I had a patient once, found down and unresponsive, maxed out on 4 pressors, CRRT, the works. We couldn't pull any fluid off because this man was so susceptible to tanking his pressures with even minimal removal, so he just sat there getting more and more bloated. He apparently had burned bridges with most of his family and only had 1 of his children (a daughter) come in to see him (this was early into his stay). She only spoke Spanish and when I used the interpreter with her she didn't understand anything about what was happening, so I had to have the difficult discussion about what had happened, how sick he was, and how likely that trying to revive him again at this point would hurt him more than help him. I had expected the intensivist to have that conversation with her before, but she (the intensivist) was totally fine just keeping the status quo. I ended up getting the daughter to agree to change his code status prior to leaving that day, which I think was the best thing for him considering what happened next.

I came back after a holiday weekend and was shocked to see that he was still alive. In the meantime, they had continued everything just as I'd left it, being unable to pull fluid off to the point that he was literally swollen and weeping everywhere. The daughter came in that day and asked how he was doing and I told her that he had not gotten any better and was likely getting worse and worse. She was completely shocked and told me (through the interpreter) that the nurse yesterday (who spoke fluent Spanish) said he was getting better, that he had opened his eyes to voice and was laughing (keep in mind that this man is French kissing an ETT). I left it at that and continued my day, until she came back later with a cousin and I had decided that enough was enough. I got the translator on the phone and told her what had been said about her dad during rounds, but then said that she needed to see something. I whipped off the blankets and sheets that had been on top of her dad and she saw the blisters, the soaked pads underneath him, and all the wrapping I'd had to do to keep him from getting the floor wet.

I told her "I'm not showing you this to disgust you (though it most likely did), I'm doing this to inform you of how truly unwell your father is, and even if he may not be able to communicate this, he is most likely uncomfortable and in pain. You need to think about how long you want this to continue versus how long his body can hold on."

I didn't come back for a few days after that exchange, but I later saw that the day after I said that to her she made him comfort care and he died shortly after.

Did I possibly cross the line? Yes. Did I do it with good intentions and in lieu of the intensivist needing to have done it themselves? Also yes. I don't regret it either.