Futile care

[sunnycalifRN]

How many times have you had patients like this?

80+ yr old patient coded on the floors, unknown downtime, lungs are trashed, in ARDS, on 100% O2, PCV, PEEP 12, rate of 24; kidneys are shot, on CVVH, heart only works because he's on dopamine, epi, levo, vasopressin and isoproteronol drips. I have no idea what the doc's tell the family but the family "wants everything possible to be done".

Of course, we all know the eventual outcome . . . a week, two weeks, a month later . . . the patient codes and we can't bring him back.

Of course, we have to care for all patients . . . but, I don't get a lot of satisfaction taking care of these patients . . . some of my cynical colleagues call them "test dummies" for the interns and residents. Your thoughts?

[caroladybelle, BSN, RN]

Do you want to know how many of them are brought in with terminal cancer whose families insist on chemo and surgery?

[sunnycalifRN]

A fair number of the patients I described were in the hospital being treated for cancer before coding and coming up to the ICU. 20%, I would guess.

[tencat]

That's why I do hospice......really ugly way to die in an ICU....But the family and the patient have to be ready for hospice. Dealing with a family right now who is NOT ready and is going to cart family member off to the hospital....sigh

[chuckz, BSN, RN]

That to me is the hardest thing. I just feel like the suffering is unjust. We had a 93 year old full code a couple weeks ago. Family wanted everything done. Eventually Ethics became involved and we let the poor thing pass. I feel ya sunny.

[meandragonbrett]

Unfortunately it happens. I always try to use it as a learning experience so that someday maybe something we did way back when can fix somebody else that is fixable.

[aCRNAhopeful]

Seems like I rarely see that kind of situation occur in my unit. Probably because CV surgery patients are usually only unstable temporarily. Whenever we do have someone circle the drain and progress to that level the families are usually wanting comfort measures only. I would seriously wonder what your docs are telling these families. Do you as a nurse ever try to let families know that comfort care is an option? In fact, most cases that I've had like that it's been the nurse to talk to the family about their options and then we called the doc to let them know and get orders.

[PMFB-RN, RN]

This is a common situation in many ICUs. It is a result of poor or inadequate communication between physicians and the family. The physicians are simply not doing their job in helping the family to clearly understand the situation. I find a good hospital Chaplin can be very helpful in these situations.

In the absence of good physician to family communication I feel perfectly free to help the family understand myself. I will explain the chances of their loved one, our available palliative care unit, what happens when we code grandpa, I will share my past experiences with similar patients. If all this fails I try to get the ethics committee involved. I have also refused to code patients several times.

[sunnycalifRN]

Seems like I rarely see that kind of situation occur in my unit. Probably because CV surgery patients are usually only unstable temporarily. Whenever we do have someone circle the drain and progress to that level the families are usually wanting comfort measures only. I would seriously wonder what your docs are telling these families. Do you as a nurse ever try to let families know that comfort care is an option? In fact, most cases that I've had like that it's been the nurse to talk to the family about their options and then we called the doc to let them know and get orders.

Exactly! I've not heard that initial discussion with the family but after we receive the patient and start all the interventions and learn the patient's history . . . the eventual outcome becomes pretty obvious. If the docs would just put it out there . . . that the patient is already dead . . . being kept alive artificially . . . maybe we wouldn't go through all our ICU machinations on the poor patient.

[sunnycalifRN]

This is a common situation in many ICUs. It is a result of poor or inadequate communication between physicians and the family. The physicians are simply not doing their job in helping the family to clearly understand the situation. I find a good hospital Chaplin can be very helpful in these situations.

In the absence of good physician to family communication I feel perfectly free to help the family understand myself. I will explain the chances of their loved one, our available palliative care unit, what happens when we code grandpa, I will share my past experiences with similar patients. If all this fails I try to get the ethics committee involved. I have also refused to code patients several times.

I agree. I've also have had discussions with the family but the words of the MD carry more weight with the family. I've personally never been this situation with any of my family; I'm sure it's not an easy decision to make a family member "comfort care only" or to withdraw support. However, my 87 yr old father is not going to die in the ICU.

[dorie43rn]

It happens all the time in my ICU. I agree it is Dr's not informing families. They will ask if the family wants the patient a DNR without explaning that we will still do everything untill the time comes that the heart does stop beating. I for one let families know what happens when we pump on their chests and jam a tube down their throats and days later their skin cracks from fluid ect. That usually makes them think. I try and get them to think of what the PATIENT would want and not themselves. Of course there are a few sick family members that I truly believe they want to see family members endure torture for whatever reason, but most will eventually understand.

[JeanettePNP, MSN, RN, NP]

I think people need to have a better understanding of what the dying process looks like. They need to know that medical science can only do so much to keep nature at bay. Once a person is actually dying the process is irreversible, and it's not cruelty or lack of faith to let nature take its course, especially if the patient is elderly. The problem is how and when to state with full confidence that the patient is already on that road and there's no turning back. Everyone wants to hold out hope and not give in prematurely. There are enough outlying cases to keep some people guessing...