It was Saturday night.  The woman was trying to engage Dr. F in a discussion about her mother, the patient in ICU 2.  It was the middle of the night.  Dr. F was alternately at the computer writing orders and attending to a very sick patient who had been transferred to the ICU 7 a few hours earlier and then stopped breathing.  The patient in ICU 7 was unstable and on a ventilator.  She had many family members who hovered around her bedside and outside the room, moving out of the way of the nurses, physicians, and techs taking care of her.

I knew a little about the patient in ICU 2.  She was in her late 60s.  She had been admitted to the ICU after she had presented to the ER on Friday.  She had a low blood pressure and difficulty breathing due to a severe infection in her lungs.  She had been placed on a ventilator and efforts were made to restore her blood pressure by providing large volumes of IV fluids and IV vasopressor drugs.

The patient lived alone.  Her history was complicated by many years of smoking one to two packs of cigarettes a day.  She had indicated that she drank five to six shots of booze a day.  A general rule of thumb is that most patients who are heavy drinkers will admit to drinking one half to one third of what they actually drink.  Her lab work showed a severely impaired liver and kidneys.  Prior to being placed on the ventilator, the patient had requested that she be made Do Not Resuscitate or DNR.   The fact that the she was on a ventilator and was receiving IV vasopressors indicated that the DNR line limiting extreme measures to keep the patient alive had already been partially crossed.

The daughter of the patient in ICU 2 had not been there the previous night.  She had a small suitcase in her mother’s room.  I assumed that she had likely flown in from some distant place today after hearing of her mother’s illness.  Her pacing, drawn face, and her desperate efforts to engage the busy Dr. F in discussions about the status of her mother made me think that she was just starting to get an idea of how gravely ill her mother was.

The shift continued on through the night.  My two patients were stable, but busy.  J, the nurse taking care of the patient in ICU 2 came over to chat with me around 5 a.m.  We talked about her patient and J said that she felt that the physician who had rounded on the patient the previous day, Dr. S, was not being aggressive enough in treating her.  She felt the patient had a reasonable chance of surviving if the patient was treated with dialysis.

I was stunned about J’s comment and dropped the conversation to go visit my patients.  I have worked as a critical care nurse for over two decades and what J was saying didn’t make sense.  But it was nearing the end of the shift, I had many tasks to complete, and I did not feel like challenging J’s assessment of the patient in ICU 2.

The next evening, Sunday, the patient in ICU 2 was on continuous dialysis, a very intensive treatment that requires a nurse to be at the bedside at all times.  J continued to take care of the patient.  She remained on the ventilator with a large tube down her throat, she was heavily sedated, and her hands were restrained to prevent her from pulling out and tubes that were essential to keeping her alive.  Besides the patient’s daughter, her son was also there looking like he had also traveled from some distant place.  There was essentially no improvement in the patient’s status.

Later in the shift I quickly reviewed chart on the patient in ICU 2 trying to understand the source of J’s optimistic comments from the previous night.  Several physicians had examined the patient and they all felt that the patient’s chance of survival were remote due to the infection that was spreading through her body, her failing lungs, liver, kidney, and heart, and her past history of smoking and alcohol consumption.  I quickly reviewed the literature on this syndrome of multiple organ system failure and it confirmed what I already knew:  mortality varied from 30 to 100 percent and mortality increased with the number of organs involved.  There have been no improvements in the treatment of this syndrome in the past 25 years.

After reviewing the chart, I was angry with J.  I couldn’t help but feel that she had influenced the patient’s daughter to ask the physicians to treat her mother more aggressively.   I tried to suppress a sense of outrage when I considered that the patient had requested that she be made DNR when she was admitted and, with that, that extreme measures to keep her alive be withheld.  I had watched and participated in too many of these futile efforts in the past with the family hovering over the patient for weeks and the patient dying a slow, uncomfortable if not painful death.  Perhaps my conjectures were wrong, but I felt that J had likely influenced the family to think that the patient had a reasonable chance of survival when this was not at all the case.

I have kept my feelings about the patient in ICU 2 to myself, except for what I write here.  I avoided speaking to J for the rest of that shift, my last shift of three, because I was angry with her and I sincerely doubted that exploring my anger with her would do anything positive. 

This is difficult to express, but I write it for you Dear Reader.  I don’t want you to have to go through the long days of futile suffering that the patient in ICU 2 and her children will likely experience.  Think about your own life and inevitable death and that of your children and parents.  Be kind to those that you love and let them know that you love them as often as you can.  Respect their wishes to live, die, and not to suffer.  I pray that you never  find yourself in a situation like the patient in ICU 2 and her family where attempts to express love and devotion result in suffering and slow death.