by Tilda Shalof
I gave a patient a popsicle once. He had been unable to take anything by mouth for many months. He had been with us for more than 100 days and had kept his strength up enough to be able to write. It was amazing to see an intact mind after such a prolonged stay. I became his favorite nurse because of the popsicle. The taste was something he had not had in such a long time. It made him so happy. It wasn’t even my idea—it was the doctor’s idea, but because I was the one who brought it into the room, I got the credit. This simple popsicle created a connection between us, and honestly, it was intimate. I had a hard time looking into his eyes after that: there was so much feeling there.
Just recently a patient mouthed to me that she wanted to die, please no more treatments. She had a breathing tube in her mouth, attached to a ventilator. It was very hard to read her lips but I was able, through a series of questions, to figure out why she tried to push me away every time I explained what I was going to do or what the plan for the day was. She confirmed that she did want information about what was going on, so I included her in everything we were doing. But she wanted none of it. It was so hard for me to tell her that I did take her seriously and I did want to honor what she wanted but was unable to because she was attached to that machine, which took away her voice—and if we were going to make a decision as serious as a decision to stop treatment, then we’d need to get that tube out of her throat so that we could speak about it. She was too sick to have the tube out, so we talked her into a tracheostomy. I told her it would allow her to make decisions for herself, once she was off the machine. She seemed agreeable to this, only because I was promising liberation and power.
So, even when people attempt to communicate and manage to communicate successfully, that may not be good enough. We need a sustained dialogue with people, to be able to honor their wishes. This woman did get her wish: she did die the following week, but only after we did a few more things to her that she didn’t want. We did them to save her life because we were not sure if she would make a different decision if she was feeling better. How much of her wanting to die was because she was in pain and just not doing well? If we could get her better would she be glad we did? Her family members did not know her wishes (she had never been this sick before) and agreed that we needed to err on the side of preserving her life, so we did, but she suffered complications we couldn’t fix and she died.
Power and voice; power and voice. I would love it if research dollars were dedicated to creating a communication device for people who cannot communicate conventionally. Stephen Hawking has a device, doesn’t he? What about all of our patients lying in ICU beds around the world? I know it wouldn’t be a straightforward intervention, an easily attached device that would immediately offer patients full communication capability so that they could make decisions for themselves. (I am neglecting to mention the number of patients who are confused after being in the hospital for so long. This population of patients would not be able to communicate in a meaningful way. But what about those who are capable of self-expression?)
My depressed patient did get out of the ICU. He won’t be coming back: bringing him back won’t help him or change his outcome. He would just end up dying on a ventilator, unable to speak in his last moments. The last time I saw him he still had the cork on his trache and was able to speak, his wife at his bedside. I still marvel at his transformation. Once he was able to speak, his wife called all his friends to come in and see him. It was fantastic. There were five or six visitors in his room. We usually allow only two visitors at a time in the ICU, but, hey, this was a special case. So they were all in there. I stayed outside the room so they could visit with him. I am not sure what he was saying that made them laugh so hard but everyone was laughing, over and over again. I thought, wow, this guy is a comedian, who knew?
He wants to live. He told us that. He asked us what kind of a chance he has. He feels technology is better now than what was available when his relative died from the disease. We didn’t tell him that there is no new technology to save him from this disease. Instead we emphasized that we should work on enriching his life as best we could, now. Let’s just go day to day and see what happens, let’s try and get you stronger. Most importantly, perhaps: let’s keep you talking; let’s keep your voice alive.
Nursing the Machines
Cecilia Fulton, RN, BScN
“So, why did you decide to go into nursing?”
I looked up at the face of my first nursing teacher, who was asking me that question. Many of my classmates had a long tradition of nurses in their families. Others were drawn to the profession by the prestige of starched white uniform and cap, and others were apparently just so damn caring that they never considered doing anything else. Nursing was their “calling.”
“I didn’t think I could make it as a professional game show contestant,” I told her. That was my brilliant reason for deciding to become a nurse.
Some ten years after cracking that joke, I rose through the ranks and found myself working in the busiest ICU in one of the largest medical centers in Canada. For many years, being part of that elite group of ICU nurses felt like the place where I belonged. It had never been enough for me to be a floor nurse, working in the general medical-surgical wards.
It had taken me a while to master the technical aspect of my job, learning to operate the machines and to keep the miles of IV tubing from strangling the patient. But after a few years, after I had progressed from novice to expert, I even began to look forward to challenging, busy days when my patients were so critically ill and unstable that I barely had time to look at them, much less talk to them. Keeping fluids balanced, titrating inotropes, weaning patients off the ventilator were skills that kept my mind engaged. At times, I was so focussed on the equipment, it felt like those machines—the ventilator, cardiac monitor, drains, IV—were my patients.
I worked in the ICU for years. I progressed to teaching new medical residents and putting them through their paces. I cherished moments like witnessing a transplant recipient take his first breath with his new set of lungs. I bonded with the other ICU nurses when we went out for drinks after work and got together on our days off, swapping our ICU stories and gossiping about the indiscretions of some of our fellow nurses.
Not many of those patients made it out of the ICU; many of those who did probably didn’t make it home. They were still extremely ill, many chronically so, with multiple medical problems. To me, the ICU was kind of like a game show: you never knew what was waiting behind door number one or two….
It was probably a combination of age and personal growth that drew my focus from the bells and whistles and back to that person sinking between the bed rails. I am all for not going “gently into that good night,” to quote the poet Dylan Thomas, but for God’s sake, when that’s what someone needs or wants to do (and nature tells us that the end is unavoidable), who am I to pump them full of medications, tubes, and oxygen just so it can be said they fought the good fight? I do know that there were and are many patients who are alive today thanks to the care and technological expertise they received in the ICU, but there also have been individuals upon whom much indignity of interventions and machinery was heaped, in their final days and hours. Those were the ones I wanted to help, the ones with no voice, the ones whose families “wanted everything done” when there was no hope of survival. For so many patients, continuing treatment was deemed futile, yet often at the family’s insistence, we would continue with full “life support.” I believed in my heart that if those patients could speak for themselves, they would be screaming out to me, begging not to be put through all this. The term “life support” became an oxymoron to me, since life seemed to be the last thing I was supporting.
It was a difficult decision, but I had to leave the ICU.
Eventually, I found my niche in community health nursing.
I recall a recent visit with Margaret, an 88-year-old widow who had been living in the same home for the past 52 years. She had had a hip repla
cement and was working hard at recovery and getting back on her feet. Every time I visited her, she had cookies and coffee ready for me. After I checked her vitals and her dressing, and reviewed her exercises, we sat at Margaret’s kitchen table and talked. I was gratified to see her recovery, knowing I had played a part in it. Soon, she didn’t need me to be her visiting nurse anymore. But even after she was no longer on my caseload I continued to think of her whenever I drove past her house. Perhaps it sounds like a visit to my granny—in some ways that’s what it was. My visits with her made me feel like I was a member of her family. In our talks, as we got to know each other, she told me that she didn’t want to ever go to a nursing home and definitely did not want to be put on life support. I met her son on one of my visits and we talked openly about how determined his mother was, and how he planned on carrying her out of that house in a pine box. Margaret has made her wishes known to her caregivers and family and, therefore, when the time comes she will not be admitted to the ICU but will die at home with dignity.
I have come to believe that what Dylan Thomas compels his reader to “rage against” might more appropriately be understood not as imminent death but as the loss of one’s independence. For Margaret and countless others, having to give up their car, move out of their house, rely on the unreliable kindness of others is a fate worse than death. Compared with being encased in a hospital bed with the side rails up, fed through a tube by a machine, and dressed by someone who has no idea what your favorite sweater is, the arrival of “that good night” may very well be a blessing—and the ICU is, for such people, the exact opposite.
I will never regret my years working in the ICU. I look back on them as some of the most exciting years of my career and my life. Many of those memories have faded; those that remain are the ones where I really got to know the person, and maybe for an instant felt like a member of their family. (Those patients know who they are, and I thank them for the privilege.)
A lack of direction led me to nursing, all those years ago. Twenty-five years later, it appears that I do care enough to be a nurse—and I’m very glad I chose to become one.
Why I Stay
Karen Higgins, RN
I HAVE BEEN A critical care nurse, working in various ICUs, for almost 28 years. I graduated from nursing school when I was 21 and went to work on a regular hospital floor. Three years later I came to the ICU and have never left. I was attracted to critical care nursing because of the challenges and rewards of taking care of very sick patients in a fast-paced environment. In the ICU my nursing skills are pivotal to the patient’s survival. Working in the ICU, I’m always learning new things; my role continues to evolve.
People sometimes ask me what has been the biggest change in nursing over the years, and my answer is that advancements in technology and medications have resulted in changes in the types of patient we are able to treat now. Many of the patients I care for in the ICU would not have even been alive 10 or 20 years ago. New technologies and medications have given more patients a chance to survive and live longer. The challenge for me as a nurse is that when patients come to the ICU, they are more acutely ill than ever before. The assumption is that with the developments in technology and medications there is less need for the care by a nurse, but in fact, the opposite is true. Today’s patients need more care and attention from the nurse than ever before. The level of acuity has increased immensely in the ICU, and therefore on the floors as well.
Let me give some examples. On a recent shift, I was caring for two patients, both of them women in their seventies. One of these two patients had severe lung disease and pneumonia, and also was diabetic. My other patient had sepsis, a blood infection that can be deadly and affect nearly every system in the body. Both patients were fully ventilated to support their breathing, had feeding tubes for nutrition and catheters in their bladders so we could closely monitor their urine output. They also both had myriad intravenous lines, into which I had to administer complex medications. They were connected to monitors to measure their heart rate and the oxygen saturation in their blood. We’re talking about millions of dollars of technology and equipment being used here. But all of it is worthless without a skilled nurse to monitor the technology and manage it based on moment-to-moment assessments of the patient’s condition.
My morning started with the patient with pneumonia, and my order from the physician was to wean her off the ventilator so she could breathe on her own. But this was easier said than done. When I tried to take her off the ventilator, her heart rate began to increase, and her blood oxygenation level began to drop. She became agitated. At that point, I knew there was no way she was getting off the ventilator that day, at least not until I could get her other symptoms under control. First, I needed to lower her blood pressure and calm her anxiety. To accomplish this, I needed to sedate her and then I could more closely monitor her oxygen levels and blood pressure until she was once again stable. She was also a diabetic and I was monitoring her blood sugar level and adjusting the rate of the insulin infusion as necessary each hour. Her diabetes was so unstable because of certain drugs (such as intravenous corticosteroids) that she was receiving in the ICU.
Once I was finally able to stabilize this patient, I was able to turn my attention to my second patient, the woman with the serious blood infection. When I made my initial assessment, I found that she had spiked a fever, which is a sign of a new infection. I immediately took samples of her urine, blood, and sputum to be sent to the lab for a culture, to determine what might be growing in those specimens and, if there was a bacterial infection, which antibiotics it would be sensitive or resistant to. I called her doctor to update him on what was happening. This patient was on a number of medications, each being delivered by an intravenous line—these medications included a sedation drip and an insulin drip that I had to monitor closely in order to evaluate her reactions and titrate the medications accordingly. I had to adjust the rate of medication based on her heart rate, blood pressure, and signs of wakefulness, anxiety, and pain. When I noticed that her oxygenation level was borderline normal and that her blood pressure was slowly dropping, I immediately lowered the head of her bed to improve her cardiac output and optimize perfusion to her brain. Then I started giving her fluids (saline) through an IV line, to try to help boost her blood pressure. At the same time, I noticed that her urine output was starting to drop. I again notified the physician of the changes. The patient was not responding to the fluids I was administering so I started giving her IV medications to bring her blood pressure back up.
My entire day was spent moving between these two patients, making continual assessments and then making adjustments to their treatment in light of those assessments. All of these actions had the goal of stabilizing the patients’ conditions and hopefully moving them closer to recovery.
The problem is that the whole time I’m with one patient, I’m worrying about the other patient, hoping that nothing significant has changed that I might miss while I’m out of the room. Granted, alarms will go off to alert me if something goes wrong, but the best nursing care is to be on the spot with the patient and to be able to intervene and head off problems before they occur. At this stage in my career, I can walk into a room and, just by looking at a patient, usually sense how the day is going to go and if there is going to be trouble.
These assessment skills have become second nature for an experienced nurse like me. I need them in the ICU, where a patient’s health status can change suddenly. I remember one patient I cared for, a young man in his thirties. He had been sent to my ICU with a pericardial effusion, which means he had fluid built up around his heart. He was also suffering from kidney disease and was on dialysis to cleanse his blood of toxins. The night before, the patient had had a pericardial tap (this means a tube was inserted into his chest to draw out the excess fluid around his heart). When I received the patient, the tube had been removed; my job was to monitor the patient and make sure that his heart function was stabilized. The plan was
to get him ready to be transferred to the floor later that day and then, a few days later, home.
It is very important to carefully monitor a patient’s heart rate and blood pressure for discrepancies. You need to listen through a stethoscope for certain irregular sounds that may signal a problem. Such listening cannot be done by a machine: it takes the trained ear of a nurse who knows what to listen for. Although this patient’s heart rate was fine, his blood pressure was a little low—but not in a range that typically signals a problem. He was eating on his own and he seemed to be doing well. The physicians were pleased with his progress. But I soon began to sense that something was not quite right. While he was on the dialysis machine, having the toxins removed from his blood, the dialysis nurse had periodically to adjust the machine, in order to draw fluid from the patient—and each time she attempted to draw fluid, his blood pressure dropped. This happens occasionally during dialysis, but in this particular patient’s situation, it seemed to me an early warning sign that something was wrong.
Still, this is not an entirely abnormal occurrence during dialysis. When I called my report in to the physician on the phone, he gave the order for the patient to be transferred. But something just didn’t sit right with me. I had cared for this patient before and knew him well. He was usually able to tolerate more fluid removal during dialysis and his blood pressure normally ran high. I had a feeling something was wrong. I couldn’t point at just one thing that signaled a problem. So I went to the attending cardiologist overseeing his care—someone with whom I had worked for years—and told him, “Something is just not right with this patient.” I went over my concerns and asked if we could repeat the patient’s echocardiogram, just to make sure, before transferring him out. This physician knew that I was a skilled nurse with good instincts, so he agreed to do it. And when they redid the echocardiogram, they found out that in fact the patient’s condition had deteriorated. Fluid was re-accumulating around his heart. My patient was rushed back into surgery within a few hours. There is a good chance that had I not intervened, this patient would have been sent out to the floor with plans to possibly discharge in the morning. He could have died.