There is nothing worse for the family of critically ill patients to receive contradictory information from different physicians. It causes an obvious distress among family members and very often leads to a “whom to believe” situation.

Situations like that are not uncommon when the patient after a complicated surgical procedure becomes critically ill and is being admitted to ICU. Sometimes, when recovery is unlikely and the patient or the family is requesting withdrawal of care, the surgeon declines to proceed to comfort measures only approach and insists on aggressive treatment.
Intensivists and Hospitalists taking care of these patients in ICU are often caught in the “crossfire” between family members and the surgeon.

A very interesting study conducted in Wisconsin and published in the Critical Care Medicine Journal examines the process of a surgical “buy-in”, or the nature of the contractual obligations between surgeons and their patients.

The authors describe the potential “obstacles” towards accepting the withdrawal of care by the surgeon. The feelings of guilt and failure by the surgeon in a case of an unexpected poor outcome were likely contributing to the failure to accept it. A poor outcome after an elective procedure had an even heavier emotional toll. This was in contrast to the medical doctor who often views a failure of treatment as failure of the patient or disease to respond to therapy.

Surgeons often assume, according to this study, that obtaining consent for the surgery could be viewed as a surrogate for bi-directional contract, with the patient agreeing to adhere to the postoperative care even if complications occur.

In my practice I have had to deal with situations when the patient is dying, yet the surgeon is refusing to accept the inevitable. Ultimately, it is the patient who is suffering, having to go through unnecessary and often futile treatment.

On the flip side of this problem, I cannot claim that I am always right and the surgeon is just refusing to see the obvious. I have been wrong about the outcome before and having somebody on the team with an opposite view on the outcome might, actually, be a good thing. After all, medicine is not an exact science.

There is no doubt that Vitamin D and calcium, both found in milk, are important for your health. Vitamin D regulates calcium content in the skeletal system and is essential for strong healthy bones.

Recently, there has been an increased interest in Vitamin D and Calcium supplementation to maintain general health and to modify so-called cardiometabolic outcomes including high blood pressure, diabetes and coronary artery disease.

It is know that Vitamin D has a significant role in our body beyond just the skeletal system. Vitamin D is important in regulating vascular tone, fluid status via the renin-angiotensin system, anticoagulant activity and insulin resistance. All of these mechanisms play a pivotal role in developing hypertension, diabetes and coronary artery disease.

It was shown in several studies that patients with low Vitamin D levels are at a higher risk for coronary artery disease. It is logical to assume that supplementing Vitamin D and Calcium will decrease your risk of developing heart disease. More and more patients are started on Vitamin D and Calcium for that reason.

How strong is the evidence to support Vitamin D with or without Calcium to protect against the number one killer – coronary artery disease?

Surprisingly, the evidence is quite scant. Two recent articles published in the Annals of Internal Medicine provide a thorough review of the available literature.

After reviewing multiple publications the authors of the first study concluded that as a whole, there is not enough evidence to support Vitamin D supplementation to improve cardiometabolic outcomes including hypertension, diabetes and coronary artery disease.

It was suggested that, possibly, Vitamin D status is a marker of good health including positive associations with young age, normal body weight and healthy lifestyle, which would independently decrease your risk for heart disease. There is also a negative association between Vitamin D levels and a history of smoking, family history of heart disease and alcohol intake. It does not mean, though, that increasing Vitamin D intake will positively affect the outcome.

The authors of the second paper took a slightly different approach. They looked at Vitamin D AND Calcium supplementation for the prevention of cardiovascular disease.

The authors concluded that Vitamin D supplementation may have a beneficial effect on the risk for coronary artery disease in the general population (the keyword here is may). Calcium supplementation has no apparent effect on cardiovascular disease risk. The authors also emphasized that very few studies, actually, investigated the effect of Vitamin D and calcium supplements on the risk for heart disease in the general population.

As a physician, I recommend Vitamin D and Calcium to my patients to maintain stronger bones. More positive evidence is needed before I can recommend it as a prophylaxis against heart disease.

Organ donation is a very complicated and involved process. The essential part of this process is organ procurement or the process of taking organs out of the organ donor body.

According to the “Dead Donor Rule” the donor should be declared dead prior to organ donation rather than dying as a result of donation. Otherwise, it would be unethical or even criminal to harvest the organs.

How do you define death for organ donation?

The patient may be pronounced brain dead prior to donation. This means that no brain activity or measurable blood flow to the brain can be detected. The diagnosis of brain death is usually made on clinical grounds with an optional confirmatory test like a nuclear medicine brain perfusion scan.

If the patient is not brain dead, donation is still possible via a “Donation after Cardiac Death” (DCD) protocol. The essence of this approach is for the patient to be pronounced dead based on the cessation of circulatory and respiratory functions, assuming that brain death is imminent after that.

In the real world if DCD is pursued, the patient would be taken to the Operating Room where life support will be removed. The physician will have to document the cessation of the respiratory function and mechanical asystole (lack of heart contractions) for 2 to 5 minutes depending on the Hospital protocol.

Mechanical asystole means a lack of heart contractions and circulation. The patient still might have electrical activity in the heart. Lack of heart contractions associated with the electrical activity (pulsless electrical activity) is sufficient to declare death.

Lack of cardiac contractility is documented by the absence of Doppler flow over the arteries, absence of blood flow through the aortic valve on a cardiac ECHO, or by documenting the lack of circulation by an invasive arterial cannula.

The usual sequence of events, once the life support is removed, is respiratory arrest leading to cardiovascular collapse. The lack of breathing and circulation should be observed for at least 2 to 5 minutes before organs should be taken. This is necessary to assure that an “auto-resuscitation” or spontaneous return of vital functions does not occur.

This is a somewhat superficial and simplified review of the declaring dead process for organ donation. Educating the public about organ donation, death and organ procurement is an essential step to improve the rate of consent for organ donation.

There are more than 100,000 people on a transplant waiting list in the US alone. Each year, only about a quarter of these patients will receive life saving transplants because of the significant shortage of organ donors. Thousands of patients on the transplant list die every year without a chance to receive an organ. The gap between the number of patients awaiting transplant and the number of organs available continues to widen.

Obtaining family consent for organ donation is a crucial rate-limiting step towards successful donation. The lack of understanding of the organ donation and organ procurement process by the families’ of the potential organ donors is one of the barriers.

A study conducted in Texas and published in the Journal of Trauma indicates that only 57% of families consent for organ donation. There were several specific barriers towards giving consent for donation identified by this study:

#1 Ethnicity
Hispanic families were four times less likely to give consent for donation. African-American families were seven times more likely to decline donation. During the past 20 years, African Americans and Hispanics represent only 12% and 11% of organ donors. Lack of understanding of brain death and the organ donation process were considered the likely explanation by the authors of this study. Specific approaches focusing on minority groups might improve the donation rates among minorities.

#2 Age and cause of death of the patient.
Older age (aged 50 years or older) and a medical cause of death of the potential organ donor were independent predictors for the failure to consent for organ donation by the family. The authors of this study indicated that the families of older patients would likely consider organ donation to be out of the realm of possibility. Many families were also unaware of the patient’s previous wishes and attitudes towards organ donation. It was found in the previous studies that the knowledge of a patient’s preference to donate increased the likelihood of donating by seven times. Efforts to improve donor designation, including the DMV organ donor program, might improve organ donation rates.

#3 Circumstances surrounding the request for consent
It was found that the sooner the family is approached about organ donation the higher the chances of obtaining the consent. Also, being approached by a member of the OPO (organ procurement organization) team, rather than by an independent member of the healthcare team also increased the rate of donation. Some large medical centers only allow specially trained individuals to approach the family about organ donation.

In conclusion, the rates of organ donation remain suboptimal. Identifying and eliminating barriers for successful organ donation will save thousands of lives every year.

Admission to the Intensive Care Unit is a major stressor for the patient’s family and friends. Dealing with the patient’s family is an essential part of the ICU physician’s practice and recognizing the emotional phases that the family is going through will facilitate communication and decision making.

Every family is different. The way the family will cope with the critical illness of their loved one, to a large extent, depends on the family’s personality. Regardless, most families are going through three distinct phases:

Phase #1: the Shock Phase
The patient is being admitted to the ICU in critical condition. The family is just getting the news. People start showing up in the ICU without a clear understanding of what is going on. Anxiety, confusion and uncertainty are at a heightened level and some people are simply too overwhelmed to comprehend and respond appropriately to the situation. Depending on the patient’s condition, over the next day or so, the family members might be sleeping in the waiting room and keeping a 24 hour vigil in the ICU. The family members will be exhausted, stressed and overwhelmed. This should be considered when trying to make important decisions regarding the patient’s care. The information should be communicated in a concise and easy to understand manner.

Phase #2 the Adjustment Phase
The gravity of the situation will start sinking in. At the same time, the family will start adjusting to the fact that recovery might take time and life is going on. The family members will be trickling in and out. The key family members (husband, wife, parents, children) will, actually, be able to get some rest. The family members will have a better understanding of the disease process and will focus on supporting their loved one. This is a better time to make important medical decisions including withdrawal of care.

Phase #3: the Exhaustion Phase
For some patients recovery takes time and the patient might need to spend days if not weeks in the Intensive Care Unit. This, surely, takes it’s toll on the family as well. The family wants to see signs of improvement and recovery and if this is not happening, a realistic prognosis should be communicated to the family. This also a good time to discuss placement or transfer to an outside facility (nursing home, ventilator facility etc.) if discharging the patient home is not a viable option. Establishing a good relationship and regular updates to the family are very important to facilitate transition to a subacute environment.

Therapeutic Hypothermia (TH) or intentional cooling of the human body was found to be beneficial after a person survives a cardiac arrest. Cardiac arrest, by definition, is a lack of adequate blood flow to the vital organs in the body due to a cessation of heart pumping function. The lack of blood and oxygen supply to the organs could lead to a severe and irreversible damage.

Our brain is the most sensitive organ to a lack of oxygen supply. Just a few minutes of no blood flow to the brain could lead to anoxic encephalopathy or brain damage from the lack of oxygen. Anoxic encephalopathy has a spectrum of manifestations. In it’s most severe form, the patient never regains consciousness and remains in a permanent vegetative state. The less severe forms of this condition may lead to disturbances with memory, cognition and emotions etc.

It has been recognized that it is possible to “protect” the brain from the harmful effects of anoxia (lack of oxygen) by slowing down it’s metabolism. One of the ways to do it is to cool the brain down. Cooling just the brain is technically difficult but not impossible. Recent research suggests that just the brain can be cooled off by using intranasal cooling (cooling through the patient’s nose). Cooling the whole body including the brain is more feasible.

There are two main methods of cooling: external and internal. External cooling is achieved by applying ice packs, cooling blankets and special cooling pads to the surface of the body. The internal cooling method is by using cold intravenous fluids and inserting special cooling catheters into the bloodstream to cool the patient’s blood directly. Using both methods at the same time is the most effective technique.

Medical literature supports cooling after cardiac arrest to improve recovery and survival. Unfortunately, the adoption of this treatment modality in the clinical practice has been slow. There are multiple barriers including complexity and labor intensity associated with the institution of therapeutic hypothermia.

A recent paper published in the Journal of Trauma, suggest that hypothermia may also attenuate acute lung injury associated with hemorrhagic shock (shock due to bleeding). By modulating the inflammatory response caused by severe bleeding, hypothermia decreased the incidence of lung injury in rats. This was an animal study and the real life clinical study needs to be conducted to confirm the results.

Yet, it is becoming obvious that therapeutic hypothermia has it’s role in treating critically ill patients. The indications for using hypothermia will likely be expanded in the years to come. More effective and sophisticated cooling methods might also expand it’s use by providing more rapid and controlled cooling.