In my case, a fairly healthy somewhat weak elderly person incurs a fall, perhaps due to a mild heart attack. She is unable to rise but crawls to an emergency call button in the middle of the night and attempts to get help but passes out just before she gets to the button. Her distress is not discovered for more than a day.
When discovered, she is transported to the hospital and treated in the emergency room where her condition is stabilized. Then she is taken to the ICU unit to be treated and monitored until she can be moved to a regular room. In the ICU, the family is solaced to see her being cared for intensively. She is connected to a heart monitor and a breathing monitor; she is apparently comfortable. Now her family sees and hears that her vital signs indicate that she is OK. One day later, this person is conscious and able to discern what is happening around her. Things are looking up!
In two days, she looks better and is moved to a regular room. She smiles and is happy to be around her family. The heart starts to beat at a high pace, so she is moved back to the ICU. Now after two days, new problems surface. Her skin is damaged by laying on the floor. She is beginning to suffer more from the weakness of being bed ridden along with the trauma of the fall and laying on the floor.
In a day or so, due to her skin condition, a special mattress for burn patients is ordered. That would seem to help and it probably did. Yet the burden of weight on those same damaged tissues presents a serious threat to her health, sustaining the wounds, even though she is turned every two hours. She is on some serious pain killers for her skin. Nurses keep saying that they are trying to make her as comfortable as possible. That is their goal. Then I am approached by the doctor. Levels of care are explained to me by the attending internist. He says she is in serious trouble and that we need to know the levels of care the hospital offers: (1) All emergency care needed to sustain her life, (2) All care to improve her health but without certain life saving procedures such as heart electrical stimuli should her heart fail, (3)Discontinue life saving techniques altogether and give her everything to make her comfortable until she passes, (4) Take her to a facility for the terminally ill, away from treatment facilities.
We chose the first level. This lady (my mom) had elected to live to the age of 90 or beyond. She was mentally competent and was able to live independently. She had events coming up that she did not want to miss. She wanted to live! So we gave her our full support.
Over the next three weeks in ICU, her health bounced around with good days and bad days. At one juncture, the internist wanted to talk to her and see if she still maintained her posture of recovery irregardless of the pain and difficulties involved. He took her off of sedatives with our consent. He told her to our surprise, that her condition was grave and she had less than a 5% chance of living through this. She could not have surgery because of her weak condition, and it appeared that she would need the surgery if her colon did not start to function very soon. He felt that her colon would never restart. In tears, my mom agreed to go to level two support. I intervened telling the doctor to at least tell her she had a fighting chance! Now I could tell that she was beginning to give in to the illness. She would never recover from this declaration by the doctor. No superman saving techniques would be allowed now.
The next day, dramatically her colon starts to function. She is recovering and able to eat now. Off with the intravenous liquid feeding. This afternoon, the doctor changes his prognosis to a 60% chance of survival, but is unable to tell her so under the same conditions as before. He does say the words, but in my estimation, she does not understand what he says. She does not respond. We remain at level two support.
A few days later, her lungs can no longer sustain her. She has liquid in her lungs and even though she is not running a temperature, the doctors say she needs breathing assistance. She has been on oxygen for a couple of days. So as an emergency procedure, her family decides to put her on a respirator. This is not considered a level one procedure but must be administered as such, because we waited until the last minute to allow it. Now she is on a respirator, a liquid food diet administered by tube, a kidney dialysis machine, and bi-daily skin care.
Her health gradually deteriorates.
Finally, after one month of intensive care, we honor her written request to be taken off of life support systems. She passes away hours thereafter.
In retrospect, I can see very significant opportunities for improvement in the processes and procedures I saw during this long time in the ICU. For one, I feel she needed to be floated, suspended in a water type bed where the medium would be about the same density of the human body. She needed to be removed from the consequences of the gravity of this earth. Medicine apparently does not offer such support systems. I ask the question, why not? Isn't such an invention available? It is an obvious solution to the problem. When we are in water, there is great relief by flotation. Then we look at the other obvious and related part to this. Should not there be some way for a person to get exercise in this environment? Is the ICU patient supposed to abandon all exercise? Is the patient capable of some form of exercise? Isn't exercise supposed to be part of maintaining the human body?
I had this general topic on my list of things to write about, but until today, I had not seen anything supporting this thought process. Today I just read one in the New York Times (see link below). This is a good start towards improving the ICU. I plan to respond, supporting this study on exercise for those in an ICU, especially for those with extended stays (more than 2 days).
It is my sincere belief that my mom died before her time, even though she was 87 years old, because of ineffective procedures and archaic thinking in the ICU. Her age and the related ICU strategies is another subject that I will write about some another time.
New York Times article - A Tactic to Cut I.C.U. Trauma: Get Patients Up
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