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.

[LovingLife123]

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.

Wjat is the whole point of a DNR if a family can override it? That makes no sense to me. If he is making himself a DNR, the whole point of that is fir when the time comes, as obviously nobody is in their right mind when the devastating event happens. The family should not be allowed to override his written wishes. To me, there is no ethical issue there and I'm trying to decide why and how this is happening. If his wishes are documented, it would be unethical to override that.

[LovingLife123]

I see it often. Most of the time, it's because family is very unaccepting of the diagnosis/prognosis and others it's waiting game trying to find somewhere outside of the ICU to place a patient. I find there are not enough LTAC facilities around that will take vents. The wait can be long.

[gonzo1, ASN, RN]

All of the above.

[Cvepo]

We have an 18-bed intermediate care unit in the hospital where I work that is usually has like 10 chronic, stable vents. The problem is, our hospital does not allow even stable vents on med/surg or tele (kinda stupid, I think). So the stable vents stay in stepdown until one of the few vent nursing homes has a free bed or they end up on trach collar. The rest of the stable ICU patients get stuck in limbo, where they are too stable for ICU but too heavy for a floor. We had a trach'd vascular patient who was a fail to wean in our SICU who waited so long for a stepdown bed on our intermediate unit, that we actually ended up weaning him on our unit (decannulated and everything) and just sent him to the inpatient surgical floor!

I see this less in Surgical ICU than I did when I worked in MICU. MICUs tend to have this problem from what I have gathered because of all the respiratory failure.

[Lennonninja, MSN, APRN, NP]

I work in a MICU and it often feels like an LTACH and it frustrates me to no end. We see all of the same stuff people have already mentioned, but our stepdown unit can't take even the most stable of long term trach vents, the ones where family takes care of the trach vent at home! And we have had a big problem these last few years where a patient is accepted to whatever place, but then they refuse to accept the bed because they don't want to leave the hospital. We had one patient do this to us for FOUR MONTHS this winter. The patient just wanted to stay with us for the patient ratio and the narcotics, they refused every other aspect of care. It was HORRIBLE.