We have a patient that makes me very sad. He’s been with us in ICU for almost a month. He came in for a straightforward procedure. But even straightfoward procedures carry risk, and he suffered some complications. He seemed to rebound briefly, but then experienced some more complications.

I don’t think he’s going to make it. Actually, I’m almost sure.

I have taken care of this man every day that I’ve worked for the last 2 weeks. That’s 10 days with someone who is critically ill. Ten days with a family that is teetering on a bridge that spans hope and despair. Every time we add some new treatment or some new medication that will hopefully save his life, my fellow nurses ask, “Why? Why not let him go? What is the family trying to do?”

I know where they’re coming from. I have been them. I have looked at critically ill patients in whose care I have not participated, to whose family I have not sat with day after day, and thought the exact same thing.

“Why must we continue with this when we already know the outcome?”

If you stop to think about it, we are obviously not treating the patient, we are treating the family. The family has, of course, given permission to us to go all out to try to save their husband, father, brother, uncle. In the end, they will take a small measure of comfort in the fact that we have done everything. This patient was supposed to have a procedure done, and be home by the next day. That didn’t happen, and now it’s becoming clearer by the hour that he will never go home.

He has started to do something that some of us call “fish breathing.” Even though he’s on a ventilator, it appears as though he is gasping for air. He looks like a fish out of water.

His family brought in pictures of him taken when he was a very strong and vigorous man. He currently looks nothing like those pictures. I would not have pegged him as being the same man. He is both swollen and wasted at the same time. His eyes are open, but there is no life behind them.

There is nothing for us to do but wait for our treatments to fail. None of us, including the doctors, feel as though we can approach the family about withdrawing care. We haven’t even broached the subject of not coding him.

If you’ve been reading this blog for awhile, you know how strongly I feel about not flogging patients that are doomed. I have written several entries about what it’s like to be coded, what happens when we withdraw treatment, and what happens when we don’t withdraw treatment. I like to think that I am an advocate for those patients who are going to die, but get stuck with all of this high-tech equipment that isn’t going to change the outcome. I certainly agree with giving the patient a chance to recover, and giving the family some measure of “we did all we could,” but I like to think that I can then steer them towards accepting that the end is near.

I can’t do that with this family. I have become a little too close to them. To bring up that subject after all we’ve talked about would feel like a betrayal. “Sure, I’ll participate in doing everything possible for this patient, but I really feel like it’s a waste of time.” I don’t feel like it’s a waste of time, I just feel very sad. I’m sad that he didn’t go home the next day, that he’ll never play golf again, that his wife and children will return to where they live without him. He is obviously very loved and has a very devoted family. I can’t bring up withdrawing when the doctors are still giving “guarded hope.” To go against doctors would immediately peg me as the enemy, and any relationship that I have built with this family will shatter. In this case, I feel as thought the docs are in a much better position to broach this with the family, because they have not spent hours and hours per day with them.

I have lost objectivity with this patient. On some very basic nursing level, I enjoy taking care of him. I know the orders so well that I have very few surprises when I take over from the previous nurse. I know the routine of medications and lab draws very well. I know the family well and enjoy hearing them talk about his life. They know my name, they thank me often, and make me feel appreciated. They literally pat me on the back. I am giving the patient the best nursing care that I know to give, but still the nagging in the back of my mind continues… I am not doing everything to help alleviate this patient’s suffering. But who am I to make such a decision? They teach us about being a patient advocate in nursing school, to do what’s in the patient’s best interest. And I want to do that. Every single doctor and nurse on this case knows how this will end. Does this sound harsh to the lay-person or medical professional who is not intimately aware of the realities of ICU?

Why is it I that must be so concerned about this patient? Why aren’t the doctors more willing to step up and have this conversation? They keep saying, “give it a few more days.” “We’ll discuss it with them next week.”

All the while, the patient lays on his bed, hooked to several machines, wires, and medications. He continues to fish-breathe. We sporadically give him pain medicine when his blood pressure tolerates it. He’s waiting for us to let him die.

Check out the story of Grand Rounds at Chronicles of a Medical Madhouse.

I recently got a comment: I struggle with the question of why I am changing careers. I used to LOVE being a nurse – I loved my job and my patients and their family members could tell. As the years progressed, I fell out of love with nursing. Admittedly, I have only worked at one hospital, but the red tape just kept coming and I knew I couldn’t continue to work as a nurse.

I think nursing and hospitals face the same issues and problems that other professions and businesses have: incompetent management, too much red tape, not enough supplies to do the job effectively… the list could go on.

There’s a lot of paperwork that one must keep up on just to be a nurse. There’s licenses to keep current, education requirements to fulfill, proof of those education hours that needs to be kept, competencies on different machines and procedures that need to be renewed (and the proof kept). We each have little folders that we must maintain that contains all of these myriad papers.

Every once in awhile, “management” comes up with yet another piece of paper or activity that we need to do or keep track of. One afternoon, my colleagues and I were sitting around the break room table one day, preparing for shift report. We were complaining amongst ourselves about the latest memo that came out saying that we must now keep track of such-and-such. It quickly went the route of the “This is what’s wrong with nursing today!” conversation. The unit clerk was also sitting at the table and at the first pause in the conversation said, “Well, that all may be so, but you guys are living the dream!” Meaning, of course, that most of us had wanted to be nurses. We went to college and trained for years in order to be able to work at our chosen profession. She got quite a laugh, and the conversation was diffused, but I think she has a point.

Many people complain about their jobs. Some people really had no idea what they would actually be doing as a doctor, nurse, lawyer, astronaut, whatever. But if you used to love being a nurse, then it’s really a shame that you’d feel like you had to leave. It’s different from getting out of school and discovering right off the bat that it wasn’t for you.

I also strongly feel that nursing is different at different hospitals. If you truly enjoyed nursing, just try a different hospital before leaving the profession altogether. I’ve gotten really lucky with all of my jobs. I’ve been very fortunate to work with very talented, fun, interesting people. Are there problems? Yes. Every unit is going to have problems… but there are problems that you can live with and some you can’t. I happen to work for a hospital that has problems that I can live with. There really are hospitals out there that nurses like working for. Or if you didn’t want to work in a hospital, go to a school, doctor’s office, research facility, children’s home, nursing home, rehab facility, home care… the list goes on! We need good nurses staying in the profession.

You know, living the dream.

This week’s Grand Rounds is up at RangelMD. He’s done a great job!

Also, Echojournal has opened the voting for the Med Blogger Awards of 2004. Go vote for your favorite! Voting ends at midnight on January 16th. Codeblog has been nominated for Best Medical Weblog and Best Clinical Sciences Weblog.

Now, I don’t claim to have all of the info regarding these nurse-to-patient staffing ratios. All I know is that as of January 1, 2004, staffing ratios in California went into effect. The whole idea was inspired by the Aiken Study, which was published in JAMA in October of 2002.

A summary of the findings are as follows:

• The study found that for each additional patient over four in a nurse