A BiPAP case study-ethics case

I just want you to know that if a doctor ever orders me on a BiPAP or Ventilator and refuses to give me anything to relax me -- like Ativan, I'll kill him if I get off. 

So here's the patient's ABGs on 40% vm:

• pH 7.2
• CO2 77
• PO2  82
• HCO3 29

The patient's wob is labored.  He has a history of end stage COPD, possible CHF.  The BiPAP is working well for the patient.  His VT is approximately 700-1000 and respiratory rate 39 on settings of IPAP 12 and EPAP 5.  I now have his FiO2 down to 30% and his SpO2 is holding at 98% and so I could actually decrease his FiO2 even further.

Yet the patient tells me he feels panicky, like he's not getting any air, and feels like he wants to pull the mask off.  I give him the speal that the BiPAP is working well and that it's preventing him from needing a tube in his throat so we can breathe for him that way.

So after my speil he says he can tolerate the BiPAP.  Yet I get on the phone and call the doctor and ask for something to relax this guy.  The doctor says, "Do you know what you're asking me to do?"

"Yes, " I said, "And you have to understand that I think if we can keep him on this BiPAP we can also keep him off the ventilator.  Even if we suppress his respiratory rate by 10, he's still getting twice the tidal volume he was getting before the BiPAP, so he'll still be blowing off CO2."

He said, "I'm sorry, but I just can't do it." 

My only thought at this point is, "I'm glad this guy's not my doctor.  Because this could be me some day. The next day I came to work and learned about the dream doctor.  

Your thoughts???

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