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April 16, 2018

Saving a Death When We Cannot Save a Life in the Intensive Care Unit

Author Affiliations
  • 1Division of Pulmonary and Critical Care Medicine, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, and Biomedical Ethics Program, Mayo Clinic, Rochester, Minnesota
JAMA Intern Med. Published online April 16, 2018. doi:10.1001/jamainternmed.2018.1198

A 64-year-old woman came to the intensive care unit (ICU) with severe abdominal pain, a blockage in her large intestine due to metastatic colon cancer, and sepsis. Six months prior, she had experienced a nearly identical episode that was treated with placement of a palliative stent to relieve the blockage in her intestine. She was not currently ready to die—and she asked us to do everything we could to give her any additional weeks or months of life. She thought this could be possible because her previous stent had given her 6 months of good-quality life at home. We decided to pursue a colonoscopy to see if there was anything we could do. We electively intubated her prior to colonoscopy in the setting of evolving shock, lactic acidosis, respiratory distress, and high risk for aspiration. Unfortunately, her colonoscopy revealed acute, diffuse, and severe ischemic colitis in addition to complete obstruction of the stent. Neither endoscopic intervention nor surgery would prevent death. She subsequently developed hypoxic respiratory failure—and we were left wondering whether we could possibly extubate her.

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