A FINAL GIFT: ADVANCE DIRECTIVES Midcoast Senior College Spring Semester, 2019 Susan Flewelling Goran, MSN, RN
THE FACTS ABOUT END-OF LIFE WISHES • 80% of people say that if • 90% of people say that talking seriously ill, they would want to with their loved ones about the talk to their doctor about wishes end-of-life care is important. for medical treatment toward • 27% have actually done so. the end of their life. • 60% of people say that making • 7% report having had this sure their family is not burdened conversation with their by tough decisions is extremely doctor. important. • 82% of people say it’s important • 56% have not communicated to put their wishes in writing. their wishes • 23% have actually done it. Survey of Californians by the California HealthCare Foundation (2012)
National Healthcare Decisions Day “In this world nothing can be said to be certain, except death and taxes.” Benjamin Franklin, 1789
UNDERSTANDING THE ROLE OF THE ICU IN FINAL DAYS Session 1: A Final Gift: Advance Directives April 1, 2019
OBJECTIVES • Explain the purpose of the monitoring equipment located in a patient’s room. • Discuss the importance of balanced family visitation in the patient healing process. • Explore the various decisions families may be asked to make for a loved one unable to participate in the decision- making process.
WHEN WAS THE ICU BORN? • Crimean War (1850s): nurses keep critically injured soldiers near the nursing station • WW II: ‘Shock Units’ were created to care for the severely wounded • 1952: Polio epidemic and the development of respiratory support via the Iron Lung • Late 50’s, early 60’s: ECG/EKC monitoring • 1960’s: Mechanical ventilation: development of the use of positive pressure to assist in airway management
TODAY’S ICU • Critical care is not an organ-based specialty (cardiologist, anesthesiologist, pulmonologist, etc.); it is a stability and vulnerability-based specialty • Treatment in a specific area of the hospital • Specially trained nurses closely monitor the sickest patients and provide continuous bedside interventions
INTENSIVE CARE VS CRITICAL CARE • SCU: Special Care Units • ICU: Intensive Care Unit • PICU: Pediatric or Pulmonary Care Unit • SICU: Surgical ICU • TICU: Trauma ICU • MICU: Medical ICU • NICU: Neonatal or Neuro ICU • CICU: Coronary/Cardiac ICU • CTICU: Cardio Thoracic ICU • BICU: Burn ICU
A ROSE BY ANY OTHER NAME….
COSTLY VISIT • Although patients admitted to the ICU account for approximately one-quarter of hospitalized patients, they account for half of total hospital expenditures in the United States, with costs estimated at $110 to $260 billion per year or approximately 1% of the gross domestic product. • 20% of Americans dies in the ICU; 25% of Medicare expenditures in last year of life Angus DC & Truog RD. JAMA, 2016:315(3), 255.
BEEPING, BUZZING, BURPING NOISE IN THE ICU • Most equipment simply provides information that ICU staff analyze to determine the patient’s baseline status, or identify changes in status • Patients are monitored both at the bedside and at central monitors located at the nurses’ station or in hallways • Alarms indicate a deviation from parameters set by the nurse, but are not necessarily indication of a crisis
VITAL SIGN MONITORING • EKG: rate and waveform • Respirations: rate and waveform • Blood pressure: may be invasive (continuous) or automatic cuff (intermittent; waveform and result • Temperature: Celsius or Fahrenheit
ECG/EKG • An electrical ‘picture’ taken of the heart from various positions • A 12-lead looks at frontal and horizontal planes of the heart • Indirect indication of blood flow through the heart to the pacemaker of the heart • Typically, in the ICU, 2-3 waves will be monitored at a given time (depends on patient history)
BLOOD PRESSURE ASSESSMENT • BP = HR X SV (heart rate/stroke volume) • A-Line: usually radial artery; allows for beat by beat assessment; requires knowledge of the waveforms • Allows for direct blood sampling • Complications: hemorrhage, nerve damage, infection
PERIPHERAL CAPILLARY OXYGEN SATURATION(SPO2) • Pulse oximetry is a noninvasive method for monitoring a person's oxygen saturation (SO2) • Safe, convenient, noninvasive, inexpensive • Uses a probe on either a finger or earlobe • Light is sent through the finger and measured on the other side. This quick, painless, non- invasive test provides a measurement of the hemoglobin, red blood cells carrying oxygen, in a person’s blood. • Used consistently in the ICU as part of the vital signs
IV PUMPS • Fluid replacement • Nutrition • Medication administration • Blood infusion • Usually not all infusing at the same time; frequent alarms.
CENTRAL LINE • Multiple lumens allow for several simultaneous fluid infusions • Allows for harsh medication infusion (potassium, vasopressors) • Access for blood draws during emergency • Risk: infection, pneumothorax, others
IT’S ALL ABOUT THE URINE • “Pee is your friend” • Kidneys reflect the strength of the heart to circulate volume • It takes adequate BP and circulating volume for urine to be produced • Infection is the #1 problem, so catheter will be removed as quickly as possible
BREATHING TUBE / INTUBATION • Failure to oxygenate; trauma, hemorrhage, sepsis, • Failure to ventilate; spinal cord damage, severe asthma, COPD, severe pain, MS • Inability to protect or maintain the airway; facial trauma, anesthesia, drug /alcohol overdose, other • The subsequent clinical course will be improved by early intubation: trauma requiring CT scan, other tests while in severe pain, probable surgery • Oral or nasal intubation: endotracheal tube (endo tube)
MECHANICAL VENTILATION • Patient frequently sedated; uncomfortable as not normal breathing response • Unable to speak as endotracheal tube sits between the vocal cords • Unable to take oral meds or food/fluids • Suction lung secretions through the endo tube; stomach fluids drained via a nasogastric tube • May require wrist restraints to prevent self-extubation
VENTILATOR WEANING • Gradual process of decreasing ventilator support • Spontaneous breathing trials: Is the patient stable? Awake? Strong cough? Adequate muscle strength? Limited sedation? • May take days to weeks; may transfer out of the ICU to a specialty unit for weaning and rehabilitation; will usually be trached prior to transfer • Once adequacy of breathing is determined, patient will be extubated and the endo tube removed • Throat may be sore and voice raspy for a couple of days • Care must be taken to ensure patient can swallow before starting oral fluids and nutrition
TRACHEOSTOMY • Original injury may require tracheostomy • Long term (greater than 7-14 days) mechanical ventilation with an endo tube • May allow patient to speak, to eat, and to more effectively wean from mechanical ventilation • More comfortable for the patient • Helps with early ambulation and rehabilitation • May allow transfer out of the ICU
IT TAKES THE TEAM….
SO MANY PHYSICIANS… • Teaching versus non-teaching facilities • Intensivists: critical care certified physicians; coordinate medical care, usual liaison to the family • Role of residents/ House Staff (physicians in training) • 4 years of undergraduate education • 4 years of medical school • 3-5 years of residency • Optional Fellowship: 2-3 years • Physician extenders / Mid-levels: Nurse Practitioners & Physician Assistants • Consultants: varying specialists including Palliative Care
IN THE UNIT… • Respiratory therapist: helps with respiratory care • Spiritual care: provides support 24/7 and comfort Nurse • Pharmacists: evaluates medication plan and consults • Social worker: family support; The nurse is there 24/7 arranges discharge plan; provides financial information • Physical Therapy: helps with patient mobility
INTERMITTENT VISITORS • Phlebotomists • Xray techs • Environmental services • Blood bank • Security Officers • Others as patient condition changes
VISITORS IN THE ICU • The nurse is responsible for caring for the patient and also informing and caring for the family members that are visiting.
HISTORY OF VISITING HOURS • Restricted hours for nonpaying patients in an attempt to establish order in the general wards (late 1800’s) • Paying patients had ‘open’ visitation • 1960s, visiting hours restricted for both paying and nonpaying patients to prevent exhaustion from too many visitors • 2004: IHI challenged hospitals working on improvement of care to open their ICUs with unrestricted visitation policies
ICU VISITATION • Rest was a major intervention and visitation was severely limited: • 5 minutes X2/24 hrs; • 2 visitors maximum • No children <16
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