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At the community hospital we don’t generally see extremely sick patients. We see a lot of patients who are finishing a long battle with chronic lifestyle-related illness. At the end of their rope. Not many in our ICU are in the grip of acute critical illness. Yesterday I saw my first patient in that category. And as we were running three vasopressors, fluids wide open, assisting in placing central lines and arterial lines and monitoring central venous pressure and ever-tinkering with settings on the vent in a desperate attempt to keep our walked-into-the-ED-with-a mild-URI-a-day-ago patient alive, I had a little thought. This is when I want critical care in my life. This is what we do best.

We are no good for the end-stage congestive heart failure patient. We often prolong suffering in the quest for unattainable health, or in the absence of goal setting or planning. See Being Mortal.

But this patient needed all of the antibiotics, all of the drips, all of the chest x-rays, labs, cultures, all of the lines and vent and monitoring, all of the time of the best nurse on the floor. All in a desperate attempt to keep her alive long enough to recover. Which, I can’t stop worrying, was in vain. But even if, this was the patient that could have been given life back by the invasive, painful, and expensive interventions we have on offer in the ICU.

I don’t have an advanced directive at the hospital (don’t tell my nursing profs). I promise that If I had a chronic severely debilitating and worsening illness I would file a DNR/do not resuscitate (but preferably an AND/allow natural death). For now I don’t trust our system to distinguish the scenarios in which I want or don’t want a ventilator. I wrote out a directive and gave it to a loved one along with specific details about what quality of life means to me. If need be they can bring it to the bedside.

You don’t know when trauma or acute illness might give your shoulder a tap. If I’ve got a chance give it to me. And I want your best nurse.

PS- I know I’m on ethically shaky ground. This is my opinion on this day at this time, emotional and not all that well-informed. It’s Wednesday and I am wrung out already.

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3 thoughts on ““This is a lesson in you never know which day will be your last” –ICU preceptor

  1. I don’t have an advance directive unless its a back and forth talk with your other one telling them what you want. Gibby adamantly wants nothing invasive done, no way, no how….I say the same but then I feel on the fence. It is hard in the ED to see some people come in coding from cardiac arrest with no idea how long they have been down yet we are doing all this “shit” to keep them alive, for what, so they can never recover even be brain dead. UGH. Makes me want to vomit. I don’t trust the system at all. Not one bit. There are some doctors who are realistic (has trauma tapped their shoulder personally) and don’t order the zillion test or say lets give this a rest AND then we have the doctor who is ordering MRI’s for a UTI! UGH.

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  2. This been on my mind. I have watched the struggle of many at critical times. Some have made it through to live another 10 years others have been consigned to 1-5 years of sheer hell on earth. (Continued health care treatments that remove quality of life to the point of sheer idiocy.) How do you know when to treat and when to let it go? These are the questions we face especially as we age. Your posts continually are authentic and compassionate. xo

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    1. Thank you Mom Hoover! I agree. I’ve heard from more than a few patients and tend to agree that the scariest part when thinking about having to do it again is not the cancer but the treatment.

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