Dying in the Intensive Care Unit

Abstract

The scenario is familiar. The patient, an elderly woman who lives in an assisted living facility, arrives at the hospital emergency room with pneumonia and a history of heart failure. She is intubated on the second day of hospitalization after a respiratory arrest and admitted to the intensive care unit (ICU) in a comatose state. Although she had no advance directives, her family states that she has always been clear about not wanting to be kept alive by extraordinary means if there was little hope of recovery. After 4 days of care in the ICU, the medical team wants to continue aggressive treatment (including a cardiac catheterization), but the nurses and family are united in their insistence that the woman be taken off the ventilator and be kept comfortable. Is this situation the norm? Nurses and family members questioning aggressive treatment? Physicians eager to treat in the face of a dire prognosis? An elderly patient receiving aggressive diagnostic tests and care when there is little or no chance of recovery? If it is not the norm, this scenario (which is fictional) reflects many conversations we’ve heard during our combined decades of experience in the ICU. Physicians are often described as “flogging” patients when there is little hope of recovery. Nurses are usually cast as advocates for compassionate care, wanting to discontinue aggressive treatment and focus on symptom management. Certainly, words like “torture” and “suffering” appear to be used more often by nurses than physicians when assessing the effectiveness of intensive care treatment. Family members and patients, as the stereotype plays, are portrayed as united in their desire for palliative care and a peaceful death. Anyone who has spent time working in critical care knows that, like all stereotypical portrayals, the one described here does not represent the full picture. Yet, like all stereotypes, elements of truth exist. In many of our patients’ lives, care in the ICU will absorb their last months of life. In fact, most individuals will not experience the death that in repeated national surveys they say they want; instead, they will die in the hospital after numerous procedures and treatments. Nurses will provide care that, unfortunately, will exacerbate pain, not eliminate it. Colliding Cultures What does dying in the ICU mean from a nurse’s perspective? An article in this issue of the American Journal of Critical Care focuses on the moral distress that nurses working in one medical ICU experienced. 1