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Can Palliative Care Exist in a MICU?

I am thinking about leaving the MICU for another type of nursing. I’ve been in the MICU for almost 2 years (if you include my student rotation). I’ve thought about leaving before, but up until now I hadn’t crossed the threshold of thinking, “I’m leaving because I can’t do this” to “I’m leaving because I don’t want to do this.”

What has set this in motion?

I went to a workshop hosted by GHOAT’s palliative care nurse. I’ve mentioned her before. She kicks butt (palliatively, of course). I think of her as “the angel of the MICU,” always swooping down to talk us through when we need it the most. When I think about what position I would like to be in 10 years from now, hers always comes to mind.

The workshop was enlightening, thought provoking…but not entirely helpful when I went back to the MICU.

I just finished a three night stretch. Here’s a sample of some of my patients:

17 year old girl with a terminal lung disease. She’s had the diagnosis for 12 years and is most likely in dying process now. The attending (from what I am told – You don’t get to participate in rounds when you work night shift) feels that because of her age, she still has a chance so they are “doing everything possible.” Mom has earned the label of “crazy.” She has been caught trying to feed her daughter strawberries (the daughter is trached and on the vent – food right now could kill her). The other day Mom gave her some sips of Coke. The next minute the daughter was gagging so Mom pulled out her OG tube while HER TUBE FEEDS WERE RUNNING. This girl is considered a difficult patient. Every moment she’s awake she is mouthing words to you. It’s usually something simple like “wipe my face” or I’m cold, I’m hot.” if you were to respond to everything she says you would be stuck in an endless loop of taking off blankets, putting them back on, rearranging pillows, swabbing out her mouth, probably for 12 hours straight.

So you learn to set limits.

I gave her all of the PRN Ativan and fentanyl that was ordered and LET HER SLEEP. Even if it meant I could not get all of my MICU rubber-stamp tasks done on time.

The next night I came back and the charge RN had switched my assignment. (I didn’t ask her too but figured it it was for the best.)

My new patient was a 50 year old woman with endometrial Cancer, morbidly obese. She’s had a THBSO (total hysterectomy and bisalpingo-oophrectomy) and her wound is infected and not healing. I’ve gotten several reports that she is “developmentally delayed” and at the functioning level of a school-aged child. I can’t find this documented anywhere but I did find it documented that her father says she graduated from high school.

In my opinion, she was a lot like the 17 year old.

I went into her room and introduced myself. The first thing she said to me was, “The horse broke its leg.” I knew we were going to get along.

(For anyone following horse racing news you will know that she was referring to the Preakness, in which the favorite horse had to be pulled out of the race with an injury. I had just happened to be watching the race the night before and had unexpectedly burst into tears as I watch the whole tragedy unfold.)

She wanted to talk to me the whole time I was in the room. It was challenging. she was on a face mask with oxygen and it was difficult to hear her. Fortunately she was my only patient so I was able to spend time with her.
Several times she would cry out, “I don’t feel good.”

“What’s wrong?” I would ask.

“I want to go home. I’m a mess.”
“I’m going to die.”

It’s hard to know what to say to that. Especially when I feel as thought she is correct: she most likely is going to die. She has cancer. They won’t start chemo until she’s more stable. She’s been teetering between 50% 02 via face mask and re-intubation (hence, they are keeping her in the MICU). The resident feels that because of her morbid obesity, her surgical wound will never heal.

In light of this I suggested a palliative care consult to the resident.

“Um… okay…. I’ll bring it up on rounds.”

Not exactly a ringing endorsement. However this was the same physician who earlier in the night a nurse was explaining “the five things” (a common theme in palliative care in which there are five things that the dying patient needs to hear before they let go) to him.

“Where did they teach you that. Nursing School?” was his smug reply.

At any rate, I set some limits with my patient. I explained to her that that I needed to leave the room for awhile to do some other things, (we received 4 admissions that night and withdrew care on another patient, so the unit was quite busy) She actually got some sleep but in between I spent a lot of time talking to her. I found out she was from my neighborhood. We talked about her family, her church. I listened to her when she said “I’m going to die,” but I also did my best to distract her. Part of her problem was simply that she was awake, bored, but also keenly aware of her failing health. By the time I was ready to leave she grabbed my hand and said, “Thank you for being so nice to me.” I realized that probably no one had given her the attention that I had given her that night. Granted, I had the luxury of time on my side (she was my only patient.) But still. How do you listen to someone weep and say, “I’m going to die,” and ignore her because she is “developmentally delayed,” and hence, “acting inappropriately.”

I don’t think I am cut out for this unit anymore. I’m thinking of pursuing hospice care.

Although part of me feels that I should stay and “fight the good fight” when it comes to palliative care in the MICU. After all, isn’t that why they keep sending us to these workshops?

But how do you change the culture of the Greatest Hospital Of All Time?

The answer is, you don’t. I just did a search at the GHOAT nursing website of the word, “hospice.” No results were returned. I did another search of “palliative care.” The only result was pointing me to the workshop that I had just attended.