All Intensivists Are Not Created Equal

All Intensivists are not created equal.

By: Debbie Moore-Black, RN

I’d like to preface this story with saying that the majority of the Intensivists I have worked with have been exceptional, caring, and professional. We had all established a good camaraderie and we had mutual respect for each other. We worked well together.

But there always seemed to be one that was the exception.

And as I drive some long miles on a recent “get away” to the mountains…, the flashback came back to me.

Joellen was 64 years old. She smoked all her life. 2 packs of cigarettes a day. She started smoking at the age of 16. Hollywood made smoking sexy and romantic.

By the time she was in her late 50’s she developed severe shortness of breath without exertion. She had difficulty breathing. She wouldn’t put her cigarettes down.

Her physician told her: “If you don’t stop smoking for good, you’re going to die.”

In and out of the hospital she progressed to a diagnosis of CHF and COPD. Her physician told her at the age of 64 she was now considered “end stage” COPD. There was no regimen of care for her as her lungs were destroyed by her incessant smoking.

She agreed to sign a Do Not Resuscitate as she entered the ICU one last time. She did not want to be intubated. But she agreed to be medically treated.

It was now my shift. Night shift. And Joellen had a very bad day. Her breathing was shallow, her lips were cyanotic, her O2 sats were in the 80’s.

It would have been an optimum time to place her on “Comfort Care”, but the patient said she wasn’t ready to die.

Throughout the night, I watched Joellen breathe with great painful effort. She sat straight up in bed, shallow forceful breathing.

She suffered so.

I notified the “Virtual MD” to request morphine for Joellen. She had nothing ordered to ease her breathing. Even a small amount Morphine IVP could help relax and slow her breathing down without as much struggle.

The virtual MD said “no” he would not order morphine for her. I explained how she was awake and alert and suffering terribly… but he said “no, I don’t want her to get addicted to the morphine.”

I then Notified the Intensivists on call.

That was our chain of command.

Before I could explain myself to the Intensivist on call, he said to me “Do you realize you woke me up from my bed at 0300”?

I told this physician how Joellen was having shallow breathing, diaphragmatic breathing, low O2 sats and she was suffering greatly and all I wanted was some Morphine to give to this poor lady to ease her breathing and her suffering.

He let me know he would get back to me after he talked to the Virtual MD.

One hour later, I received a call back from the MD on call. Lasix 20 mg IVP stat. That will take some fluid off of her and it will help her breathing.

We don’t want her to become addicted to morphine”

And that was his answer.

And here I was faced with a dying woman. Lasix didn’t touch her. Her breathing became more shallow. Her lungs filling with fluid, barely able to auscultate. Her O2 sats slowly dropping to the 70’s and 60’s.

I sat next to Joellen and held her hand. Wanting to breathe for her. Wanting to comfort her…wanting to provide her with just a small amount of morphine…. but unable to.

I was given the most inappropriate order ever from 2 MD’s who claimed a dying woman would potentially become addicted to morphine.

Poor Joellen. As I held her hand, her breathing slowed to a minimum. She had worked so hard. Her eyes rolled back, and she let out her last breath.

I felt defeated. That a simple order from an MD could not be obtained.

Joellen died a painful death.

Eventually I found out that there was a review of this “case”.

I’m sure there was a “mild reprimand”

I drive up to the mountains. The leaves changing into their vibrant colors…

And I still see those haunting eyes of Joellen.

Comfort in my final hours

Originally published on KevinMD

My name is Lucy.

I have stage IV liver cancer. I wanted everything done — even though the doctors told me this disease is terminal. My family, my church and my friends were praying for “the cure.”

Though I believed in God and the hereafter, I wasn’t ready to go. 74-years-old with beautiful children, grandchildren, and a great-granddaughter.

I woke up confused. In the background — wherever I was — I could hear music: “How great thou art.” One of my favorites.

I had a tube in my mouth, and I couldn’t talk. My wrists were restrained, and I couldn’t move. They had me tied down. Everything was blurry. My chest hurt like someone had pounded on it. People in white coats and scrubs surrounded me. I became aware that I was in a room with doctors and nurses and respiratory therapists.

A man introduced himself. He said he was a respiratory therapist, and he was going to pull the “tube” out of my mouth. The endotracheal tube. I gasped and took a deep breath, and I could barely talk.

The team explained to me that I was in the ICU. And because I wanted everything done to me, I had been emergently intubated, restrained, pain and sedation meds given through my veins continuously. My heart decided to stop, and “the team” did CPR on my fragile body. Because by now, I didn’t want to eat. I had lost over 25 pounds from the liver cancer.

I was told that some of my ribs cracked during CPR. I had pneumonia.

A palliative nurse came to talk to me within a few days. I wasn’t out of the jungle yet.

The palliative nurse talked to me about comfort, about acceptance, about peace and being pain-free and being with my family and friends surrounding me.

Comfort care. DNR, DNI.

New words for me.

I was so sick, so tired, so much in pain. I led a wonderful life.

Now, it was time for acceptance.

I remember those words from my doctors: terminal, no cure, palliative chemo … extending your life.

But at what cost?

Was it worth staying in an ICU in a comatose state? Was it worth having your chest beaten on with CPR and cracked ribs and pneumonia set in? Was it worth being tied down?

I knew the answers.

I was always stubborn. But maybe it was time for acceptance.

Maybe the prayers being sent my way were meant for a peaceful death. A peaceful entrance into the heavens.

I called my family in with my physician, my nurse, and the palliative care nurse.

I begged my family to please not put me on a ventilator again.

Please let me be comfortable.

Please make me comfort care.

DNR and do not intubate and do not treat.

I slept quietly going in and out of consciousness. My sons and daughters gathered around. They laughed and cried and told many fun stories of when they were young! My grandchildren and great-granddaughter held hands as they sang “Yes, Jesus Loves Me.”

Another favorite of mine.

And their tiny voices uplifted me and my soul.

I was surrounded by love.

This time — I was ready.

Who is alive: man or machine?

Originally published on KevinMD

He had cardiomyopathy and CHF for over 20 years. At the time, doctors told him he could die at any time. That was 20 years ago. His EF was 10 percent — barely livable.

Two decades later, this admit kept him on a see-saw with respiratory distress, a bad heart, bad lungs, atrial fibrillation with RVR and heart rate in the 140s all day long. He progressed from nasal cannula to Optiflow to 100-percent BiPAP. A Cardizem drip was added to no avail. His next step would be intubation.

I pulled his wife outside of her husband’s room. And I told her that he wasn’t doing well and we may have to progress to a ventilator, and not to let him drink anymore — aspiration and aspiration pneumonia.

I could see the years of suffering on their faces. The dedication and love they had for each other.

His wife agreed. But 20-minutes later, she came to talk to me.

“We don’t want a ventilator. We’ve dealt with this for over 20 years. He doesn’t want a ventilator,” she said.

I grabbed our intensivist and gave her the heads up. She talked with the wife and the patient who both requested a DNI.

The patient stated he would go through one round of CPR … just one round. A strange request, I thought.

The MD added DNI to the patient’s chart.

An hour later, his wife came to talk to me again, “This doesn’t make any sense to not put him on a ventilator but to do CPR and crush his ribs and hurt him when we know he has a bad heart and lungs. I think it would be cruel! He’s ready to die. He told me so. We don’t want to see him suffer anymore. He just wants to be pain-free. No more pain and suffering.”

I could see the years of suffering on their faces. The dedication and love they had for each other.

Back in the day, we had a universal policy: All or nothing. Either a full code with CPR, intubation or nothing at all. Now patients and families can choose. There are different variables: no intubation but do CPR. Or give ACLS meds but no CPR. Many of these variables/ protocols make no sense to me, but the families and patients get to choose.

I agreed with Mrs. Smith and explained to her as we were surrounded by three respiratory therapists that by not intubating but doing CPR one time was like giving him a car but telling him he couldn’t have any gas.

The respiratory therapists agreed.

I introduced the thought of morphine in small amounts. A 2 mg IV push helps with breathing and anxiety and air hunger.

She agreed. And Mr. Smith was made a DNR/DNI.

The man’s family came from near and far. His sons, daughters, sisters, brothers, his buddy from elementary school, his favorite chaplain and his wife. They all sat by his side and kept vigil. They shared stories of Mr. Smith as they laughed and cried.

As Mr. Smith nodded in and out of consciousness, they held hands and hugged one another as a tear rolled down Mr. Smith’s cheeks.

We made Mr. Smith “comfort care.” And that’s what it means: providing comfort at end stage lung, kidney, heart, liver diseases, terminal cancers and multi-system organ failure.

Morphine was given as needed for comfort.

And we watched Mr. Smith drift away from our universe — the inevitable.

I cry as I write this. But I rejoice in knowing that we did not torment this man with CPR, cracked ribs, ventilator, wrist restraints, central lines and dialysis.

I remember something my husband once said to me,”Who is alive: man or machine?”