What is this feeling? Why am I feeling it?

if you've working in critical care long enough, you've seen people die.

what may be worse, you've seen people that should die, but have families attached that want 'everything done.' these people, for whatever reason, think that their aged/sick/unresponsive/brain dead/kidneys-dead/lungs-dead/whatever family member is going to make a complete recovery.

everybody (staff) talks about how the family needs to get a grip. we speak like that under our breaths with each other, and try to be as objective and non-judgmental as possible when actually speaking with the family, of course. we say things like, if i'm ever so far gone that {insert medical treatment here, such as 'maxed out on pressors,' 'wearing a rectal tube,' 'on continuous dialysis,' 'stuck on a vent,' etcetera}, just let me go, man.

sadly, it seems that the majority of people that end up on our units are like that. maybe the smart ones stay away, and know better then to end up in a hospital when the inevitable happens. maybe the majority of people that die are smart about it and make their wishes clear and the ones we see are the minority.

i doubt it.

at any rate, when we get a 'do all you can,' type, we accept it and go about our work.

end case is usually a stable patient on a vent (usually trached), with pressor support (levo, dopa), and sometimes something for the heart, like cardizem or amiodarone. the patient, so to speak, spends their day like this; oral care every two hours, getting suctioned with breathing treatments every so often. once or twice a day the patient gets 'bathed,' with little foam wipes. Shaved occasionally, lotioned occasionally, and turned at least every two hours. the turning is important to combat the pressure sores that usually, inevitably develop, if not from the constant pressure of laying in a bed all day, then from the breakdown of the skin in the peri area. even with special mattresses. there are daily shots, at least one a day for the lovenox, a anti-blood clot med, and maybe more shots for blood sugar control, not to metion the finger sticks to check said blood sugar. for sure there is a catheter to collect the urine, so there is risk of infection from that. at this stage, there is usually a central like, something stable like a PICC or a subclavian line, which presents another avenue for possible infection. then there is the constant battle with pain and the constipation it brings on, which leads patients either having raging belly issues due to constant constipation, or raging diarrhea. there's hardly ever any inbetween.

is this life? is this quality? is this how you envision yourself going out of this world?

who would choose this for themselves? who would choose this for a loved one?

many people do.

and we get a lot of people like this. i mean, like, a LOT.

here is the problem. there are two kinds of old people (because, mostly, we're talking about old people here), the prepared, and the unprepared. the prepared ones know enough not to go to the hospital. if they get sick, they make themselves comfortable, gather their families (if they have time), or they go quickly. or they get something acute.

man, what happened to G-ma?

well, we found her down. she musta had a stroke. but man, you know how she hated hospitals and doctors and stuff, we all knew better than to call an ambulance. she knew what she wanted, she knew it was time.

yeah, she wanted to go out on her terms. that was our G-ma; always a fighter, and a classy lady. she went out in style.

yeah man, she was cool. she died in her favorite rocker, with a newpaper in hand. i think she was picking her fantasy team, man.

really? who's she have.............

the other kind are not prepared. this population is fragile. any number of 'one little things,' could push them over the edge. like, for example.....

older people are usually dehydrated. they don't have either the bladder control to hold it for long periods of time, the memory to drink enough fluids to remain in a state compatible with healthy living, and they'd rather sit than be drinkin' and peein' all the time. so this group of elderly probably live in a constant state of renal insufficiency and dehydration. not to mention malnutrition. you're just not as hungry as you get older, and that's if you're not fat to begin with. then there is just the age thing. when things get older, they don't work as well, nor do they recover as well. a 96 year old pair of kidneys or lungs is not gonna function as well as a 40 year old set.

what i'm saying is, it does not take that much to push you over the edge. then begins a cascade of events that leads to a state we like to call, 'circling the drain.' one thing leads to another, and before you know it, you have more problems than you can fix.

this is a really long post, and i haven't said anything you haven't heard before or don't already know, but i promise i have a point. thanks for sticking with me.

anyways. rarely do we have somebody come in to the hospital at the beginning of the Bad Cascade of Events that Will Lead to Ultimate Demise, recognize the writing on the wall, and say, you know what? let's not do this. no dialysis, no intubation, no CPR, no drips. lets just make Dear Family Member comfy, get'em outta this place if we can, and get some where we can gather and experience a peaceful death surrounded by loved ones and memories and not machines, meds, tubes and medical types.

you know what happens when we do get somebody like that? i get a sense of revulsion. i call it revulsion, but maybe that is an inappropriate term. i'm not sure what to call my reaction, but internally, i recoil. maybe that is why is is so hard to let go. maybe i'm all talk, and letting go, even after what i've seen of dying, is something that would be hard for me to do.

i'm all, like, man, they're letting go easy. did they not really love Dear Patient? what's going on? why don't hey wanna fight till bitter end?

why, after all my griping about having patients and families that Don't Get It, do i feel this way? why?

maybe asking for comfort care is a Hard Thing. a Rational Thing. can i make that choice, if not for myself, then for others?

i guess someday we'll see.