In Our Own Words

Who Tells a Patient’s Family That Their Loved One is Dying?

Imagine the following situation: You are assigned a 91-year-white female, admitted with urosepsis, requiring mechanical ventilation and intubation. Despite IV antibiotics, fevers jump through the roof along with climbing WBC counts and bands with a left shift. Within hours, Levophed is infusing at 60 cc/hr, NS is running wide-open, urine output stops flowing, and acrocyanosis arrives. Dopamine is added. Pitressin comes next. Soon you run out of electrical wall sockets as more inotropic drug support is added to sustain life.

The family hovers outside the door, without any sort of DNR discussion with the medical team. As the night wears on, the patient looks paler and paler, her cardiac rhythm now shows major ST depression leading way to a wide complex slow ventricular rhythm. By morning the patient’s systolic blood pressure is near 54/?, and she’s unresponsive as you provide oral care. Yet still the family "wants everything done." But there is nothing more to do. Palpable pulses barely exist. Mottling creeps along her limbs. There is no life.

The two residents seek to place a new arterial line instead of sitting down with the family to initiate a discussion about medical futility and comfort care. The nurse mumbles to the team, asking them to talk with the family about death and dying all night long, to no avail. The family continues to wonder in the hallway, hovering outside her room as her HR slowly begins to drop. They want dialysis now.

Still, no one talks to them about DNR options. No healthcare proxy exists. If you were in this situation, what would you have done? Does a nurse have the right to tell a family about DNR options or should it remain a discussion with the physicians?

Some related resources:

The Hardest News: Death Disclosure in the Emergency Department

The Last Hours of Living: Practical Advice for Clinicians

Choosing Quality vs Quantity of Life in Heart Failure: Decisions Often Made Early

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How High Tech Must We Go in ICU Today?

Reading the latest news (360 Degree Care) about Sloan-Kettering’s newly developed ICU, I have one key question to ask -- how high tech must we go to give efficient care to patients today? Is rubberized flooring necessary? Do Web cams interfere in patient privacy? (Would you want to be seen weeping on a Web cam with your dying family member?) The article on Nurse.com describes how “Rooms have Web cams to let nurses monitor patients and beds that turn 360 degrees, perform respiratory percussion and vibration, turn and weigh patients, and elevate them to a chair position.” What happened to an aide and a nurse physically getting a patient out of bed, letting them dangle by the bedside, and then stand and walk to a chair?    
 
I have not seen this new ICU although there are constant advertisements, "Come Join Us," in nursing magazines for job positions in the unit. But I do like the idea of more room space; there never seems to be enough in any ICU. And I certainly like the concept that nurses had input in designing the unit architecturally. New beds, no manual chest percussion. My arms can get a rest now!

Has your critical unit been updated recently? What would your optimal ICU look like?

Will Hiring Foreign Nurses Solve the Nursing Shortage?

There is a bill being discussed in Congress, HR 5924, which focuses on providing employment-based visas for foreign-educated nurses. HR 5924 refers to the Emergency Nursing Supply Relief Act. The Act would allocate 60,000 visas for the next 3 years for nurses.

I’m not so sure how this will resolve the shortage long-term, as the bill ends in 2011. What then? I know one thing -- I’ll be ready to retire! The bill focuses on solving the current domestic problem of a lack of nurses. Seems to me that all of this is cyclical in nature.

Haven’t we done this before? Brought in Irish nurses? Brought in nurses from the Philippines? Do we need to do it again? What are your thoughts?

You can read more about this Act here

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