So…the end of the line is near for my sister-in-law. Her breast cancer moved to the bones and now to her lungs. She’s been on a ventilator for the last 5 days and heavily sedated. The doctors said they will leave her on it for another couple days and then give her a tracheotomy and send her back to the nursing home for the final run.
I don’t understand the purpose of the tracheotomy. I was under the impression a trache was done if there was an obstruction that kept air from entering her lungs, as opposed to a ventilator, which forces the air into her lungs. If she’s no longer having air forced in and cannot breathe on her own, what good does the trache do? Also, she doesn’t have a DNR in place. Can they even take her off the ventilator? Won’t she suffocate?
Thanks for all responses, both medical and anectodal.
Speaking in generalities here… with my sympathies about the situation with your sister-in-law:
Endotracheal tubes (ET) - the kind that go in through the mouth or nose, through the vocal cords, and into the trachea - require a fairly intensive regimen of care to clear secretions, maintain oral hygeine, and ensure continued proper positioning. Many nursing homes will not accept patients with ET tubes for this reason. People with ET tubes almost always need to be kept sedated because the tube in the throat triggers the gag reflex and is uncomfortable. A tracheostomy tube is shorter, has a larger balloon cuff at the end, and enters the trachea via an incision below the vocal cords. A tracheostomy tube also requires continued nursing care, but it is much easier to manage than an ET tube. A trache causes less wear and tear on the tracheal lining, so if someone is going to require mechanical ventilation for a prolonged period (say, more than 10-14 days), a trache is usually recommended.
A person can breathe spontaneously through a tracheostomy tube, or it can be hooked up to a ventilator in the same way that an ET tube can - see Christopher Reeve. So, in a hypothetical situation, a person will need mechanical ventilation for the indefinite future. They can be ventilated through an ET tube, but this requires sedation so they will not gag/cough on the tube. If a tracheostomy is placed, mechanical ventilation can continue, but the person’s sedation can be lessened/stopped, allowing for wakefulness.
For patients who are unable to communicate their wishes and in the absence of a pre-existing living will or DNR order, decision-making normally falls to next-of-kin. So, in theory, if the doctors agree that her condition is terminal and her husband elected to remove the ventilator, it would likely be removed. This is not normally done for conscious patients. Depending on the situation, the ET tube or trach can be removed, or they may just be disconnected from the vent.
I’d be happy to answer any other questions you have if I can…
It would be nice to verify that the nursing home has expertise in hospice care.
Now, everyone go write your advanced directives, and discuss your preferences with your people.
When cancer is extensively, invasively metastasized to the bones, the pain is unbelievable, and the only real way to manage it is to basically put the person into a medically-induced state of oblivion.
Kalhoun- I am so sorry, this must be such a difficult time for you all and you have my sympathy.
I would imagine that the tracheostomy would be hooked up to a ventilator, and although it would prevent her from being able to speak, it would mean that she could be more comfortable and less heavily sedated, meaning that the family could have some time with her, knowing she was aware of their presence.
Although a tracheostomy is technically more invasive (i.e. involves a surgical incision), it is actually less invasive for the patient, and would be thought of as more a dignified option in terminal care.
Well…she was lucid for a short period of time yesterday. She communicated to her goddaughter that she wants out. Goddaughter called the nurse and she again communicated to her that she wants out. This is good, as her son was going to have to ask the painful question of her and he doesn’t have to do that now.
So the doctor has been notified and he will go through the legal steps to confirm that these are indeed her wishes. They said they’ll up the morphine and lower the ventilator down to nothing, and they assure us she will slip away painlessly. We’re hoping for that to happen today or tomorrow.
My mother in law has lost two children, her husband, her brother, and her sister-in-law in only 3 years. This is the third child (and also an adult grandchild) she’s had to bury. Life can sure stink sometimes.
Thanks, Missy2U. As I mentioned in my other thread, I now have to figure out how to actually say good bye to her. She will be conscious and doing her good-byes just before they turn off the respirator. I’m freaked to say the least. We were very close at one time. I’m at a total loss for how to handle it.
As Brossa aptly put it, speaking in generalities, and with my sympathies to your family, I have learned a little from having done this poorly. Hold your feelings of discomfort in abeyance. Ask your sister-in-law to share all she wants you to know, what she wants to say, how she feels. This is not the time to unburden your conscience; let her leave you in peace. Resist the desire to avoid asking her the difficult questions–this is the final gift you can give your sister-in-law. If you are able, ask what you can do for her now and when all is done–for her family, etc. And then, cry with her. May she, you, and all your family find peace as you move forward.