My patients are often too sick to speak, much less ask questions about how their care plan is progressing. Yesterday I was lucky to have a patient with family at the bedside. Children that were young and healthy, and based on not subtle comments had the advantage of money and power thus the ability to control everything in their environment. Under normal circumstances. Things had rapidly deteriorated for their mother over the previous 24 hours and frustration with serial specialists painting differing pictures was high. It was very important times for therapeutic communication.*

For caregivers and family with loved ones in the ICU, there are two basic questions:

How did this happen?
To a nurse or a doc the handful of illness we see in the community hospital (pneumonia, sepsis, organ failure, stroke, all of the above) run a well worn path and are nothing to get excited about. To the family of the patient, their loved one was watching baseball two days ago and now we’re telling them to hurry up and sign a paper giving permission to place a central line and intubate. Mom is unrecognizable from the edema in her face and her toes are turning blue. How did it happen so fast?! Family members will show me pictures on their phone insisting that I note the date stamp, “look at her, she was fine!” And she was, until she wasn’t. The turn of events, the speed, the randomness of having some soup go down the wrong pipe into the lungs or reaching for the door handle and noticing you can’t feel your hand. We aren’t able to reconcile it.

As the nurse, validate that this is a catastrophic change. No one is running around screaming STAT! but it’s is as serious as it gets. Permission to be shell shocked. Run through the series of events that got the patient to ICU. Do it again. Answer questions. Do it again. The brain is a non-stick surface when people are experiencing a trauma. ICUs are traumatic.

What next?
This is a toughie, but everyone wants to know. Ask loved ones if they would like your nursing assessment, and if so, share it. People are intelligent until proven otherwise. Your mom is very sick. Here is what we are doing to help her breathing/kidneys/heart/infection. If she gets worse here is what it might look like and the interventions that may be considered. If she gets better here is what it might look like and what the next steps would be in recovery. Tell them what modern medicine can do support their body through acute illness, and where the end of the road is with these interventions. Offer resources. Talk about what the patient was like in health, and what they would want.

If the patient is stable remind family that things can change very quickly but their loved one is in a place where there are professional eyes on them every moment. They are as safe as can be guaranteed. Now might be the time to get sleep since however the ICU stay ends, be it in acute care and recovery or in planning a memorial, laying a body to rest, and grieving, they are going to need strength for the next part.

And you know what? Tell the family what the numbers on the monitor mean. They stare at them for hours not knowing what this alien language is besides scary and important. When you go to silence an alarm like you do twenty million times a day remember to explain why. The lead fell off, the probe is not reading properly. Nurses see the bad wave form and know the data is garbage, but patients and families hear the alarm and think emergency. Communication, comrades.

*Different people are going to want different amounts of information at different times. Nurses assess that first, K? What’s appropriate and when is a soft skill. One pro-tip, and this counts for life as well as nursing: you don’t know how they feel. Don’t say that.

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