5 Triggers for Palliative Care in the ICU

Right now, I notice that some patients get palliative care too late in their stay at the hospital and sometimes pass away a day later after the consult was put in. We can do better than that to ensure patients are living the way they want to!!

I came across an article in a critical care newsletter called Estimates of the Need for Palliative Care Consultation across United States Intensive Care Units Using a Trigger-based Model. It said 1 in 7 patients need palliative care and that there are 5 triggers that indicate the patient has a poor prognosis and the healthcare team should put in a consult. It will give the patient and the family members more support and help guide them through difficult decisions. Here are the 5 triggers:

  1. ICU admission after hospital length of stay of at least 10 days
  2. failure of three or more organ systems
  3. stage IV malignancy
  4. status after cardiac arrest
  5. intracerebral hemorrhage requiring mechanical ventilation

 

In bed by 8:07am

Wow, I’ve never driven home from work, shower and be in bed by 8:07am. Yay!!! And I’m getting report from the same nurse tonight. I love that– back to back report to and from the same nurse.

My First ICU patient who passed away

He officially passed away this morning
while I was on break. DNR status.

Yesterday his son asked for my thoughts.
“I think he’ll make it tonight.”
Even though he was slowly deteriorating,
Maxed out on oxygen and 3 drips to keep up his blood pressure.
On fentanyl to make him comfortable.
He made it.

I returned last night.
It was a different story.

“Jessica, how’s he doing?” His son asked.
The generic “he’s fine” is off limits. It was time for the truth.

“Last night his respiratory rate was 9 or 10. Now it’s 15-18.
Often when people are nearing the end of life,
it goes from slow to faster and back to slow again.”

“But his heart rate looks ok. It’s 85.”

“Yes that’s true.
But his blood pressure is slowing decreasing.
His heart is still trying to compensate.”
He cocked his head. I tried again.
“His heart is trying to get enough blood to his body
but it’s not working. It will eventually give up.”

Optimism in his voice,
“But wouldn’t the heart rate slowly taper off?
I thought he would live a couple more days.”

“No, his heart can suddenly stop because it’s giving up.
I’m not sure if he will make it through the morning.
His drips cause his blood vessels to constrict.
That explains why his hands are cold
and the oxygen probe to not read well.”

After midnight, his HR was suddenly dropped to 42. RR was 9. SpO2 77%.
“Can you give us an update, doc?”

“Well I’m not a doctor.”

“It’s ok. We’ve promoted you. Just give it to us straight.”

I started to tear up a little bit.
It wasn’t easy for me to tell them what I thought:
He’s on his way out.

They told me that they’ve shed their tears already
and were waiting this.
“Thank you for taking great care of him.
You should be proud of you and your coworkers.
Tremendous sense of purpose and goal and comradery.”

His blood pressures stop reading.
Apnea alarm sounds.
That probably should’ve been my cue.
I still felt a carotid pulse.
I checked my drips.
Gave report and went on break.

I came back from break and looked at the monitor.
His was black.
“Your patient expired.”
Icy cold hospital terminology.

I debriefed with the experienced nurse covering for me.
What could I do better next time?
1. Listen for his heartbeat, not only feel for pulse.
2. Consider the BiPAP machine delivering breaths for him.
What’s the rate set at and what is his RR now?

In the final progress note
Include: heart rhythm- PEA,
who pronounced time of death,
which doctors notified of death.
Family at bedside or contacted.

In the end,
This family was ready to accept their father’s fate.
The son shared his friend’s voicemail message:
“How did they prepare the chicken?
They told him he was going to die.”
We chuckled.
Humor can start the healing process.

After I gave report,
I said bye to the family
And they all gave me a hug
And thanked me again.

I drove home
Half crying
Trying to drown the feeling
By turning up the radio.

I showered, ate, and wrote this down
So that I don’t forget.

Caring from the heart is nursing

Yesterday I wrote about a frustrating moment I had. A reader said that nursing is caring from the heart. I agree with that.

Since going to the ICU,
most of my patients can’t talk to me.
But one was A/O x3, could speak, though didn’t seem normal quite yet.

He was what I called “call-bell happy.”
Too hot, too cold, not comfortable–
it can all happen in a matter of 10 minutes.

1st night- “can I have a sleeping pill?” “Ice, ice, ice” “blankets on, blankets off”

2nd night- slept throughout the night but I’d catch him when he woke up and waved at me to come over. “hurts, hurts, hurts” “your bum?” He nods. I turned him to the other side and boom! He was fast asleep again.

3rd night- he looked like a new man!! Ahh the wonders of a good night rest.

He waved me over to fix him up at change of shift. He proceeded, “thank you. I knew that the moment I looked at you that you’re caring from the heart. You have made a big difference for me.”

I was a little bit shocked that he spoke so normally. We continued to talk and he spoke about another hospital. I asked him about his experience there. His eyes lit up and said, “You should be working there! There’s where you belong. You see that everyone collaborates and works so seamlessly as teams.”

I was taken back a little bit because I felt my unit had members who worked well as teams too. Does that mean he implied that here was worse than there?

He continued, “Leave your information. I’m friends with the head doctor there. I’ll get you a job there. I will. Include your specialty.” And he repeated this several times before he went to sleep.

Unfortunately, he was a step down patient and a critical care patient needed to get transferred into his room. So he left. And a new patient went into his place.

I never did leave my information because I felt that it was a little unprofessional but also, would he really remember? He still has to go to rehab to recover and it would be odd to have my information amongst his personal belongings. I’m not sure if I would’ve gone- I kinda like where I am now. Plus I’m just starting here!!

Another patient- I also had her for 2 nights with a couple days off in between. On the 3rd night she just came back from a procedure. She saw me and reached out for me. The PACU nurse said, “aww she really likes you!” I squeezed the patient’s hand and she squeezed back.

I think that says everything.

When the human condition is in conflict with itself

Wow, I just read grrm.livejournal.com blog and it reminded me of how I used to write. Just as myself and not another “list” or really thought out piece. So here’s my start to get back to journaling.

I came across another article about stories– the only stories worth reading are the ones when the human condition is in conflict with itself. You have a set of ideals and yet you’re torn with how you feel.

For example, last night a patient was complaining of pain and her nurse gave her pain medication. 15 minutes later, she’s asking for help. Her nurse is across the room and she saw me sitting at nurse’s station. I knew that her nurse had already attended to her so I ignored her (wow that sounds bad but I was busy catching up!!). After she called 3 more times I walk over and ask her, “what’s the problem?”

“Why didn’t you come over right away?” She probed.
“Your nurse just spoke to you. What’s going on?”
“I’m in pain!”
“Did you tell your nurse?”
“Yes. He gave me pain medications.”
I overheard him say that he gave the pain meds 15 minutes ago. “Ok, then you have to let it kick in.”
“Yes but it hurts!!!”
“Ok but you still have to wait for it to kick in!” I thought to myself, why made her think that complaining to me would make any difference?

I felt sympathetic for her because face it, who likes to be in pain? But I felt the issue was already addressed and that’s nothing left for me to do. Is that wrong? Did I lose my patience?

She ended up falling asleep.

As a nurse, I feel compassion and empathy but there’s only so much to go around. I pour it all on my patients and any patient that has a 3 alarm star going off… Or I’ll help out another nurse “boost” a patient up in the bed. But that’s about it.

Critical Care Orientation

Hi future critical care nurses,

Here were the topics that we covered in my critical care orientation. While the instructor said that this class is not to provoke anxiety, some of the topics made me a little nervous, but I guess that’s normal for anyone doing something for the first time.

Day 1

  • Compensation Mechanisms
  • Pharmacology

Day 2

  • Arctic Sun (Hypothermia therapy)
  • Hemodynamics I – Arterial lines, CVP
  • Intra-arterial thrombolytics

Day 3

  • Hemodynamics II – PA Catheters (Swan Ganz)
  • Hemodynamic Scenarios

Day 4

  • Glycemic Control
  • DKA/HHS
  • Insulin Infusion with Delta
  • Neuromuscular Blockage
  • IABP
  • TPA for MI
  • Temporary Pacing

Day 5

  • Phillips Monitoring
  • Acute Renal Failure
  • Peritoneal Dialysis
  • DIEP

Day 6

  • Mechanical Ventilation
  • Oxygenation
  • ABG Analysis

Day 7

  • Shock States
  • Sepsis

Day 8

  • ACLS Part 1 (BLS + videos)

Day 9

  • Intra-abdominal Pressure (IAP) Monitoring
  • Pulmonary Vein Isolation (PVI)
  • Crash Cart – Defib, Cardioversion, Pacing
  • EPIC Code narrator/critical care flowsheet

Day 10

  • Neuro RRT/tPA
  • Neuro Assessment
  • Neurosurgery
  • Intracranial (ICP) Monitoring

Day 11

  • Exams (Core and Pharmacology)
  • PACU Day – recovery from anesthesia

Day 12

  • ACLS Part 2 (Respiratory, Tachy, Brady algorithms; Test “Megacode”)

At least now I have some background information!

Anyway, happy holidays! Can’t wait to start.