The other day, while I was carefully loosening a perfect oyster from its bearings, a good friend said to me, "Signout, your blog rocks my world. However, what is up with--if you'll excuse the expression--all the mental masturbation?" (Quite the wordsmith, this friend.) "You should use your blog to offer more than just discussion of interesting problems: you should offer concrete solutions."
I said, "Solve this," and pointed him toward the following post. Then, with great regret, I schlepped my bags to the airport and headed home.
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The other night, I started writing about one of the things I hate about the NICU, which is that no one there talks about death. I didn't finish it, so I didn't post it, thinking I'd get to it the next night.
The following morning, instead of our usual attending rounds, we had a "debriefing," which is basically a meeting of everyone in the NICU involved in the care of a patient who has died. As these things often are, it was a lovely example of the support that people can show for each other at moments when they question their own actions and motives. But beyond that, the session helped me understand why people in the NICU do what they do.
For an intern like me, there are plenty of things to hate about the NICU: long hours, patients we often can't touch and can't ever talk to, questionable ethics of some of the things we do. But there's also a lot to like: acuity of disease, opportunities to educate families, interesting physiology, occasional adrenaline rushes, and the odd chance to "test neurological status" by letting a baby suck on your finger. In our NICU, there is also as much free coffee as a person can drink, and really, isn't that enough?
But in the NICU-and in pediatric medicine in general-we don't talk about death. This is in direct contrast to adult medicine, where we are trained to reflexively consider what will happen if, instead of making patients better, we make them much, much worse. As part of every admission to an adult medicine service, we determine the "code status" of each patient, asking when we need to stop trying to make them live. Some people want us to withdraw care when they're no longer able to breathe independently, others when their heart stops beating. Some people don't ever want us to stop, and that's fine, too-but we ask.
In the NICU, we don't ask-at least, not until it's hardly a question any more. And in not asking, it seemed to me that we were choosing for these babies a lifetime of painful existence-the kind of existence that we give adult patients the option of avoiding having to live for even one unnecessary day.
But that's not exactly what's happening, and I didn't get it until I heard the NICU staff talk about it. Everyone who works in the NICU is at times conflicted about whether intervening to prolong the lives there is ultimately to their patients' benefit. Nevertheless, they do intervene, and they do it for two reasons.
The first is their committment to families. Their best reason to do what they do is to give parents time to align their hopes and dreams for their children with the reality of their prognoses, and on the basis of that, to make choices. Their next best reason is their own experience: about once a week, a child comes into the NICU who, years earlier, doctors thought would never leave it alive. Our smartest attendings can't count the number of times they've been wrong about a child's prognosis; it's hard to recommend withdrawal of care from a sick baby when you've seen equally sick ones live well.
The non-longitudinal nature of a resident's contact with the NICU and our limited contact with the children who actually make it out of there makes it difficult to keep these motives in mind. And it's hard to understand what a difficult choice it is for a family to withdraw care from their child if you're not sure you have the instinct to breed, or if you see disability as a burden to a patient and a family. I easily fit into both of these categories.
But I can understand that in addition to treating sick infants, we're treating anguished parents, and that you can't force an adult to come to terms with a loss. Before they can let their child go, some parents need to see that everything that can be done has been done-and sometimes, we agree to cause a child prolonged suffering in order to fill that need. We rationalize doing this by remembering the times when the suffering, against all odds, resulted in a living, happy child. But in the absence of certainty, we prioritize a parent's emotional well-being over a child's pain.
I'm not sure whether this is the right thing to do, but it is comforting to know that the doctors in the NICU are weighing something when they keep sick babies alive. Even if they don't often talk about death, they are thinking about it, all the time.
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Isn't it interesting that you never once mentioned nurses. Why is that, I wonder? (This is not directed at you alone. Almost never are nurses mentioned by physicians or patients, except in peripheral assistant roles of no significance. I'm curious about why this is.)
"The NICU staff" and "everyone who works in the NICU" very much includes the techs, nurses, respiratory therapists, residents, attendings, and anyone else who's involved in NICU care--I'm not sure why you'd think it doesn't. In the remainder of the piece, the focus is medical decision-making, which is the domain of doctors.
I mention nurses when nurses are part of the story. Same way I mention patients when patients are part of the story, and the way I mention danish when danish is part of the story.
Look, my blog is beginning to resemble my life! Awesome.
I see - to you, they're just part of the background noise. In your world, nurses have no role in determining healthcare decisions?
It may interest you to learn that your view is not an accurate one. Perhaps you will strike up a conversation or two and explore....
Nurses are to patients are to pastry - that's a new one. ;)
Yeah, in our NICU, the nurses don't make end-of-life decisions. If they did, there'd be a lot more mercy in the place.
I don't think you know me well enough to tell me what my views are. I'd urge you to read this blog less defensively.
Why is it that so many nurses seem to have so much insecurity with their roles in healthcare. Have MD's made them feel unappreciated? Have patients? Are they themselves incapable of patting their own backs and taking satisfaction in their role within healthcare?
I agree that nurses don't get a lot of airtime, but how much appreciation airtime do MD's get in nursing conversations? Usually I see only frustration with us a lot. I think we all appreciate and rely on you to handle a lot of work within the system and as such, we are freed up to concern ourselves with things that lie within our domain. I will try and be more vocal about my appreciation if nurses will try and stop feeling so insecure about their roles alongside MD's. After all, when is the last time you appreciated, vocally, your trash collector. Without them, we would have streets filled with stinking piles of garbage and disease would be running rampant, so don't they deserve airtime too?
Lack of vocalized appreciation does not mean lack of appreciation, we could both be better with that, but don't attack people simply because they don't talk about you when they are discussing their own problems. This blog post was about the this MD's experiences it seems to me.
ScutMonkey and Signout: as novice physicians, it behooves you to demonstrate some intellectual curiosity about the legitimate roles of other healthcare providers. Neither of you appears to have interest in learning about nursing. So be it.
I brought questions to Signout because from his post, he discussed a care question that he appeared to believe was in the sole purview of physicians, but that is in actuality and practice well within the scope of practice of nursing as a collegial - and not subserviant - profession.
You both will be shocked - shocked - to learn that the discussion that is so elusive to Signout occurs with regularity, professionalism and comfort by nurses with the infants' parents and families. And that it isn't hidden or covered up. But that Signout is oblivious to it because he hasn't engaged nurses in discussion about it. Ignorance is not bliss. I tried to lead him to striking up these conversations on his own. Ah, but subtlety is lost here.
Appreciation of garbage collectors? All nurses seek appreciation - from physicians? Now I'm getting the distinct impression that the both of you harbor stereotyped images of nurses. Nurses, in general, don't seek appreciation from physicians. They do earn and demand professional respect. But no, nurses aren't dependent on physicians for their professional worth.
I didn't attack Signout (or ScutMonkey). I invited him to be curious and to engage. That the point was missed may be a factor of his medical education. There isn't usually an emphasis on interdisciplinary case management in the basic medical curriculum. GME varies greatly by program and specialty. However it's a critical component of your education. I hope you'll partake of it.
Both of you made many wrong assumptions about nurses in general and me in particular. Indeed, your stance reads as dismissive of nurses. Rather than pursuing your incorrect impressions, why not engage in some discussions with the nurses in your clinical environs and explore their roles, where your practices intersect, and where they differ? I guarantee that you will come away with very different impressions than you have now.
Pardon - Please change my he's to she's and hims to hers - too late and not enough coffee.
If you knew how Signout feels about pastry, you wouldn't feel offended in the least by any such comparison, real or implied. And are you so sure that Signout is a "he"? You know, on the subject of stereotypes and assumptions...
Why climb the wrong tree? signout is having a hard enough time as a first year resident doing her best being an extremley compationate physician.She is describing her obvious pain in seeing young life and their parents in pain, and this is what it is about here .Nursing or any other subject is not point of this discussion....
N=1, you have made many unreasonable assumptions, among them that you somehow have the right to turn this comments section into your own personal referendum on what is wrong with me.
I'm not going to respond in an itemized fashion to your hot mess of crazy. If you'd like to continue to have posts accepted in this comments section, I'd recommend focusing on the issues at hand--there are so many to choose from that do not involve belittling me or reinventing me as an enemy! I invite you to check out the archives, where you will also note that I am not a dude.
One more post that presumes to tell me what behooves me, what shocks me, what impressions I have, or what kind of relationships I have, and anything further from you will be systematically and unceremoniously deleted.
I take enough shit at my job. I don't need to take it on my own goddamn blog.
Carry on.
The more I think about it, the more I think it would be a good idea for residents to shadow nurses through a nursing shift (to get a better idea of what they do and of all of the shit they have to put up with) and about how just as good an idea it would be for nurses to shadow a resident (preferably an intern, since it's interns that they page all of the time) through a 24 hour shift to see what it is they do and all of the shit that they have to put up with, and so that they can understand what it's like to be on hour 23 of a 24 hour shift and get called about someone's colace when the patient's usual team is coming in in 1 hour and will be seeing the patient shortly.
I think it would improve communications on both ends. I am not even going to pretend that nurses aren't often underappreciated, but actually, so are residents.
Just my $0.02!
Go Signout, you badass! I tried to write a post yesterday, coming down hard on N=1 about giving you shit on your own blog and making terrible assumptions, but my diatribe was, well, a long-winded diatribe! Your reply, however, was perfect! Amen, sugar!
I'm sorry that you interpreted my comments as judgmental. I was inviting you to engage in discovery and dialogue. I will follow your directive not to revisit your blog, and I acknowledge that your gang has got your back.
As for what Midwife With a Knife wrote: Indeed, my education involved attending all medical science courses with not only nursing students, but with the dental and medical students (A&P, physiology, and gross dissection). Medical and nursing students also rounded together during several university hospital clinical rotations. When I staff nursed, I rounded at about midnight with the PGY 1 and got "through the night" prn orders on all patients, and routinely the intern was able sleep from about 12:30 until whenever his or her morning rounds began, unless an ED admission arrived or a patient coded. I didn't realize that this practice wasn't the norm until one of the residents clued me in. But it built in mutual respect - they knew that when I called, that I had already assessed the patient and could give them the short version of significant findings and I knew that I could rely on them to respond and be able to act quickly on a plan that had been discussed during rounds.
Siloing nurses and physicians isn't conducive to very much in the way of positives, in my own experience. That was all I was trying to get across. Aloha
As a patient, I have never seen a doctor mistreat a nurse in public. However, I have seen nurses be really brutal to both doctors and patients. I'm sure it happens, and maybe it's just that the nurses in our local hospital are thugs: You can't call a patient who's just come out of an iliac bypass or a gallbladder removal, or has a blood clot in his calf, for example, a malingerer because they need pain medication after they come out of anesthesia and tell them to shut up because they're crying after thirty minutes asking for pain meds (what is it, you're on probation and the terms of it prohibit you from handling controlled substances? then get someone else to give the sixty-plus-year-old patient some pain meds, please), and you don't tell a woman in labor that it only hurts because she's hysterical. And you don't contemptuously tell the anesthesiologist to walk the patient to the bathroom while you joke together with a group of nurses. (Why the anesthesiologist who was forced to walk the opposite sex patient to the bathroom didn't turn around and tell the nurse to shove it was beyond me.)
(Yeah, I know, you gave birth without any drugs and she's crying during stage I labor -- yeah, you're a hero. Sorry she's interfering with your magazine reading and all. The ob/gyn referred to you to the patient and the family as a "lazy b**h"; heaven knows you were upset with someone that night, and everyone around you could see it. Anyone who quarrels with a woman's pain tolerance in Labor and Delivery needs to go someplace where pain isn't an issue, like, oh, the Coroner's Office.)
Yes, doctors can be arrogant pricks. Sometimes they don't know the patients as well as the nurses do. But I have to say, the raw visible rage that seems to be so publicly visible in some nurses in some hospitals is worrisome. I'll allow that it might have been the culture at that hospital -- the local first responders avoid that hospital like the plague -- but it seems to be evident in many nursing blogs as well.
The number of people you folks find worthy of compassion can be counted on the fingers of a defective hand. Of course drug-seeking malingerers are annoying and time-consuming and all of that. And of course it's terrible when the person having the miscarriage doesn't understand why she's not being seen when there's been a multi-car pileup and two heart attacks. But the sixty-three-year-old woman who just had an iliac bypass is entitled to some narcotic painkiller and screaming at her to shut up because she's crying? Um, someone needs to take a vacation because she's seriously burned out, and it isn't the woman who just had the double iliac bypass, although I guess since she was about 35 pounds overweight, you could argue that she asked for it (although the nurse that screamed at her could have stood to lose at least 50 pounds herself). But really, does that mean you scream at her?
A lot of people have blogs to vent. I get that. But I think the point of it is that the blog is for the venting, and public is for the public face that you're supposed to have. My point is, the rage that a lot of nurses seem to express on their blogs is equally-visible to bystanders and family members, let alone patients, in the hospital during the crisis.
OK, let's get back to the topic of talking about -- or raising the possibility of -- death in the NICU.
My son is a survior of two NICU and many PICU stays, but he's among the vast legions of walking wounded. Repeatedly, I've wanted to discuss the "what ifs" before surgery, and found no one wants to talk about it.
Adults are asked to establish advance directives before surgery (even relatively minor ones). But parents -- at least at the half-dozen facilities we've experienced -- are discouraged from doing so. Parents are expected to make those decisions in the heat of the moment.
I think I have realistic expectations for medical interventions. I KNOW we'll eventually run out of miracles. When my no-longer-a-baby is lying happily watching Barney in the bed next to me, I can calmly discuss my lines between heroic and futile care. I can calmly discuss my thoughts about organ donation and autopsy.
If I'm rushed to the OR and standing over the split open bloody body of my child, I doubt I'll be able to make many calm decisions.
I WANT to talk about it.
I don't wish for my son to die. I don't want to ever not give him a reasonable chance. I do want the entire team to realize that sometimes kids die. Talking about death won't make it happen, but it might make the aftermath easier when it does.
The words "persecution whore" comes to mind here.
Interestingly enough, N=1 doesn't allow contrarian opinions in the comments on her own blog. I wonder why?
Signout,
Beautifully written - and no, there simply isn't a solution, although Q's mom offers a partial one. We do need to listen carefully when the parents need to talk to us.
It is so hard to know which children simply have no hope of growing up and impossible for most parents to begin to imagine that while the baby is still in the NICU. We fumble through and do our best -- and pray that we make the right choices.
Responding late to this piece. In regard to the subject at hand, (apart from the "professional debate") I sympathize with Q's mother who, for her child's and family's sake and comfort, would prefer to explore ,in detail,however grim- if so inclined- ALL possible outcomes of her child's condition.
Doubts have their own "negative energy" that either goes nowhere or in circles. Doubts can be a great burden.
You both will be shocked - shocked - to learn that the discussion that is so elusive to Signout occurs with regularity, professionalism and comfort by nurses with the infants' parents and families. And that it isn't hidden or covered up. But that Signout is oblivious to it because he hasn't engaged nurses in discussion about it. Ignorance is not bliss. I tried to lead him to striking up these conversations on his own. Ah, but subtlety is lost here.
A former colleague of mine, experiencing symptoms associated with burgeoning schizophrenia, went to a therapist who eventually told him to stop his work on evolutionary biology, become a born-again christian, and reject Satan's influence; in other words, this state-sponsored counsellor was simply a recruiting agent for a local church.
I think I have realistic expectations for medical interventions. I KNOW we'll eventually run out of miracles. When my no-longer-a-baby is lying happily watching Barney in the bed next to me, I can calmly discuss my lines between heroic and futile care. I can calmly discuss my thoughts about organ donation and autopsy.