Intensive care units can be impersonal places. Patients lose their identities. They are stripped of their clothes and jewelry and separated from the lives they had before the event that brought them to the hospital. Some patients have tubes in their windpipes and can’t speak to doctors, nurses or their families. Others are in so much pain that they’ve been put to sleep with medications. Massachusetts General Hospital healthcare providers are trying to ease the strain of the intensive care unit (ICU) on patients and families, as part of a broader effort to transform the nature of critical care medicine.
Visiting hours no longer exist. Families can be with their loved ones in the intensive care unit at any time. They can stay the night. Cribs are brought in for families who need them. If appropriate, families can help feed their loved ones and dress wounds. They can attend medical meetings, if the patient gives permission.
So far, the response to the changes has been positive, says Taylor Thompson, MD, director of the Medical Intensive Care Unit. Dr. Thompson adds that family members who are part of daily medical rounds are not afraid to learn that specialists may have different opinions.
“Diagnoses may be elusive early in the intensive care unit course of treatment. When families are involved in rounds and see us work firsthand, they find uncertainty to be strangely calming and reassuring because they see how hard we work to solve complex problems,” Dr. Thompson explains.
A Patient’s Proudest Moment
Another new initiative offers families the opportunity to create posters to help intensive care providers get to know their loved ones. They can list favorite movies, books, meals and pets as well as share photographs of the patient before he or she became ill. They can write about the patient’s proudest moment and what the person enjoys. The posters provide physicians and nurses a point of conversation with families and insight into the patient’s life.
Meanwhile, Mass General’s vision for the intensive care unit of the future has also grown to include a more gentle way of saying goodbye. It started with medical resident Curtis Chong, MD, PhD, who had been pondering metaphysical questions during his medical training. He wondered: When does a person’s final thought occur? And, what if patients can hear doctors and nurses after being declared medically dead?
The suddenness of death struck Dr. Chong at 2 a.m. one morning after he was summoned by the hospital intercom to the bedside of a patient in cardiac arrest. It was the first time Dr. Chong ran a medical code.
Medical codes are a flurry of heroic actions. They are called when a patient has an unexpected change of status and is near death. The senior medical resident’s role is to try to reverse the patient’s decline. From the foot of the bed, the senior resident issues orders. Other healthcare providers pump the patient’s chest for CPR and monitor the heart. Sometimes, patients are placed on breathing machines.
When efforts to save the patient become futile, the code ends. After such a death, physicians typically leave to care for other patients. Nurses stay behind for final preparations and to locate family members, if they were not present. A code is different from other situations, where loved ones have more time to say a final goodbye.
Mass General’s vision for the intensive care unit of the future has also grown to include a more gentle way of saying goodbye.
Providing a Moment of Closure
On that morning of his first code, Dr. Chong and others worked on the patient for 45 minutes. The patient’s wife arrived near the end. The team couldn’t save him. Dr. Chong sensed the wife’s immense loss. He did something different. He paused to reflect. He asked everyone in the room to share a moment of silence and said a few words to honor the patient.
Since then, other healthcare providers have followed Dr. Chong’s lead. Colleen Snydeman, RN, nursing director of the Cardiac Intensive Care Unit, is working on having language placed on the back of code carts so healthcare providers have a guide for what to say in such situations, should their own words fail them. The cardiac unit now has its own prayer that was created with help from the unit chaplain.
The final goodbye and moment of silence after a medical code provide closure for families and caregivers.
For Dr. Chong, who is very conscious about how we may not know when life really ends, it is a final act of compassion. “The last thought you would have, hopefully, would be the doctors and nurses at Mass General, respecting you and remembering you, if your family could not be there,” he says.