PALLIATIVE CARE BY THE SURGEON Management of Dyspnea at the End of Life: Relief for Patients and Surgeons

I first met John, a 72-year-old retired professor, in the trauma room where he was brought after a motor vehicle crash while driving to his physician’s office. He was in severe respiratory distress with obvious chest trauma, multiple fractures, and an oxygen saturation of 86 % on oxygen mask. He was intubated and placed on mechanical ventilation with minimal improvement in his oxygen satura-tion. His workup revealed multiple rib fractures, pneumothorax, pulmonary contusion, and trau-matic brain injury. I spoke with his family during his resuscitation when they told me of his severe chronic obstructive pulmonary disease. He had been intermittently on steroids and home oxygen during the last 6 months. I was dismayed to hear the news, because I could already foresee a long complicated intensive care course for John if he survived, with a high likelihood that he would become ventilator dependent. John’s family mentioned an advance directive, which stated his wishes that he would not want to be ventilator dependent at the end of his life. During the first few days of his hospitalization I hoped that some of his pulmonary injury would be treatable and reversible, allowing him to be weaned from the ventilator. But after 10 days there was little progress or improvement. He became hypoxemic and tachypneic when the ventilator was weaned. I discussed John’s condition with his family again, an