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.