Are You a Nurse?

Back in December, my mother was having knee replacement surgery. Six months prior she had had her other knee replaced, and there had been complications: delirium, probably from dangerously low sodium. Her surgeon was going to discharge her despite the obvious mentation changes and had to be practically bullied into running blood tests to check her electrolytes.

So after the second knee surgery, when the hospitalist (with residents in tow) came to check on her, I started to advocate strongly for what I felt was a necessary level of care. About five sentences in, he turns to me and says "are you a nurse?" At first I felt a little defensive (I was afraid he was perceiving me as a meddling relative), however when I said "yes," his response was to say "OK, then I'll explain things in more technical terms, and you can explain to your mother."

Last night, a family member called in asking about their relative. I didn't know the patient very well, they had been admitted while I was off, but I was looking through the notes trying to garner more information, and as we were talking the caller started to ask more technical questions, as well as explain things about the patient that was not clear (or downright wrong) in the chart. Almost unbidden from my mouth came the words "are you a nurse?"

Pause.

"Well yeah."

"OK, then I'll go into detail about what this report states."

Nothing like having the shoe on the other foot to gain better understanding of how we humans behave.

Deactivating ICDs

Here's an ethical question for you:

When is it appropriate to deactivate an ICD (implanted cardioverter-defibrilator)? To give some background: an ICD is a device that is surgically placed in the chest of a person who are at risk of sudden cardiac death due to ventricular fibrillation. Unlike a pacemaker, which uses electrical impulses to control the heart rate, the ICD "shocks" the heart when detecting an abnormal rhythm--just like the paddles used externally. From what I hear and read, the shock is a pretty nasty thing, and can cause pain, anxiety and a loss of consciousness. The issue here, is that when someone is close to death, their heart rhythm can go wacky, resulting in repeated shocks being delivered by the ICD. Turning off an ICD is not a simple matter: it is a process that requires specific skills and equipment. Theoretically, one can deactivate (temporarily) an ICD with the use of a magnet, but it is a stopgap measure--it needs to be taped to the patient's chest to keep it deactivated, and, I've read that sometimes the magnets don't work.

We currently have a patient, end-stage cancer, who also has an ICD. It has been discussed with him at least twice, and he has declined to have his ICD turned off. The problem, is that the other day, he got up unassisted (he's pretty weak) and was shocked by his ICD, causing him to blackout. Since then he has been anxious and afraid to sleep: afraid that he'll be shocked in his sleep. On Friday night, I managed to reduce his anxiety by providing him with an anti-anxiolytic and pain medicine. When I was back on Sunday afternoon, and heard in report that he was again, not sleeping and anxious, I decided to go down and talk over his options. Options seemed pretty limited: continuing to provide support and comfort via medication, conversation and presence, and, as far as I could see, also included offering to tape that big ol' donut shaped magnet onto him. The issues with the latter are multiple:

1. He is confused, and I'm not sure about his decision-making ability
2. He is fairly withdrawn, and when I attempt to talk with him he pretty much shuts me out
3. What are the ethics here? How confused is without capacity to make appropriate decisions? What are the ethics of doing a stop-gap measure that may, or may not work?

Luckily, I did not have to face this question head-on: the patient did sleep most of my shift, and I knew that the next day was Monday, when more services (including the most awesome social worker and the patient's provider) were available to discuss and revisit the matter. I did leave a note, as requested by the physician indicating his distress and concern. I know the folks I work with--they will continue to talk with the patient about the issue.

But what if he had been more awake and I less busy with another patient who was needing one-on-one care monitoring for delirium? What about the next time we have a patient in this situation? What if he/she clearly does not have decisional capacity, and, like is so often the case, has family members who disagree on the appropriate course?

This problem is not going to go away. Rather, it is most likely to come up more often as time wears on.

---

I did a quick lit search and found that:

1. Deactivating ICDs is in general considered ethical if it is the patient's desire, or the desire of the patient's surrogate.
2. The most discussed aspect of deactivating ICDs in the articles I read was the lack of discussion about this issue with patients before it becomes critical with a decision needed now (as in the patient is unconscious, dying and receiving repeated shocks). Sounds like so many of the end-of-life discussions that should, and don't happen (or happen too late).
3. Christian Sinclair over at Pallimed has contributed to articles in health care journals about this subject at least twice. And in a bit of synchronicity, Pallimed has a new post up about heart failure and implantable devices.
   

Results

This morning, at 9:00 it would have been three weeks.

Three weeks and two days since we got the email with our questions.

Two days which involved approximately 40 of the 48 hours alloted being spent in front of the computer.

48 hours which passed with no time to re-read what I wrote, never mind edit it.

48 hours and 15 minutes after I received the questions, I sent 36 pages back. Because of computer wonkiness (whatever possessed me to download a new copy of Acrobat Reader in the middle of such a time?), I was 15 minutes beyond the deadline (it was OK, they accepted it).

I've never written 36 pages in two days before.

I have also not read what I wrote in the ensuing three weeks.

This morning, I started to obsessively check my email for results.

At 2:00 this afternoon, I got my answer.

I passed!!!!!!!!!

Oh, there's still plenty of trials and tribulations ahead of me: proposal defense, orals, IRB submission, dissertation defense, applying for post-docs...

But I will never have to pass comprehensive exams again.

I will not have to worry about feeling like I disappointed my adviser and my department chair.

Makes me feel downright smart...maybe a bit of that particular "impostor syndrome" has been decreased.

Go me.