Is anyone else's ICU more like LTAC?

[ICUchick]

Just curious what other regions/ hospital systems are experiencing....

I am an ICU nurse at a Midwestern hospital (community size roughly 250k) and we are the main hospital system in the city - we have 3 ICUs... Med/surf, cardiac and neuro/trauma. I am in the MICU/SICU.

More often that not it feels like we are a long term acute care. As you know there are generally 3 outcomes: the patient passes, the patient survives and moves on to rehab....or the patient gets stuck somewhere in the middle. The fate worse then death (in my opinion). Majority of these are trached and pegged and often can't be placed or they are placed and what we see are multiple readmissions of these same patients.

The nurses on our unit are struggling more and more with the initiation of medically futile care and often we continue to care for these patients for months or years on end until they pass from some comorbidity or the family finally goes end of life.

I'm wondering if this is a trend other ICUs are seeing as we continue to see medical advancements that enable us to sustain life in favor of quantity over quality?

I'm getting a bit burnt out and long for the acuity and complexity of a real ICU. I'm currently in an ACNP program so this is less of a "where is my future going" and more of curiosity what other people are seeing in their ICUs.

[april*rn]

Yes I see this also. Actually wrote a paper on futile care in ICU for school recently. Very frustrating, expensive and not always even what the patient might have wanted (family overrode polst or no family no polst so so everything by default).

[ArmaniX, MSN, APRN]

Does your hospital not have stepdown units ? If the patient will be long term vent dependent then they get trach/peg and off to stepdown. Only reason they would warrant ICU afterwards is for vasopressors/severe sepsis.

I'm curious how/why you have the same patient in an ICU for a year.

[brownbook]

I felt this way and I left ICU over 20years ago. I had hoped this sort of situation had changed.

[FutureRNArk]

Yup. I was just talking to someone about this the other day. I've only been a nurse 8 months, all in the same unit, and it just feels like we hold on to these patients way too long, providing care that is futile. And I'm already starting to get burned out on it. We're a 20 bed Coronary Care Unit in a 450 bed hospital in the south, about the same size city as yours. We also get overflow from our MICU/SICU and Neuro ICU. We've had patients in the unit for months, one particular that's been here since I started.

These patients need to go to step-down or LTAC, but often, these are Medicaid patients or uninsured, and we can't get them anywhere, and so we sit on them forever.

[Wolf at the Door, BSN]

dying is not accepted in America as an option.

[firemedic12, BSN, RN, EMT-P]

This is the exact reason I volunteer to be first admit every night. I'm stick of doing trach and PEG care on the guy with an anoxic brain injury that has coded 5 times in the past 6 months only for family to override the DNR that was originally in place. Or the attempted suicide that is vent dependent, on TPN, CRRT, and has an ex lap literally once a week to attempt to fix where he took a shotgun to his gut.

[calivianya, BSN, RN]

Does your hospital not have stepdown units ? If the patient will be long term vent dependent then they get trach/peg and off to stepdown. Only reason they would warrant ICU afterwards is for vasopressors/severe sepsis.

I'm curious how/why you have the same patient in an ICU for a year.

We have one who's been in the same room since October 2016, currently, and I work at a 900+ bed tertiary referral center.

It's quite simple - we transition him off of CRRT and on to intermittent HD - and he codes the very first treatment, every time, no matter if we already have pressors at the ready, etc. The number of times he has coded have surpassed the double digits. Sometimes he surprises us and codes the second treatment off of CRRT instead of the first.

EF under 20%, absolutely CANNOT tolerate that first pressure drop with HD. He cannot live off of CRRT and pressors. He has been septic many times. He has many, many MDRO bacteria living in him at this point.

Crazy family wants him to be a FULL CODE. The wife insists that he is going to go home and this long hospitalization is just "Jesus testing her". Because obviously nobody ever dies. Death is not allowed.

Poor man gets his pulse back right after the first round of epi and compressions, every single time. He's never been pulseless for more than four minutes and it's always caught immediately. Coded more than 10 times and he's still fully neurologically intact. It's ridiculous. He's telling us he's tired, that he's ready to go, that he has a good relationship with God. He makes himself a DNR.

Then... he gets septic again, develops altered mental status... and he's no longer capable of making his own decisions, so his family takes over and makes him a full code again.

He's trached and pegged, of course, against his wishes.

He's had at least seven or eight different vas cath, central line, and art line placements each, because every time he gets really septic again we pull all the lines and put new ones in. Talk about unnecessary suffering!

We've consulted and reconsulted the ethics committee at least five times, and they can't do anything. It's awful. I refuse to take care of him - I had him five nights in a row over Christmas and since then I have not been able to bring myself to stick so much as a toe in that room. I just can't deal with him anymore. Fortunately, I'm charge a lot, so I can give him to someone else.

[MYSTICOOKIEBEAR]

I work in a Cardiac/Transplant ICU in a top 10 hoospital and more often than not we do NOT see these kind of patients. Although every now and then we will have a very critically ill patient who just takes a few weeks to recover but that is the exception rather than the rule.

I feel like I see those kind of patients more on the NICU/MICU side of things rather than the CTICU/SICU/CCU. Your mileage may vary.

[BedsideNurse]

We have one who's been in the same room since October 2016, currently, and I work at a 900+ bed tertiary referral center.

It's quite simple - we transition him off of CRRT and on to intermittent HD - and he codes the very first treatment, every time, no matter if we already have pressors at the ready, etc. The number of times he has coded have surpassed the double digits. Sometimes he surprises us and codes the second treatment off of CRRT instead of the first.

EF under 20%, absolutely CANNOT tolerate that first pressure drop with HD. He cannot live off of CRRT and pressors. He has been septic many times. He has many, many MDRO bacteria living in him at this point.

Crazy family wants him to be a FULL CODE. The wife insists that he is going to go home and this long hospitalization is just "Jesus testing her". Because obviously nobody ever dies. Death is not allowed.

Poor man gets his pulse back right after the first round of epi and compressions, every single time. He's never been pulseless for more than four minutes and it's always caught immediately. Coded more than 10 times and he's still fully neurologically intact. It's ridiculous. He's telling us he's tired, that he's ready to go, that he has a good relationship with God. He makes himself a DNR.

Then... he gets septic again, develops altered mental status... and he's no longer capable of making his own decisions, so his family takes over and makes him a full code again.

He's trached and pegged, of course, against his wishes.

He's had at least seven or eight different vas cath, central line, and art line placements each, because every time he gets really septic again we pull all the lines and put new ones in. Talk about unnecessary suffering!

We've consulted and reconsulted the ethics committee at least five times, and they can't do anything. It's awful. I refuse to take care of him - I had him five nights in a row over Christmas and since then I have not been able to bring myself to stick so much as a toe in that room. I just can't deal with him anymore. Fortunately, I'm charge a lot, so I can give him to someone else.

That's ridiculous, isn't it....I wonder if the wife ever thought instead of "testing her" maybe Jesus wants her husband to come home to heaven, hence him dying over a dozen times, or whatever (!). Smh.

[clarkheart]

I think one of the issues that we need to discuss is how the physicians discuss the care of these patients with the families. There are times when the most dignified care these patients could receive is to allow nature to take it's course. I don't want to get on the soap box here but it is just plain cruel to allow families to continue life support for hopeless patients for their own selfish reasons. I am fortunate that our intensivists are very proactive in keeping the families informed on the patient's condition and are very honest when it appears that there will be no purposeful recovery.

[Corey Narry, MSN, RN, NP]

I work as an NP in various adult ICU's with Med-Surg, Cardiac, and Neuro patient populations. While we are not immune to challenging situations where families want everything done in a patient with a clear poor prognosis and continuation of medical treatments are futile, we rarely see patients linger on for months in the ICU. We do have a multicultural population with some ethnic groups with beliefs and practices that condone continuation of futile care. However, we have great staff resources such as the Palliative Care service and in extreme cases, we have gotten the Medical Ethics chief involved. I've rarely seen unilateral DNR's done here but it has happened.