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I'm on staff in a 20-bed specialty intensive care unit for neurosurgery patients, but our census is low today and I was temporarily assigned ("floated") to the 20-bed medical intensive care unit (MICU) at our large urban teaching hospital.

Things are always busy in the MICU. There's always somethng interesting going on. Here's my day so far...

I can't provide any information that would make it possible to identify my patient without running afoul of the strenuous .privacy rule that is an essential part of HIPAA.

It's fair to say that my patient is very ill as a result of several severe traumas and health crises over the years, and like many patients in similar situations requires a variety of technological interventions to monitor and maintain essential life processes. My patient is much closer to death than (hopefully) we are.

Upon arriving in the MICU I was given a very thorough report by the nurse who has cared for the patient for the last three nights. We reviewed the pertinent events, the parameters we're measuring, and the team's near-term plans for the patient.

The patient's family met with members of the team last night, and they're facing the decision to redirect care. We've been using this term lately, rather than the terms withdrawing care or comfort measures only, since those two latter choices don't really express what happens when such a decision is made. They can also give the family the false impression that their loved one is somehow going to be abandoned.

The term redirect more accurately describes what the team does when treatment is not likely to improve the quality of life or lead to a positive outcome. We change our focus, and redirect our efforts.

Extraordinary measures are discontinued, like mechanical ventilation and drugs to fight infection or control heart rate, rhythm or blood pressure; and we move more explicitly towards focusing solely on the troubling symptoms that can accompany end of life, like pain, seizures, and difficulty breathing.

While the ICU is a high tech environment geared towards aggressive life-saving, the fact is that patients here are sicker, and as a result many of them don't survive.

The patient's immediate family needs to consult with several extended family members before making a final decision, for cultural reasons. They'll talk again with the team tonight, probably after I leave at 7pm.

Meanwhile, here we are - me and my patient.

When I first walked into the patient's room, the wall-mounted flat screen TV was loudly tuned to CNBC. It's a sad fact that the TV is on in a substantial number of the rooms in any hospital.

While a patient who's awake may need some distraction from long periods of boredom, I'm a zealot when it comes to turning off the TV when the patient's unconscious - and even when they're not. The scenes on the screen change and flash at a furious pace, and they're often frighteningly violent - not conducive to good health or recovery.

The cable system on my regular unit provides access to a couple of XM satellite radio channels, including traditional classical, so all of my unconscious and sedated patients, as well as some of the conscious ones, get at least a partial day's dose of Beethoven, Shostakovich, and the like.

I ran through the channels in the MICU. There was no XM, but I did find a radio station that I'd never heard before - it broadcasts a continuous stream of Islamic prayers and chanted recitations from the Koran. I've had it on all day.

My patient's not Muslim, and neither am I. I don't know any Arabic, but the sound of the chanting is comforting, and it's been filling the room with the presence of something from another part of the world:

The Sunnah recommended that a believer, whose waliyy, muslim relative, passed away should make du'aa, supplication and instirjaa saying the following, for his deceased relative:

Inna lillaahi wa innaa ilaihir
raaji'uun.
Allaahummah ajirnee fee
museebatee we akhlif lahuu
khairan minhaa.

To Allah we belong, and to Him is our return.
O Allah reward me in my affiction and
let him be succeeded by the best.

Originally posted to RubDMC on Thu Apr 03, 2008 at 01:37 PM PDT.

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Comment Preferences

  •  Is there a real differnce between ICU & MICU? (6+ / 0-)

    Or is the only difference in what the hospital chooses to call it?

  •  Lovely diary, Thanks (7+ / 0-)

    I am with you on ICU noise and noxious stimuli-alarms, voices, phones.  A peaceful passing denied, much less a quiet healing place to get better.

    Those who hear not the music-think the dancers mad

    by Eiron on Thu Apr 03, 2008 at 01:45:02 PM PDT

  •  Good to see you around Rub (6+ / 0-)

    I've missed your diaries.

    I think TV screws with your sleeping (and maybe, by extension, one's unconsciousness).  I know that when I've fallen asleep by the TV at night, I'm not rested the next day.  I don't know what it is, maybe the lights flickering on the TV.  I know that if I fall asleep with public radio on, I sleep fine.

    NetrootNews coming soon!

    by ksh01 on Thu Apr 03, 2008 at 01:49:06 PM PDT

  •  Recently had a friend die after (4+ / 0-)

    three weeks in the hospital, the last three days they moved him to "comfort care" due to the fact that both his liver and kidneys were in such bad shape that any aggressive measures taken in one area would have only speeded the crisis in another.

    The nursing staff was very attentive, helpful and patient.  They responded quite professionally to my friend's (not the patient)sometimes intrusive demands.  

    There was a time when I wanted to be a nurse, unfortunately my 3.36 college gpa was nowhere near high enough to get me into the program here in California.

    Thank you for your story.  I am sure that you are every bit the wonderful professional as the men and women I met here in Sacramento.

    There are bagels in the fridge

    by Sychotic1 on Thu Apr 03, 2008 at 01:52:24 PM PDT

    •  Your GPA sounds high to me (5+ / 0-)

      Our profession's loss.

      Palliative care and end of life are very strong professional interests of mine. I've done plenty of cowboy heroics over the years, and this stuff freels better to me now. Palliative care nurses are the best group I've ever met, bar none.

      Very sorry about your friend. We're all gonna die, and we know that on many levels. We just don't want to die alone, or suffer.

      •  You'd be a wonderful addition (2+ / 0-)

        to any palliative care staff.

        Your diary brings back memories of sitting vigil beside my mom's bedside.  The caring staff made so much difference, and  was so relieved to be able to have quiet in her room.

        Good to see you here. Peace.

        •  Three-year MICU nurse here... (1+ / 0-)
          Recommended by:
          RubDMC

          I've seen way too many things done to way too many people who were way too far gone for anything to help beyond prayers for their soul and a healthy dose of morphine and versed.

          I got into nursing originally intending to be a CRNA, but the more I have seen, the less that interests me.  Many of these poor people wind up in the shape they are in because of some ridiculous surgery that should have never been attempted on them in the first place.  Ethically, I don't want to be a part of that.

          I applaud the palliative care nurses.  For myself, I am redirecting to become a psychiatric nurse practitioner.  I am burned out already after only three years, and I just want to get away.  My wife is bipolar, and the mind and its workings fascinate me.  After seeing how she was helped by her psych NP (some of the newer drugs actually seem to work, imagine that!), I'd like to help people in a similar way.

          "People should not be afraid of their governments. Governments should be afraid of their people." --V

          by chriscarlson on Thu Apr 03, 2008 at 10:07:59 PM PDT

          [ Parent ]

    •  Don't let that stop you please. (2+ / 0-)
      Recommended by:
      RubDMC, Eirene

      There was a time when I wanted to be a nurse, unfortunately my 3.36 college gpa was nowhere near high enough to get me into the program here in California.

      There are Community College courses that can give you a AA for (called an ADN) Nursing. Of course you need to take State Boards for your RN. But it's the same State Board exam that a four year grad takes (called a BSN).

      It takes longer, many working RNs still want to get their 4-year degree and do.

      Besides both paths require clinical bedside experience and THAT'S what makes a nurse.

  •  One of my goals in life is to NOT die in an ICU (3+ / 0-)
    Recommended by:
    RubDMC, JG in MD, Eirene

    It's possible that I might anyway, and for appropriate patients, there's no other place to be.  But I'll never understand why they are used so heavily for patients who are almost certainly near death, regardless of the technology employed.  They're expensive, and even if there's no TV running all day, they're noisy and hectic.  It's no wonder that there's actually something called "ICU psychosis," where otherwise mentally normal people get psychotic symptoms when they've been in an ICU for awhile.

    I'll never forget the comment of an anesthesiologist of my acquaintance during the big healthcare debate in the Clinton administration, when Hillary's father spent a fairly extended period of time in the ICU after a massive stroke.  Hillary had been pushing to hold medical costs down, and this physician's comment was, "Not keeping comatose octogenarians who've had massive strokes and have no realistic chance of ever regaining any reasonable level of functioning would be a pretty good place to start."

    "Those who would sacrifice liberty for security deserve neither liberty nor security." -Ben Franklin

    by leevank on Thu Apr 03, 2008 at 01:57:50 PM PDT

    •  Yeah, it's a sticky subject (3+ / 0-)
      Recommended by:
      Eiron, Bernie68, Eirene

      We fear death, and so we often deny and avoid it at great cost. If there's one family member among a dozen who pleads that "everything be done" for a loved one, they can undo the best efforts of the other 11 who've agreed on a more honest course.

      Lots of ICU delirium has been shown to be related to sleep deprivation, whether drug-induced or as a result of overstimulation. There's a reason that sleep deprivation is the Cheney administration's favorite form of torture.

      ICU delirium has also been shown to have long-term detrimental effects on high-level cognitive function. The folks at Vanderbilt in the above link are doing some terrific work in this area.

      It's gonna come down to dollars. I don't know how old you are, but as baby boomers age and hit the system, we won't get indefinite, high-cost stays in our final months of life. It's just too expensive.

      And, as you've pointed out, there are much better alternatives out there.

      •  I agree with you about Baby Boomers (1+ / 0-)
        Recommended by:
        RubDMC

        As a society, we simply won't have the money for some of the intrusive end-of-life-extending therapies that we use now, and I think that's actually a very GOOD thing.  I'm pretty much at the leading edge of the Baby Boom generation (born in early 1949), and my 4 years older wife technically isn't a Boomer at all.

        I'm sure you will agree that it's extremely important for all adults to have in-depth conversations with their loved ones who might have to make medical decisions for them about the kind of care they want as their life is approaching its end, and to have both advanced directives (aka a "living will") and a health care power of attorney (or whatever it's called in the various states) designating someone to make decisions in the event the person can't do it themselves.  But by all means, people need to TALK to their loved ones in advance, because it's impossible to design an advanced directive that covers all of the possibilities, and having TALKED about the things one values in life, and what one's attitudes are about its end, makes the job of the person who has to make those decisions infinitely easier.

        One of the reasons this is so important is exactly the problem you describe, where one family member can insist on prolonging a death that other family members are ready to accept.  I've done some pro bono legal work for indigent hospice patients, and I've seen the problems that this can cause.  One of the best things anybody can do for their family is to talk to their loved ones about what kind of care they'd want near the end of life, and then be sure that somebody who is willing to go along with the overall approach has the authority to make those decisions.  And even if disagreements among family members aren't a problem, it's much easier for the person who must make the decisions if they've had "the conversationL and have reasonable confidence in what their loved one would want done under the circumstances.  Having had to make those decisions for both of my parents, they still aren't easy, but I can't imagine how much more difficult they would have been without that background.

        And one more piece of advice for those who have read this far:  Don't just have "the conversation" with your elderly parents about what THEY'D want done, and make sure that they've got the necessary documents prepared and signed.  Have it with the people who would make the decisions for YOU about what YOU'D want done, and get the paperwork done -- no matter how young and healthy you may be.  And if you're middle-aged and having "the conversation" with your younger adult children about the decisions you'd want them to make for YOU, make sure you know what THEY'D want done, and that THEY have completed the necessary paperwork.  Very few young adults have taken these steps, and the results are such tragedies as we saw in the Karen Ann Quinlan and Terri Schiavo cases.  I'm sure that none of us wants to bequeath such a legacy of pain to our families.

        It's not even necessary to go to a lawyer, at least in most states, to complete the necessary paperwork.  Many state attorney general's offices have the forms, and many hospitals also have them (because having as many people as possible prepare for that time avoids putting the hospital in the impossible position of being in the middle of a family fight).

        "Those who would sacrifice liberty for security deserve neither liberty nor security." -Ben Franklin

        by leevank on Thu Apr 03, 2008 at 02:59:29 PM PDT

        [ Parent ]

        •  Yes, excellent advice (1+ / 0-)
          Recommended by:
          CWalter

          I always point people to The Five Wishes, which is recognized in 40 states and serves as a useful template for having and documenting the discussion.

          Having this conversation in a relaxed setting, perhaps with a glass of wine, when the issues can be discussed more thoroughly sure beats having half a conversation under pressure in a busy hospital hallway when the key parties can't all join in on it.

  •  Nice to see you around! (2+ / 0-)
    Recommended by:
    RubDMC, Bernie68

    Good diary.

    "The Revolution Won't Be Microwaved."

    by Glinda on Thu Apr 03, 2008 at 02:12:36 PM PDT

  •  bless you (2+ / 0-)
    Recommended by:
    RubDMC, Eiron

    I spent nearly a month in CICU, and the nurses made it bearable. Bless you and all ICU nurses.

    We had a channel called, I think it was, the Care Channel. It had soft, soothing new age-y music, more spritely during the day, and very soft and almost not there at night. During the day it showed scenes of nature and animals, and at night a very slow-moving starscape. One of my friends called it the "flamingo channel," because for some weird reason, every time she visited, they were showing a clip of flamingos hanging out, eating and flying. That channel helped get me through. At night CICUs can be very noisy--hospitals in general. And having the TV on that channel gave me a sort of white noise that helped mask it all and help me sleep.

    Of course, the narcotics helped...

    :)

    •  Nice. What's the hospital... (1+ / 0-)
      Recommended by:
      LynnS

      ...if I may ask. I've been wondering about getting that sort of thing going here.

      And, yeah, there's nothing like a little taste o' the poppy when you really need it.

      Glad you're back in the saddle.

      •  Providence Portland (OR) (1+ / 0-)
        Recommended by:
        RubDMC

        One new-fangled unit, all glassed-in and relatively quiet as CICUs go, which is to say, not very, and one old-fashioned unit, where the patients are separated only by curtains and it is noisy as anything. I was trying to avoid sleep meds and getting by ok until they moved me to the curtains. The first night some poor old soul of about 80 spent the night sobbing for her mother; poor dear, I wished I could have done something for her. Didn't sleep at all. And the next night, they brought in a very sick gentleman who threw up blood all night in the bay next to mine.

        I took the drugs after that. Started hallucinating after a while, but what could I do.

          •  must be an Oregon thing (1+ / 0-)
            Recommended by:
            RubDMC
            Sacred Heart Medical Center in Eugene also uses a Care Channel or facsimile.  And they did a great job with my FIL's death.  He got pneumonia and they helped us pursue a no-treatment option that allowed him to pass in about three days in a regular hospital room.  Many hospitals will send the patient back to wherever he lives for that death, but FIL was allowed to stay.  They brought in a "music thanatologist" to play harp for him for an entire hour, gave him loving massages, and fully supported us in playing music for him (and keeping it going when we were out).  
        •  Decentralized nursing is great for quiet (1+ / 0-)
          Recommended by:
          RubDMC

          The new (2000) Surgical ICU at Regions Hospital in St. Paul, MN has a massively decentralized nursing model.  There is no nursing station, there are microstations between each two rooms.  There is a single double loaded corridor (patient rooms on both sides).  The corridor is also curved, so you can only see about 1/3 of the length of the unit from any given location.  It is the quietest ICU I've ever seen (and I've seen a lot of them).  Patients love it.  Their nurse is always right at their side, and they (and their families) love the quiet.  

  •  I imagine that Gregorian chants would .... (2+ / 0-)
    Recommended by:
    RubDMC, joyful

    ....soothe in the same way.

    Reminds me of drumming and the heartbeat.

    but the sound of the chanting is comforting, and it's been filling the room with the presence of something from another part of the world:

  •  Your description of the Islamic TV channel ... (5+ / 0-)

    reminded me of an incident from late in my mother's life.  At that point, she was in middle stages of Alzheimer's, had been injured in a fall for which she'd had to be hospitalized, and was in a nursing home for rehabilitation in preparation to going back to her assisted living facility.

    My mother was a Baptist for most of her life, and at one point, had begun preparing to be a missionary.  The nursing home was run by an order of Catholic nuns.  One Sunday afternoon, I visited my mother, only to find that a Buddhist group devoted to caring for others was leading a sing-along at the nursing home.  They were leading this group of old people, mostly women, in old-time songs, including old-time Christian hymns, and the warmth and mutal love flowing between the nursing home residents (who were all white or black, and virtually all Christians of some denomination) and this group of Asian Buddhists was almost palpable.  I remember thinking how much of a tragedy it is that those who want to demonize or even kill others over religious differences couldn't see this group of Buddhists acting with love toward an elderly Protestant lady in a Catholic nursing home, and realize that while we are all reaching for the divine in our own ways, we are ALL reaching for the divine.

    "Those who would sacrifice liberty for security deserve neither liberty nor security." -Ben Franklin

    by leevank on Thu Apr 03, 2008 at 03:12:41 PM PDT

  •  Why Rub, I didn't know you were a healthcare pro. (2+ / 0-)
    Recommended by:
    RubDMC, Brahman Colorado

    I thought you were just a reprobate with an outlaw internet radio station.  Ya learn something new every day.  :-)

    Good to see ya man.  Great diary.

    "The truth shall set you free - but first it'll piss you off." Gloria Steinem

    Iraq Moratorium

    by One Pissed Off Liberal on Thu Apr 03, 2008 at 04:06:30 PM PDT

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