I spent the last week in the “VDU” which is short for “Ventilator-Dependent Unit”. It is a unique ward that could be described as a combination of an in-hospital LTAC and a palliative care unit. One of the primary purposes is ventilator weaning, both for patients that are able to be weaned off the ventilator while in the hospital and for those who are ventilator-dependent now requiring 24 hr care. The latter group of patients are destined for home as there are no LTACs that can care for patients on ventilators in Chiang Mai. The time they spend in the VDU (usually about a month) is focused on training the family to provide all of the care the patient will need at home. Some families are able hire a home care provider (e.g. nursing assistant) to help but most will take on the responsibilities themselves.
The resident I was working with that day received two new consults for patients to transfer to the VDU. The first patient we saw was an elderly woman who suffered a large stroke with poor neurologic outcome. She had been in the stroke unit for the last 7 days without improvement. Our attending told us that the family had a meeting together yesterday and they all agreed that the patient would not want long term, 24-hr care. “But… they want her to be extubated in the hospital.” Pause. I noticed a sense of hesitation and concern in his voice.
I waited for the follow-up question. “What would you do in the US in this case?” he asked. I was a bit confused at first, thinking to myself, “What do you mean? We would extubate of course. Isn’t that what the patient and family wanted?” In fact, I thought this case was particularly straightforward since the patient previously said that she did not want long-term life-support and the family was in agreement. But I could tell that this path was less well-trodden here. I ended up telling him what we would typically do and that, “Sometimes we call it ‘compassionate extubation’…we do this quite often in the US, probably almost every day in the ICU.”
He told me that legally and ethically it is difficult to extubate patients in the hospital in Thailand so they do not do it. They can refrain from intubating in the first place (e.g. DNI) if the patient and family have stated their preference for this and they can switch to providing only supportive cares (e.g. no antibiotics, fluids, pressors) but extubation is not usually an option in the hospital. Some families take the patients home and extubate them there, perhaps in the presence of a monk, but the family typically needs to learn how to provide some of the home cares for the patient before making this transition.
This case made me pause and realize how much we take for granted as simply “the way things are” in our own culture. We forget that the laws and norms we have today are a result of past events and lessons learned gradually over time. It also reminded me that one of the great privileges of immersing ourselves in another culture is that we are able to learn more about our own. I will be curious to see how the culture and legal system in Thailand evolves in the coming years around this topic. Certainly, whatever decisions are made will be based on their unique history and experiences, and likely the growing influence of palliative care philosophy here.
*Photos:
Cute little monk statue at forest temple "Wat Umong" not far from the hospital.
Tamarind fresh from the tree!
Happy to be wandering through the medicinal plant garden at CMU.
One of many "wisdom signs" at the local temples.
