Kathy - Death and Ethics in the ICU

Kathy -







Nursing as a profession engages us not only in personal connections with people, but in using our brain power to save lives. We have an emotional calling to care for people, and we use our intellects and our analytic capabilities, as well. The two are interconnected in nursing, which is one of the things I like.

The work of nursing has always been hard, but these days expectations and responsibilities are extremely demanding. The work environment has gotten more complicated. Unfortunately, the need to be cost- effective and efficient actually defined healthcare for a time. The work culture was about serving that economic need, rather than honoring the work of caring for patients.

Now I'm sensing a growing acknowledgment that the culture of a healthcare organization has an impact on the people in it: patients, doctor, nurses, and staff, as well as on the bottom line, profitability. We know people work more efficiently when the environment is healthy, respectful, and empowering.

We're realizing that there underneath the need to be efficient, cost effective, and profitable, is the importance of giving good care to patients. Care is at the center of everything we do.

One of way to create healthy work environments is to move toward more collegial."I struggle to keep goodness in the forefront, and not allow my soul to be robbed." and collaborative relationships between nurses and physicians. Especially in academic teaching hospitals the physicians, especially residents, are there temporarily, and so they rely on nurses, who are present every hour of every day. The residents are invited guests in the nurses' environment.

Especially in the ICU, physicians depend on the expertise of the nurses to provide continuity and to be gatekeepers for the patients. Overall, I've had some excellent experiences of that. But I know that's not true in other environments, and we have a lot of work yet to do.

Part of the problem is the long history of nursing as a primarily female profession and medicine as a male profession, with all the historical implications of inequality and oppression we've moved quite a ways beyond those stereotypes, but traces remain.

For instance, sometimes we as nurses enable physicians to continue their bad behavior. Nurses make excuses for doctors, "They're stressed and busy," or "Their work is so hard." Most of the time we're oblivious to how we as nurses keep the behavior going. We're caught in the pattern, and we need more education and awareness of harmful dynamics. All of us could benefit.

Working in the ICU in a teaching hospital, I saw some painful ethical dilemmas around the issue of death. When someone is dying, they want their death to mean something. They want the process to be peaceful and honorable and appropriate. In that situation, we were constantly searching for the balance between the physicians’ need to learn, and the need of the patients to die an honorable death.

At some point, learning the technology has to give way to respect. I have attended patients who were dying, and treatments and procedures were imposed on them, even though the outcome was known. When a doctor comes in and throws technology at a dying person, he robs them of a good death. Whenever that happened, it hurt my soul.

I struggle to keep goodness in the forefront, and not allow my soul to be robbed. Watching patients endure, watching them suffer, only makes sense when I know that the patient and the family have been given an experience they can value. When that doesn't happen, we forfeit our compassion and the trust of others for the sake of technology and someone else’s learning.

As nurses we must insist on a process that results in something good for patients, even if we can't save their lives. Even when the outcome is hard or painful or tragic, we can give care, comfort and be the witness for ethical decisions. That way, when we sense something that seems disrespectful of a life or a family we can intervene and provide education, or a different suggestion. It’s those moments when we don’t intervene that accumulate and bear down on us. We get burned out and cynical. Grief accumulates. Anger grows. Fatigue takes over.

We need more recognition of how difficult the work can be. We always want a happy ending, and we don't always get that. We also need our healthcare organizations to communicate and prove that they value integrity so people will want to come to work each day instead of wanting to leave.

My hospital is successful that way, because we have a mission that people connect with and want to be part of. The mission is to serve the population that comes to us with energy and effort and cutting-edge technology no matter who they are, or from what walk of life. That means the jail patient who's incarcerated for a felony. The homeless woman on the street. The baseball player who needs surgery.

What I value--and I think most nurses value too--is a sense of meaning and purpose in what we do, and respect for the difficulty of the work and how much of our selves we invest in it. At a certain point, I decided I couldn't tolerate that loss of my soul, so I went into a research position. I didn't leave healthcare; I didn't leave the system. I found work that had a different emphasis, and that kept me in the profession.

Power Strategy: Sovereignty, Integrity, Compassion
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