I've been thoughtful lately.

Not the sort of thoughtful that sends flowers for no reason, but the kind of thoughtful that explores ethical problems.

If you were taking care of a patient who'd specifically asked--when he could talk--for certain things *not* to be done, and you'd heard a doctor promising his wife that those certain things, if done, would only last for a couple of days and give that patient a chance at recovery, and you knew that statement was a bald-faced lie, what would you do?

*heavy sigh*

Here's the deal: a nice guy, about my age, came in with a nasty infection secondary to a recent bone marrow transplant. It was a MUD, not that that matters; what matters is that he and his wife had agreed on what was appropriate in terms of heroic care and what wasn't. He was able to talk for the first two weeks of his hospitalization, so we had a number of discussions about allowable things and dis-allowed things.

The poor guy took a nosedive a week ago. When I say "nosedive", I mean nosedive in the sense that only somebody with a platelet count of fifteen (not fifteen thousand) and a white count of two (not two thousand) can take a nosedive. It was sudden, unexpected, and horrible. I watched as the docs intubated him nasally because he was too jacked up to intubate in the usual way, then spent hours suctioning him so that he didn't choke on the blood he was oozing from every orifice.

That was something he and his wife and I had agreed wouldn't be done. Yet, because his doc said Oh, What The Hell, We Do This All The Time And People Are Better In Seventy-Two Hours, his wife gave the go-ahead.

I knew the doctor was lying at the time. I've never seen anybody get better after they've been intubated in this (much more complex than I'm telling you about here) situation.

The textbook response would be to schedule a meeting with the family and the doctor and lay out your concerns there. The textbook response never, in my experience, works. The Manglement response would be to involve Manglement, but again, Manglement never responds in the way you might feel is best for the patient.

Years and years ago, I had a guy in who was obviously actively dying, yet his docs (the same doctor, come to think of it) weren't willing to let him die. They kept pumping in fluids and pulling labs and running antibiotics, and it took me having an actual shouting match with a resident (me as a new nurse of less than a years' experience!) to change the treatment plan.

I'm not any less willing to shout now, and I'm not any less sure that what Dr. X is ordering is a bad idea, capital B, capital I. It's just that, in a critical-care unit, the stakes--no, the expectations--are different. You can't let people die with dignity in the CCU, because it's seen as a defeat. On the floor, where people die more often without the sort of technological insults they sustain in the CCU, they see dying differently. At worst, it's a neutral ending to a battle that's been hard-fought with honor. At best, when you have the privilege of laying a hand on a patient's chest to feel their heart stop, it's a victory over cruelty and unreasonable hope.

If I ruled the world, things would be different. People would still die, but it'd be seen for what it is: a transition in the same way that birth is a transition. I've talked before about midwifing the dying, and that still holds true: dying as an active process is just as much work as is giving birth. It's the lying there intubated with drips going and a tube in your nose and a tube in your bladder and more tubes here and there holy shit that deprives you of the chance to do your work.

And that, friends, is the problem with critical care: we do not allow things to take their natural course. There are some things we can intervene in, and should: brain tumors, spinal problems, you name it. The trouble comes when we start keeping people technically alive when they shouldn't be.

I do not know what to do. For the first time in my practice, I am at a loss. This is a bad feeling.