Critical care dissatisfaction

[RNtoMD87]

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I am an RN that works ICU and stepdown.

Do any of you residents/attendings/med students with critical care experience share in my lack of satisfaction in dealing with the volume of vegetative patients that don't even know they're alive? I really like the depth of knowledge and ability to titrate drips etc but it's discouraging taking care of patients for YEARS who are probably better off dead.

I'm asking because I was wanting to do pulmonology as a medical specialty, and love all other aspects of the floor, and dealing with high acuity, it just makes me feel bad feeling like I'm prolonging patients suffering that have a terrible quality of life. Basically keeping bodies alive so families can collect a check.

 

[LizzyM]

If they don't know that they are alive, how are they suffering?

 

[RNtoMD87]

If they don't know that they are alive, how are they suffering?

Is self awareness necessary to feel pain?

 

[Tenk]

Yeah this is one of the reasons I did not do critical care. To make it worse the news will highlight these 1/1,000,000 miraculous recovery cases which gives the layperson false hopes. You are definitely not alone.

 

[siliso]

It made me vacillate between CC (taking care of people in the ICU) and palliative (getting people who don’t belong there out of the ICU), before ultimately deciding on neither. If you’re in a position of decision making and family meeting holding, you can help to guide people to a peaceful transition of goals toward comfort, rather than being in the position of just having to carry out orders for what seems to be futile or inhumane care, so that’s different and maybe more rewarding.

 

[getdown]

@RNtoMD87 I agree with Tenk and yourself. I understand and respect the families wishes to prolong their loved ones lives and the hope for a miracle to happen. I also believe that patient autonomy is very much a central tenant of our healthcare. I also agree that sometimes families should be given a few days to come to terms with the diagnosis or bring other family members from out of town to say goodbye to their loved ones. So having them stay on support for a few days is ok but definitely not for months at a time. And let me be the first to acknowledge that I have seen patients on ventilators for months and been discharged quite healthy. But like Tenk said, those are really rare and should not be taken as the norm.

However, that being said, the amount of wasted resources and futile care that goes on in America because of this is unbelievable. At some point, the family and or patient has to be brought to understand that their condition is not going to get any better. I am a firm believer of utilitarianism in healthcare as well as quality over quantity of life. There's a lot of contradicting papers out there about the actual amount of money spent on end of life care, but ultimately the amount of money spent is not insignificant. As much as people like to believe, we do NOT have infinite resources. The majority of patients that end up in tertiary care ICUs are older cancer patients who should be in palliative care but keep bouncing in and out of the hospital. It's very sad, a majority end up dying in the ICU unconscious, hooked up to so many lines and tubes they look like part of the machine.

 

[siliso]

If you have or can develop impeccable skills in communication and empathy, you can attune yourself and the patient’s family to the same wavelength of caring intensely about the patient’s best interest and doing what is really best for the patient, even when that means switching goals from aggressive attempts at cure/prolongation to aggressive and dedicated pursuit of comfort and peace and dignity. This can be immensely rewarding and fulfilling and the most human thing you can get to do in medicine, and CC is one of the most fruitful places to do it if you have that personality and skill.

And then you’ll also get the competing humility of realizing you don’t know when someone occasionally has a destiny to beat the odds and that having the technical skill to get them through the night will allow the situation to declare itself, tomorrow or the next day.

 

[Nedsson]

That's an element of CC for sure. But not the only one. There will be (and you probably have seen) cases where you'll have unique opportunities to make an impact with your skills and knowledge. And I think that many other specialties deal with a high ratio of bs/ actually significant patients and pathology too. I loved the ED, but some days the malingering, scrip seeking, and stuff that should have gone to the doc in the box really got to me. Other days though...you catch the stemi, help the kid with the asthma attack...and you remember why you wanted to do this. Its like life in general; its rough...but it's still the only game in town.

 

[Mt Kilimanjaro]

I was pretty appalled with most of my ICU experience in medical school. Marginally indicated interventions, multi-million dollar hospital stays that would have better for the patient and the family if palliative care and/or hospice had been initiated months earlier, massive mid level creep, etc. Lots of “House of God” moments.

 

[RNtoMD87]

Basically feel like a corpse farmer and breaker of 90 year olds ribs. * snap snap snap snap*

 

[HuskyMD Emeritus]

At one hospital where I work, the ICU is semiclosed and all the patients are managed by intensivists who are in the ICU almost all the time. The hospitalists do not follow their patients in the ICU. Most of the patients therefore are in the ICU appropriately. We do get a few futile cases but because we are available to speak to the family, are available to answer their questions, hold family meetings, show them data regarding prognosis, many cases are changed to comfort measures and end of life care. We also hold multidisciplinary rounds every morning with the families invited to to attend, so they know we transparent with the treatments given. There are a few frustrating cases where we flog the patients until the very last heart beat..... Having a step down unit where all the chronic ventilator patients go is also a great help.
At the other hospital were I work, it's an open ICU and there are many patients admitted there inappropriately just because the hospitalist or the floor nurses are "uncomfortable" despite the patient not requiring any ICU interventions.
Don't let your concerns about providing futile care dissuade you from going into pulmonary-critical care, just choose the group you work with and the hospital you work at wisely.

 

[RNtoMD87]

We have step down at our icu and they only send the critical patients to the ICU. Hospitalists Dont manage icu patients, the step down is managed by CCMS, HMS, ENT, OMFS, and many others.

We have multiple icus, CICU, MICU, SICU, TNCC, NCCU,