According to the right-to-die laws of most states, a patient has the right to refuse extraordinary life-supporting measures if he has no hope of recovery. If the patient can’t make this decision, the patient’s next of kin is usually permitted to decide if life support should continue. A written statement of the patient’s wishes is always preferable. Because of the Patient Self-Determination Act, each health care facility is required to ask the patient upon admission if he has an advance directive. (See “Advance directive,” pages 9 to 11.) An advance directive is a statement of the patient’s wishes that becomes valid if he’s unable to make decisions for himself. An advance directive may include a living will, which goes into effect when the patient can’t make decisions for himself, as well as a durable power of attorney for health care, which names a designated person to make health care decisions when the patient can’t. The Patient Self-Determination Act also states that the patient must receive written information concerning his right to make decisions about his medical care.

If life support is to be terminated, read the patient’s advance directive to ensure that the present situation matches the patient’s wishes, and verify that the risk manager has reviewed the document. Allow adequate time for the family to interact with the medical staff to ensure their questions and concerns are addressed. Check that the appropriate consent forms have been signed. Ask the patient’s family whether they would like to see the chaplain and whether they would like to be with the patient before, during, and after life-support termination.

Thoracentesis involves the aspiration of fluid or air from the pleural space. It relieves pulmonary compression and respiratory distress by removing accumulated air or fluid that results from injury or such conditions as tuberculosis and cancer. It also provides a specimen of pleural fluid or tissue for analysis and allows the instillation of chemotherapeutic agents or other drugs into the pleural space.

Thrombolytic drugs are used to dissolve a preexisting clot or thrombus, commonly in an acute or emergency situation. Some of the thrombolytic drugs currently used include alteplase, reteplase, anistreplase, and
streptokinase. Thrombolytic drugs are used to treat acute myocardial infarction, pulmonary embolism, acute ischemic stroke, deep vein thrombosis, arterial thrombosis, arterial embolism, and to clear occluded arteriovenous and I.V. cannulas. Patients receiving these drugs must be closely monitored for bleeding and allergic reactions.

Tracheostomy care is performed to ensure airway patency of the tracheostomy tube by keeping it free from mucus buildup, maintain mucous membrane and skin integrity, prevent infection, and provide psychological support. The patient may have one of three types of tracheostomy tubes: uncuffed, cuffed, or fenestrated. An uncuffed tracheostomy tube, which may be plastic or metal, allows air to flow freely around the tube and through the larynx, reducing the risk of tracheal damage. A cuffed tube, made of plastic, is disposable. The cuff and the tube won’t separate accidently because they’re bonded. A cuffed tube also doesn’t require periodic deflating to lower pressures, and it reduces the risk of tracheal damage. A fenestrated tube, also made of plastic, permits speech through the upper airway when the external opening is capped and the cuff is deflated. It also allows easy removal of the inner cannula for cleaning. However, a fenestrated tracheostomy tube may become occluded. When using any one of these tubes, use aseptic technique to prevent infection until the stoma has healed. When caring for a recently performed tracheotomy, use sterile gloves at all times. After the stoma has healed, clean gloves may be used.

On occasion, mucus may obstruct a tracheostomy tube, causing occlusion. When suctioning or withdrawing the inner cannula doesn’t clear an occluded tube, follow your facility’s policy. Stay with the patient while someone else calls the doctor or appropriate code. Continue to try to ventilate the patient using whichever method works; for example, a handheld resuscitation bag. Don’t remove the tracheostomy tube entirely because doing so may close the airway completely.

Tracheostomy suctioning involves the removal of secretions from the trachea or bronchi by means of a catheter inserted through the tracheostomy tube. In addition to removing secretions, tracheostomy suctioning also stimulates the cough reflex. This procedure helps maintain a patent airway to promote the optimal exchange of oxygen and carbon dioxide and to prevent pneumonia that results from pooling of secretions. Requiring strict sterile technique, tracheostomy suctioning should be performed as frequently as the patient’s condition warrants.