George L. had been on a breathing machine in the intensive care unit for 11 days. My resident ran through George’s complicated review of systems, then told me he would receive a tracheostomy, or “trach,” in the operating room on Day 14. “They had an opening in the schedule so we took it,” the resident reported, the pride of efficiency in his voice.

Temporary breathing tubes, which enter through the mouth, can cause damage to the delicate tissues of the throat. To mitigate this risk, a more permanent tube is surgically implanted through the neck at the Adam’s Apple, usually on or around the fourteenth day. I call this “the two-week trach point.” In addition to preventing damage, trachs are more stable, more comfortable, and easier to clean than temporary breathing tubes. Their secure placement makes it possible for patients to be moved to a less acute location, which is much more cost-effective. And so my resident’s forethought would likely save the health care system money.

For patients who have a good chance of recovery from their illness, the trach can be a lifesaver. Sometimes it takes longer than two weeks to regain strength and alertness enough to breathe on one’s own again. But for those patients who are dying or have almost no chance of returning to a quality of life they would find acceptable, it can be a trap.

Yet doctors tend to treat all patients — those destined for robust recovery and those approaching death — in the exact same way.

The information and consent process for the trach usually revolves around the risks of surgery — bleeding, infection, death — rather than the longer-term implications of the decision. For 66-year-old George, whose catastrophic CT scan foretold a future of severe neurologic compromise, his future with a trach would most likely include permanent attachment to a breathing machine, a feeding tube sewn into his stomach, and arm restraints to prevent dislodgment of these tubes.

George might remain alive in this condition for weeks, months, or even years. He would probably never eat again, nor interact with his family and friends. But his family had no idea. They thought that the trach would help cure George. (…) Read Full Article Here

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