Working in an ICU has it's ups and downs. I have been able to stand alongside patients as they recover from heart attacks and open heart surgery. It's always a good day when a patient that struggled initially during recovery is wheeled up to the stepdown unit smiling and waving. Those are the happy times. But I've also stood alongside patients as they've taken their last breaths. Most of those patients have been classified as either a DNR or DDNR. Their families have made the choice to withdraw care, allowing their loved one has passed peacefully. However, having that conversation with the family about the decision to withdraw care is not an easy one. Bringing it up for the first time is never pleasant, and any further conversations are approached very carefully. Usually, it is not a quick decision for a family to make. It takes a lot of thought, consideration, and sometimes painful conversations about the patient's potential outcomes. Sometimes expectations are shattered. When a loved one is admitted into the hospital, the hope is always that they will be able to leave. Families rarely expect that they will be planning a funeral by the time the hospital stay is over.

One thing I've noticed is that communication regarding withdrawing care can be somewhat confusing. Telling another nurse during shift hand-off, "the family decided to withdraw care today" just sounds wrong. Which is probably why it can be hard to explain that withdrawing care doesn't mean that we aren't going to care for the patient anymore...even though that's what the phrase sounds like. Honestly, it kind of means the opposite. When a family decides to withdraw care, the patient is placed on comfort measures. What withdrawing care really means is that we take out all the unnecessary tubes, turn off any IV drips containing medications stabilizing heart rate and blood pressure, and let nature take its course. If the patient was intubated, we turn off the ventilator, take the ET tube out, and either put the patient on a BIPAP, mask, or nasal cannula so that oxygen is still being delivered. If the patient was receiving enteral feedings through a tube going from their nose or mouth down into their stomach, we take that out. One less tube to worry about means that the patient will be a little more comfortable. We take the patient's restraints off, if there were any, and make sure that they are getting adequate pain relief. We usually leave urinary catheters and rectal tubes in, just in case the patient needs to use the bathroom. Sitting in urine and feces does not promote comfort, so if they're already in, we leave them in. We try to give the family some privacy as they spend some precious quality time with their loved one, but if they need anything at all, we're there for them.