:21,585 - [Technician] Did you get ahold of the funeral home? 6343 05:44:21,585 --> 05:44:23,010 - Yes I did. 6344 05:44:23,010 --> 05:44:25,593 Yes I did, thank you very much. 6345 05:44:34,858 --> 05:44:39,658 - [Technician] Keep it on that side, just take the sheets. 6346 05:44:39,658 --> 05:44:40,991 One, two, three. 6347 05:44:49,569 --> 05:44:51,061 Check the tag. 6348 05:44:51,061 --> 05:44:53,265 - Oh yeah, it's the right one. 6349 05:44:53,265 --> 05:44:55,389 - [Technician] You don't wanna get home and find out-- 6350 05:44:55,389 --> 05:44:57,914 - Find out I got the wrong body. 6351 05:44:57,914 --> 05:44:59,081 Dorothy. - Yep. 6352 05:45:23,658 --> 05:45:25,408 - That's good. - Good. 6353 05:45:27,731 --> 05:45:32,564 - [Technician] She's gonna have to come down a little bit. 6354 05:45:36,607 --> 05:45:38,774 - The zipper doesn't work. 6355 05:45:40,814 --> 05:45:44,814 - You got your pins? - No, I don't have anything. 6356 05:45:53,004 --> 05:45:55,587 We're gonna go that way. - Okay. 6357 05:46:35,625 --> 05:46:37,835 Okay. - Take care, see ya. 6358 05:46:37,835 --> 05:46:39,364 - We'll see ya. - All set with your paperwork? 6359 05:46:39,364 --> 05:46:40,829 - Yeah, I got all my papers yeah. 6360 05:46:40,829 --> 05:46:42,996 Thank you very much, yeah.