Thursday, February 04, 2010

The problem with the CCU.

They will not let you die.

That, right there, is the whole problem with critical care.

Regular readers here at HN are thinking, "Dude. Death again?" I say, yeah, death again. Because, let's be honest: it's not the people who get better and take two turns around the floor with the help of physical therapy that send you home at the end of the shift to stare at that six-pack in the fridge.

It's the purpose of a hospital to help people heal, and mostly we do pretty well. I'd say 95% of the people I've cared for over the years have gone on to have decent-to-exceptional recoveries, and that's coming from a nurse who works in one of the strangest branches of medicine. When something goes wrong with your brain, a whole lot of other things tend to go off the rails a bit, and when we get those fixed, well, there's still something wrong with your brain. Ninety-five percent is good odds, given those limitations.

And when you're used to seeing most of the people you work with get better, the ones who don't hit you particularly hard. Every death is a failure. Some are more FAIL than others; it's harder, naturally, to lose a patient who's younger than average, or nicer than average, or who just had a run of crappy luck.

Which is where the problem with critical care starts.

Critical care is, by definition, critical. Like, "anything could go wrong, so I'm going to be particularly paranoid" critical. Like, "let's hope this thing in your head doesn't bust loose all of a sudden" critical. Like, "we've tried everything, but the rare and aggressive blood dyscrasia that's killing your 25-year-old wife won't go away, so let's put her on three pressors and pressure-bag some fluids in and put her on a ventilator" critical.

That last is where my own personal sticking-point is. Sometimes, people have to die. I hate it as much as the next nurse, but I come from a background of watching people die on a fairly regular basis and mostly being relieved and happy for them when it finally happens. It's not a big, scary horrible monster for me, and mostly it's not an admission of failure by the time it comes about. Instead, midwifing somebody through the process, letting them take the lead while still responding to their needs, is a tricky, thoughtful business, and one I'm glad and proud that I can do well.

But the folks in critical care (especially the oncology guys, because really, that's a tougher call than seeing a black brain on a CT, right?) don't see it that way. Death is something that *can* be beaten, and *will* be, no matter the cost to the doctor, family, or patient.

So we keep the patients alive, no matter what. A nasty case of sepsis can be fought. A stroke or brain injury can be fought. Multiple broken bones and pneumothorax can be fought. Those things are reasonable and logical--the person with the problem will likely go on to make at least a partial recovery, so you're not wasting your time or torturing them.

But the ones who simply won't get better, who've used up all nine of their lives? Those ones bother me.

Honestly: if we have you on three different drugs to keep your blood pressure up and your systolic won't come up out of the sixties, or if you're so damn sick that you've got three different central lines running six different antifungals and antibiotics, and you're still not improving, it may be time for us to give up. You've probably left the building long ago and are waiting impatiently for the chance to get on with things.

It's hard to make that call, and I respect that doctors don't want to judge too quickly. We've all heard about or seen miraculous recoveries (or at least, unexpected improvements). It's not up to anybody to determine, actively, when another person's life should end.

Still, it leaves me with a nasty, metallic taste in my mouth that has nothing to do with the drugs I've been running into someone.

I wonder what it's like for the person in the bed, the patient. I can begin to appreciate what it's like for the family; I've fielded plenty of tough questions even in this short time. I know what it's like for us: a colleague of mine is getting the hell out of nursing and going back to accounting so she doesn't have to be sad every day.

Maybe we should be more accepting of failure. Maybe we should turn our attention to the whole situation, and realize that sometimes, that small failure in losing a patient can mean a huge comfort for the people who are left behind. They won't have to think about, late at night, whether they caused more misery than they prevented. And it would be better for that person in the bed, sometimes, to just up and say, "Look: we can bring her back, but it would mean that her intestines would be dead, that she'd be comatose, that she'd be dependent and in a nursing home for the rest of her shortened, sickly life. Is that worth it?"

We have amazing technology and incredible understanding of the body and the brain. Sometimes I wonder if our humanity isn't lagging a bit behind our understanding and technology.


Lisa G said...

Great post. I spent 11 years working in various brands of ICUs (trauma, open heart, etc.), and what finally burned me out and sent me packing was exactly what you wrote about here.

All that suffering, and they die anyway. Just because you can do a thing, doesn't mean you should do a thing.

Just sayin'.

Nurse Stella said...

You said "Maybe we should be more accepting of failure" I don't call it failure. The doctors and nurses give it their best. Unfortunately, it is the patients' "time". Instead of calling it a failure, we should call it "we did everything we could." And take pride in that. Then call in the Hospice or Palliative team, and let them help the patient and their family and yes, even the staff, with the end of life. CCU/ICU nurses amaze me in their knowledge, determination and caring. I'm a hospice nurse. And as I tell colleagues and families, "You've done your best. It's ok to say no more".

painting with fire said...

Not a nurse but after watching several family members go through extended illnesses before dying I do think there's a hard balance between trying to help people get better and helping them have a good end. We all die. The transition between working full out to keep someone alive and easing their passing isn't always graceful and making the call on when to stop fighting to keep someone going and shift to a graceful and is tough. I think you raise excellent points in this point. They are important issues and need to be talked about more!

Jenn said...

I cannot tell you how many times I've said "Just because we can, does NOT mean we should." Sometimes, though, (and actually I've found this to be the case more often than not in our MICU), it's the families that do not want to "give up." Even when you paint that picture, they refuse to believe it. And then they watch their family member suffer. *sigh* It's the only thing I don't love about my job.

bobbie said...

Excellent post... yes, we have the technology, but that doesn't mean it should be used every single time...
Sometimes it's just not appropriate.

An Open Heart said...

Wow, this is a great post. I often wonder how cruel it is to keep someone on life support when the measures for the living and not the sick person.


Anonymous said...

Thank you for these thoughts. I agree with Nurse Stella, don't let yourself think of it as a failure.

My father died last fall. Letting him go gracefully was a hard thing to do, but as is so often the case, hard things to do are the most valuable ones. Thanks to hospice. Thanks to my father, who never left us in doubt of his choices. Thanks to you, Head Nurse, and your willingness to keep doing this. Yeah, we've got the technology. We don't have enough thoughtful people like you who are ready to give so much.

Jo said...

An excellent post - there is such a world of difference between saving a life and prolonging an existence.

There is a news article on the BBC website ( about being able to scan the brains of patients in a p.v.s. and, in some cases, by asking Yes/No questions, and asking the patient to think about motor imagery for "yes" and spatial imagery for "no", and looking at the different brain scans, they could communicate with the patient.

This means that:
"It does raise many ethical issues - for example - it is lawful to allow patients in a permanent vegetative state to die by withdrawing all treatment, but if a patient showed they could respond it would not be, even if they made it clear that was what they wanted." (my emphasis)

Minja said...

keep on educating baby, most American's just don't understand death. Had a patient last week- "just 4 more units and we call it", "um, you said that 16 units ago." The doctors finally came up with a VIR procedure with a 98% chance of death on the table and best case patient being brain dead another week. Family says "do it". Are you kidding me? One MD finally said "this isn't right" and refused. Please don't let me die with a blakemore tube inserted, catchers mask on face, and suction at my mouth and ass. Rock on girl!

woolywoman said...

Yup, and Yup, and Yup.

Gert said...

If only physicians were allowed to make the right call without having to worry that they'll be tied up in malpractice suits from family members who really really really don't understand.....We need to try to make people understand.

Sorry you neglected gramps/gran/dad/mm when he/she was alive but you really can't show your "love" (i.e. guilt) now by refusing to let them die peacefully.

I'm one who went to nursing school in order to be a hospice nurse, and after spending three years getting the hospital experience I have no doubts that too much is done for too long in hospital.

stampqueen said...

Rock on girl - agree 150%.
Gert said - also rock on - agree 2000%.
My 2 cents worth - patient has diabetes with chronic renal failure, COPD, heavy smoker and needs Open Heart surgery for multiple blockages but has so many abscessed teeth in his mouth (doesn't know what a toothbrush is and has never been to a dentist in his whole 65 years) that he had to be on antibiotics for 2 weeks first - what is really the benafit of doing this surgery (oh BTW - chronic ETOH abuse too).....flat out stated he won't quit smoking or drinking and oh yes surgery paid for by tax payers......
yup I just may be a bit burned out at the moment.....

Lynn Dykstra said...

In my silent conversations with my comatose hospice patients, one question I often pose to them is, "What took you so long to come to me?" I can't believe what has been done to so many patients before they enter hospice. I know I am looking at them when it was finally obvious they belong with us, but, come on, this could have been called much earlier in the game.
By this time the family is exhausted, we are viewed as merchants of death because we are not the cheerleaders they have been used to. Some families are grateful; most are too numb to see this as a precious time.

Christie Allen (Talulla's Mom) said...

Well said, madam, well said.

The line "midwifing" through th eprocess of death you describe is very apt. I transitioned from 10 years of critical care to a high-rsik brihting center. People constantly ask me why "such a big change?!". To be frank, it is NOT such a big change...
I wipe tears, remind people to breath, I see the start of life and I am a witness to the experiences and realities that shape families.
But yes, I had to leave the ICU. Because being there on everyone's worst day of their lives just gets old. I can count on one hand the joyful moments I experienced in the unit in my tenure and I can count the same number in the last week where I work now. In an off balance, I have helped deliver the sibling of a child I coded and took off life support 4 years ago.

I will never forget my mom asking me a year after a massive basilar artery stroke left my Gram esentually a vegetable at 80, "But no one TOLD us! The nurses should have at least said there was no hope!!" And I had been all but chanting throughout the experince that this would not end well.

For all our technology, for all of our intervention, we nurses are the warm bodies that witness, that advocate, and help let go. A lot of very odd things are done to patients by their families in th ename of love. Sometimes it just hurts to watch.