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Chapter 45: Intensive
Care or Insensitive Care? |
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Death
is a punishment to some, to some a gift, and to
many a favour.
- Seneca
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The technology of medicine has advanced to the point
that aggressive intervention can prolong the lives
of even the most seriously ill or injured persons.
Almost every hospital has an intensive care unit
( ICU ) equipped with ultramodern instruments such
as ventilators, dialysis machines, monitors, resuscitators,
defibrillators and catheters to aggressively support
patients whose life systems are failing.
The equipment and the human resources needed to provide the heroic care in the ICU are very expensive and costs continue to soar. Yet only one out of every ten critically ill patients treated in the ICU survives. Clearly, there is a need to reconsider, from a compassionate viewpoint, how we choose to use this expensive, often painful and infrequently beneficial treatment option. In fact, countries such as the UK have decided to control ICU admissions so that doctors send only those patients with clearly treatable conditions there.
Patients and their families must also begin to look objectively at intensive care treatment. While the ICU can, undoubtedly, provide the best of technological medicine and prolong life, the care is aggressive and potentially dangerous and should not be chosen lightly. Nor is expense the only consideration; the ICU can be a cruel, harsh and demeaning place to spend one's final days.
It is not easy to make decisions involving life
and death. The best time to make these decisions
is when we are well and can think clearly, but few
of us bother to do so! This tendency to procrastinate
forces us to make crucial decisions during a crisis,
and the decision-making process tends to be clouded
by the disorientation or bewilderment caused by
the sudden illness or by emotions of grief. The
medical system, slanted towards aggressive intervention,
may not provide the most balanced viewpoint ideal
choice during this difficult time.
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As you grow older or become more disease prone, you need to discuss openly how to approach your final days. You should be thinking about 'living wills' and 'physician directives' in order to guide your family members and physicians on how you wish them to act on your behalf when you can no longer make decisions for yourself. While you are in good health, decide what medical intervention you want undertaken on your behalf in case of serious illness or accident. Record your wishes unambiguously in a living will. Even though living wills and directives to physicians are not legally binding, they are helpful in guiding your physician in case you fall seriously ill. Reviewing these documents with your physician in advance has the added benefit of finding out his attitude towards the care of the terminally ill.
The following tips could prove very helpful for the relatives and the loved ones of a critically ill person:
If you do choose to proceed with aggressive, life- supporting measures for a family-member, you must constantly monitor your actions to ensure that you don't get carried away with the glamour and glitter of technology and, in the process, neglect the patient's basic human needs.
Intensive care is almost always invasive. You must decide if your loved one's pain and suffering are ultimately worth the effort. Also, the following questions need to be kept in mind: Is the condition curable? What is the increased likelihood of recovery with intensive care? Is the ICU the appropriate place for treatment?
Often the decisions regarding the care of the gravely ill are clouded by the intensity of the psychological grief that the family is experiencing. Guilt almost always plays a part in how family members feel when dealing with critically ill loved ones. It is natural to wonder what more we could have done and to blame ourselves for any past conflicts we may have had with a dying person. It is important to ensure that these feelings and emotions do not interfere with rational decision making about how aggressive one should be with regard to the prolongation of medical care.
Keep track of who exactly is caring for your loved one. If a number of specialists are involved in the treatment, make sure that your family physician is acting as the 'captain of the ship'. This physician should coordinate all aspects of the care process. The fragmented effect that can result when several specialists are involved could be inefficient, expensive and even dangerous. To avoid such possibilities the primary care physician should ensure that nothing is duplicated; he should give specific directions as to the care needed.
The coordinating physician should also take into consideration the humanistic aspects of the care process. He should continually evaluate factors such as the likelihood of survival, the patient's need for psychological support, as well as the needs of the family.
While it is definitely important to have your primary
care physician coordinate the various procedures,
intensive care usually requires the expertise of
specialists. Doctors who specialise in taking care
of patients in intensive care units are called 'intensivists'.
Depending upon the complexity of the problem, many
consultants may be involved; for example, a heart
specialist or a kidney specialist. However, remember
that the bulk of the care in an ICU is really provided
by the nursing staff. They usually work on shifts,
so that you may encounter a new face each time,
but try to get to know the nurses who are looking
after your patient - such meaningful contact can
make a world of a difference to the care he gets!
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Visiting privileges are usually highly restricted in an ICU for medical reasons. Consequently, you cannot see or meet the patient, and it's often very difficult to find out how the patient is doing. Reliable information about your patient's condition is hard to get, and the medical staff often provides only very guarded replies, all of which tend to increase your anxiety levels considerably! Many relatives maintain all-night vigils, armed with cellular phones, often in shifts, outside the ICU, in case there is a sudden change in the patient's condition. However, while the conditions outside the ICU for relatives are miserable, the condition inside the ICU for the patient is often even worse !
The ICU is typically a large windowless room, sometimes with curtains between the beds, sometimes not. Men, women and children are usually clubbed together. There is a central nursing station from which all beds are visible. Bright lights are on day and night. The ICU tends to be noisy as monitors beep all the time. People are constantly dying. Sleep is usually impossible. Disorientation is common, not only because of illness or injury but also because of the constant din, bright illumination, hectic activity and lack of sleep. Small wonder that an ICU can be a terrible place to be in! Also, because ICU patients tend to be debilitated and gravely ill, the ICU is the most dangerous place in the hospital because one can easily catch a serious infection.
The preceding reasons should provide you adequate motivation to try to get your patient discharged from the ICU as soon as possible! Each day, make it a point to ask the as to exactly why intensive care continues to be necessary. Sometimes round-the-clock special duty nursing in a regular hospital bed can provide equally good medical care and that too at a fraction of the cost of an ICU bed.
It can be scary a loved one in an ICU, with tubes
and pipes coming out from all parts of the body.
However, try to provide as much love and encouragement
as possible --- remember that emotional support
can make the difference between life and death!
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To help you in monitoring the usefulness of intensive care, the following can be helpful.
Intensive Care checklist
(1) Diagnosis -------------------------------------------------------
(2) Reason for intensive care (what couldn't be done in
a regular hospital bed)? -------------------------------------
---------------------------------------------------------------------
(3) If condition is critical, what is the chance of survival?
(a) In an ICU -------------------------------------------------
(b) In a regular hospital bed? ----------------------------
(4) What are the current invasive procedures?
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(5) Who are physicians involved? Why?
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(6) Primary physician ('captain')? ---------------------------------
(7) Length of time expected to be spent in the ICU?
_______________________________________________
(8) When are visitors allowed?-------------------------------------
By whom? -------------------------------------
(9) Can the family be involved in the care?
_______________________________________________
(10) Who is spokesperson for the family?
Comments _____________________________________
_______________________________________________
_______________________________________________
The best person to complete this checklist would
ideally be a loved one. The questions should be
reviewed daily to ensure that the ongoing intensive
care is both necessary and appropriate.
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