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.

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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.

Logical, Consistant withTrade-offs Explicated: Let the Comps Begin

Well, if anyone is still looking at this blog occasionally -- think good thoughts for me over the next 48 hours. I just received my two (one qualitative, one quantitative) comprehensive exam questions. I have 48 hours and 32 to 40 pages (16-20 pages per question, double spaced, no smaller than Arial 11 font, one inch margins) to prove I know enough about research and research design to do my own work. I just received the questions. I think they're doable...

If I start going crazy, I might just come back over here for a breather.

School's Out!

Good intentions and all that, I still don't seem to have gotten the hang of this regular blogging thing. But schools out, and I'm done with coursework! Well, almost--I have planned to take one more teaching course in the fall.

But my core coursework is done...all I have ahead of me, before I can officially start on the dissertation phase is...(cue Jaws music)...Comprehensive exams. What is that you're asking? Just an opportunity to show that I've absorbed and synthesized everything I’ve been taught in the past two years. We’ll be getting two questions on Monday, July 23, and will have 48 hours (and a page limit) within which to respond.

In the mean time, my cohort as been attempting to review all of our core coursework, but we have not done as well as we had hoped in terms of formal review. We do have a 4 day ocean-retreat planned for a couple of weeks from now, but I’m still nervous. (And frankly, tired of all the people saying “you’ll do fine,” I think that creates as much anxiety as it attempts to dissipate!)

The up side of all this is that, for a little while at least, my schedule is somewhat opened up for the first time in ages. Yes, I have that studying hanging over me, but no formal writing or reading to do, and I’m only working three days a week….which is two days more than I have been working.

So hopefully, I’ll have more things happening worth posting about (I have a recent experience which I need to get on paper soon), and more time and energy to actually post, not just think about posting.

I’d say “watch this space,” but I don’t want to set myself up.

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And in different news, I’ve been accepted into the Palliative Care Fellowship at the VA. I’m not sure exactly when it will start, probably in September or October. It’s for nine months, and I’m really, really looking forward to this experience.

Confusion

He has heart failure, diabetes, and dementia.

She has multiple morbidities of her own. She has a history of abandonment (not picking him up after a respite stay – staff finally drive him home).

He has no short term memory (but he “can remember back to when he was in diapers”) and makes multiple calls home. Sometimes he’s accusatory, sometimes he just sounds desperate. Sometimes all he wants to do is say “I love you.”

She can’t take it anymore. Now, he gets one or two calls a day.

He is on hospice, but he’s not really that close to dying (damn those uncertain trajectories!)

Sometimes he thinks she’s dead. Sometimes he thinks (rightly so?) that she’s abandoned him. “After 67 years, I’ll never see her again.”

He was on a high dose of pych meds for his "behavior" at home. He's been being weaned down.

Sometimes he gets angry, sometimes he just sobs.

But give him some attention: a back rub, some comforting words a milkshake made specially for him, and often you can distract him from his pains, physical and mental.

At least for a while.

Procrastination, Conciseness and Celebration

Well I started this blog with great intentions and somehow it got lost in the usual slog of procrastination and coursework.

At this point, I have several partly written pieces that I just haven’t gotten back to. Part of my problem, I realize is that I have a hard time writing short, pithy pieces—succinct has never been my middle name (is that why I have such a hard time spelling it? Thank the goddess for spell-check).

But learning to write tighter and shorter is not only an admirable, but a necessary goal. An F31 (NIH predoctoral training grant) is limited to 10 pages. I think an R03 gives you 20. Many journals have page and/or word limits. And my Hartford application was limited to a 2-page letter and a 3-5 five page “professional development plan.”

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Which brings me to the third word in my title.

The John A. Hartford foundation through the Hartford Geriatric Nursing Initiative supports the Building Academic Geriatric Nursing Capacity (BAGNC) program, which has, among other things, the BAGNC Predoctoral Scholarship (are you still with me?). If you go to the site, you’ll see that this scholarship is very generous. And very competitive – check out who is on the advisory committee here and the selection committee here. I mean, the directors of NINR, NIA, AACN and GSA? (among others). You don’t get much bigger in terms of Names in Nursing.

So, last year, I applied. And didn’t get funded. This year I applied. And got selected! I am so stoked, amazed, honored, thrilled….you get the idea. The timing is also perfect. Next quarter is my last quarter of coursework. The funding, which will start after this school year, is for two years. That means I have two years to work on my dissertation without financial worries. It also means I have Very Good Incentive to finish in two years.

So, hopefully (if anyone is still with me after my long silence) you’ll be willing to raise a glass with me in celebration.