Continued from Page 2

For good reason, many nurses do not want family present during an emergency procedure. Family members may become unsettled or argue against a procedure because they do not understand why it’s being done. Family presence may interfere in teaching and mentoring situations. But nurses understand why families want to be present, Medina said — it may be their only chance to say goodbye.

“We shouldn’t have the door closed, nor should we have it completely open,” Medina said.

Wiles understands firsthand the need for family presence and for open communication with nurses. Her first husband was fatally injured in an auto accident when they were both 21. She remembers the ICU nurses discussing with her in detail his injuries, and how much that information helped her deal with her sudden loss.

Wiles, who serves as a preceptor to incoming ICU nurses at Banner Mesa Medical Center, said critical care nurses have a responsibility to be as open with the family as possible. “We have a new grad nurse treating a patient who was not neurologically intact. She saw that the family didn’t understand that he wasn’t getting better, so she saw to it that they talked with the doctor. She learned that from me.”

Moral distress

Critical care nurses are starting to talk more about end-of-life issues and to confront the moral distress many nurses suffer from the decisions they’ve made — or have been unable to make in deference to physician or family preferences. For years, Cathy Schuster, RN, BSN, CCRN, has been troubled by a pair of DNR patients who died on her watch as a night-shift nurse at the University of California, San Francisco Medical Center.

Schuster, after consulting the staff, once continued care for a sedated elderly man against his wishes after a desperate call from a family member. The relative begged them to resume care long enough for her to arrive before he died. “My dilemma was, could I delay death for her visit? Morally and ethically, you’re torn,” Schuster said.

In the other case, Schuster was troubled by an unresponsive patient in her 40s who showed signs of agitation when Schuster began the withdrawal of care. She and the staff chose to continue withdrawal, unsure whether to contact the family.

“We sometimes feel the futility of continuing with aggressive and supportive care. 85 That becomes a dilemma for us,” Schuster said. “When death is inevitable, we need to switch our mode of life to one of comfort.”

The improvements in health care that can extend life sometimes cloud the ethics for nurses, who suffer high burnout rates because of moral distress. Ultimately, many palliative, end-of-life decisions are for families and patients to make, so nurses have to provide the guidance.

“I think there are more choices people are going to have to make,” said Chris Wesphal, RN, MSN, CCRN, with Oakwood Healthcare System in Dearborn, Mich. “The shift to patient autonomy has made the need for decisions on choices [some people] are not prepared to make.”

Instincts

Not every nurse can handle the emotional baggage of the ICU. Death happens in the ICU, and that inevitability in cases is at odds with a nurse’s determination or a family’s false hopes. Critical care nurses cannot stoke those desires for a positive outcome, no matter how much it may appear to smooth the pain.

“You don’t want to take all the hope away, but you have to prepare the family,” Martin said.

Martin said it took her nearly two years to feel “comfortable” as a critical care nurse. Those greener years of her career saw her waking up in a cold sweat after dreaming she was the only nurse in the unit, overwhelmed by the alarms, buzzers, tones, and beeps from the monitoring equipment.

“It’s really hard to come straight out of nursing school and go into the ICU,” Martin said. “Plenty of nurses can’t make the adjustment. You can’t wait for someone to tell you what to do.”

“They also find out really quickly they can’t do this without the help of their peers,” Martin said. “When there’s a code, all but one nurse will head to the room and one will remain on the floor.”

Having been a critical care nurse for nine years, Martin has honed her instincts well. She knows which patients may be on the cusp. She knows which ones will probably make it. And she only has to look at the calendar to prepare for the rush periods. Each fall brings a flood of flu and pneumonia victims. The holidays have arrived when high-cholesterol, stroke, and heart attack candidates check in after indulging on family feasts.

Martin said there’s no sign yet of the influx of spring patients who overexert themselves with outdoor activities. She’s prepared for them, as well as the “frequent fliers,” as Martin calls the chronically ill patients from nursing homes and other hospitals who could fill up the rooms today.

She looks over at the BiPAP patient again, and reads through his medical records that have just arrived nearly three hours after his ICU admission. To the layperson, he still looks near comatose, but Martin turns to walk back into his room. She knows better.

“He might be waking up soon,” and be a little confused about where he is, especially without any family members around to tell him where he is, Martin explains.

“Excuse me for just a minute.”

To comment on this story, send e-mail to editormtw@nurseweek.com.