Mr. D was an 80-year-old patient admitted to the surgical intensive care unit (SICU) after repair of a fractured hip. This was his second stay in the SICU for repair of the same hip fracture just 4 months earlier. Reparative surgery was completed with the caution that Mr. D would never walk again and at best would be bedridden in an extended care facility. Other medical problems prominent in Mr. D's history included renal insufficiency, heart failure, and type 2 diabetes.

Immediately after surgery, Mr. D was extubated, but later required reintubation for respiratory distress and possible aspiration. Mr. D's family was extremely close and had a strong faith tradition. They had spoken as a family with the intensivist and a do-not-resuscitate order was written. After 48 hours, Mr. D had improved enough to allow for extubation. The family requested he not be reintubated in the event of respiratory failure because of his explicit wishes with regard to resuscitation. At that point, the family also requested a palliative care consult, which the nurse ordered. The palliative care nurse liaison came and met with the family, assessed Mr. D, and called the intensivist to update him on the consult. The intensivist arrived in the unit a short while later to speak with the family, saying that he could have cured Mr. D if he'd had one more day. After he left, the family and staff were bewildered because they perceived that they had honored the patient's wishes.

Decisions, decisions

This situation unfortunately continues to occur with relative frequency within the ICU. In a recently published study, surrogate decision makers made 75% of decisions regarding end-of-life preferences. Of those, 88% made decisions based on their prior discussions with family members.1 Palliative care and hospice care services are available to all Medicare beneficiaries, yet very few access this benefit.2

Critical care nurses care for patients during their most vulnerable periods and can provide education and information for families and other healthcare team members. As professionals, it's incumbent upon us to keep ourselves current so that we can provide needed support. The American Association of Critical-Care Nurses (AACN) supports the nurse's role in assessment and management of patient symptoms and provides resources for critical care nurses to access through their Web site.3 Resources available through the AACN Web site (http://www.aacn.org) include the Clinical Practice Guidelines for Quality Palliative Care.3 In addition, the American Nurses Association has developed the Code of Ethics for Nurses with Interpretive Statements and has several position statements on end-of-life issues available at its Web site (http://nursingworld.org).4

The palliative care nurse in this case study was able to speak with the intensivist, and the patient was started on a morphine drip for pain. Mr. D remained in the ICU for another 24 hours before dying with family and friends at the bedside. The physician didn't speak further with the family, and the palliative care nurse acted as the liaison between physician and family.

Many issues went unaddressed in this case. What part do provider preferences play in patient care? What are the benefits and side effects of symptom control? Answers can be found through continual interdisciplinary education and dialogue with each other.

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