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Life, resuscitation, and the pursuit of dignity

October 1, 2009

Tomorrow is my last day of my ICU rotation. I was afraid in the past of undertaking such a rotation as an elective, because the medicine can be extremely complicated and the outcomes uncertain. However, it’s been one of the best services I’ve ever worked with. The real challenge was not in understanding the pathology and management of complex illness, but in dealing with the fragility of life, in about 10 sick sick patients, every day.

I have been on the periphery of much loss this year. Delivering bad news is a part of my job in Family Medicine, and there have been some especially challenging circumstances. A few times, it’s been telling a patient that there is something ‘funny’ on their chest x-ray, which warrants further investigation. Other times, it’s confirming that the worst-case scenario is unfolding. There’s so much yet to learn about supporting people through these times, and in the ICU, it’s right in your face. Sometimes, it’s helping a family decide to switch their loved one from life support to comfort care measures only. Sometimes, it’s going through the simple routine of assessing for signs of life and pronouncing a patient dead while their family of six surrounds the bed, and trying not to feel overwhelmed as they graciously give thanks for this closure. Usually, it’s struggling to answer the question “so, doc, tell me: is she going to be okay? is she going to live?”

I’ve been to quite a few courses to learn how to save lives in what might otherwise be their last moments. Courses like Cardio-pulmonary Resuscitation with Automated External Defibrillator (CPR-AED), Advanced Cardiac Life Support (ACLS), Advanced Life Support for Obstetrics (ALSO), and the Neonatal Resuscitation Program (NRP) pile up on my mental resume. Rarely have a I had the occasion to employ this knowledge. It feels like I’m just saving plastic mannequin’s lives, one resuss course at a time.

There’s a lot more we can do to save lives before we get to the part about pounding on someone’s chest. In family practice, a lot of our time is spent on preventative care and this is a much more economical and effective means of helping people live healthily. What has become obvious over the years is that “saving lives” doesn’t necessarily equate with prolonging them. Comfort and dignity are valued above a beating heart by many people.

In the ICU, we do aggressive care but we also do a lot of palliative care, focused on making decisions with individuals and their families about quality rather than quantity of life. These are tough conversations for everyone involved; balancing optimism with pragmatism, we aim to respect the wishes of the family and the patient, all without benefit of a crystal-ball-of-medicine informing us of prognosis.

The intensivists and nurses I have worked with this month have modelled compassionate care beyond what I ever expected. Yes, the ICU is a vigorously medical place, but it is also the scene of warm hearts and gentle truths.

NB:

For those in British Columbia who want to think about their “Living Will” or what sorts of measures they would like taken in the event of severe illness, talking to your doctor about the effectiveness and appropriateness of resuscitation is a good idea. Talking with your family is an important step too, as if you are unable to communicate, we will ask them what your wishes would have been. A good way to make sure your choice is always known is to wear a MedicAlert bracelet indicating your choice. You can read more at the MedicAlert website, as they provide free bracelets to BC residents whose wishes are not to have cardiopulmonary resuscitation undertaken.

2 Comments leave one →
  1. October 1, 2009 9:03 pm

    Excellent post. I discovered Palliative Care during my Intensive Care Unit rotations as a second year resident. It was a time when I felt like I was not helping anyone even though I providing excellent evidence based care and had a extensive knowledge base and good teams to work with. I realized despite the excellent medical care provided by myself and all around me, people still had progression of their illness, and the simple fact that I could not remember being thanked at all during my first 18+ months of residency for a job well done. Not trying to be egotistical, but it really took a toll being unappreciated. Right during that emotional burnout/low point I had a tough family meeting where the family got upset, cried, but came to terms with the patriarch’s eventual decline and likely death. At the end of that family meeting I was thanked and hugged for having an open, honest conversation. ICU and palliative care go together since mortality is so high if you ever get to the ICU in the first place and goals of care discussions are crucial to good medical care.

    Thanks so much for sharing. This is one blog post that will be going up in Grand Rounds this next week.

    Oh and you have my personal invitation to be my guest at the AAHPM Annual Assembly in Vancouver in 2011.

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