The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital (41 page)

Medical providers can override a DNR because of a family dispute “and not really risk punishment,” said Arthur Caplan, Division of Medical Ethics director at NYU Langone Medical Center. If a DNR is vague or was filled out many years ago, physicians might doubt whether they can trust the document. “Think of a DNR as something that tells you a person’s wishes, but it’s not a binding order. Sometimes it can’t be binding because it’s confusing. Sometimes the family’s screaming a lot and we don’t want to cross swords with them,” Caplan said. “Sometimes the nurses don’t feel involved in these discussions with the physicians and don’t know why they decided not to treat further, so the nurses line up with the family. I have seen nurses fighting with each other about a DNR.”

It’s unlikely that the medical team will be penalized for overriding a DNR written with a patient’s consent, Caplan said, “because if you’re trying to keep someone alive, no lawyer will take that case.” If the medical team abides by the DNR, despite the family pushing them to override it, the family could sue, but would most likely lose. However, “Hospitals are afraid of being sued unnecessarily, so they tend to do what families want. Usually the patient with a DNR is pretty sick, probably not even talking. The family’s talking a lot. The easier route is to just do what they want. Forget a lawsuit; hospitals just don’t want to get into a fight. There’s a lot of deference to families who make a lot of noise, particularly families who are rich. I’m not sure every family counts the same.”

If there is time, hospital ethics committees can review cases in gray areas, such as when family members disagree. A New Mexico travel nurse said that physical fights break out among families over this issue. “People get desperate at the end,” said a California travel nurse.

The outcome may depend on the physician’s comfort with discussing the DNR process with family members, said a Canadian critical care nurse. “Patients have told me they wanted a DNR because they ‘can’t take it anymore,’ but doctors have overridden the patients’ decision because they said I was ‘playing God’ by advocating the patient’s request to die peacefully,” she said. When a Maryland hospice nurse told a physician that her patient had an advance directive for “no life-support measures in an end-stage condition,” the doctor replied, “I am not a lawyer,” and resuscitated the patient anyway.

The hospice nurse said that the waters would be less murky if doctors told patients’ families, “Your loved one filled out a form after a conversation with her physician that said she would want only comfort measures at this time. We would like to honor those wishes.”

Nurses also wish that healthcare providers did a better job of explaining resuscitation efforts to families, and that family members had more honest end-of-life discussions with each other. “I think if people better understood exactly what ‘do everything’ entails, they would be less likely to demand it,” said the Texas travel nurse. “Performing CPR is probably going to break multiple ribs, [some patients] will almost certainly die in the ICU after a prolonged barrage of horribly toxic medicines, and we can put someone on a ventilator but their anoxic brain injury means they’re never waking up again. If we could show families how much more horrible it is to prolong treatment of a dying person, perhaps they would choose differently.”

Some medical teams have a hush-hush way of dealing with discrepancies between a patient’s DNR and family members’ demands. In some hospitals, as a Missouri nurse told me, “there are lots of unsavory things that the polite public would make hay with,” including the slow code, a little-known term to the general public. Various units have different designations; at a Canadian hospital, medical teams distinguished between a full code, which they called “code 55” and a slow code, or “code 54.”

Some physicians will unofficially call a “slow code,” which will never appear in a patient’s chart, if a coding patient is elderly or chronically ill. The signal notifies a team that they are not expected to revive the patient but should go through some of the motions anyway. “Responders literally walk slowly, are slow to respond, give medications slowly, or hesitate to intubate so that the patient is unlikely to be revived,” said a Midwestern nurse.

“It’s often for the sake of a family who needs to see us doing something, anything,” said the Texas travel nurse. “We do [these things] when it’s painfully obvious someone is so far gone they can’t be saved, and occasionally when the patient is a DNR. The CPR and meds are the same, because it’s a dangerous line to cross if you withhold standards of care, but if it’s a young, healthy guy, we might code for 45 minutes, whereas with the elderly terminal DNR we will only code for 10. Usually we do a round of CPR, check for cardiac motion on the ultrasound, and then call it.”

A Midwestern nurse said the slow code is “not ethically appropriate” and used only by certain teams. As a Washington State PACU nurse explained, “Pounding on the chest of an extremely frail, elderly person is torture, not lifesaving. In instances when family members insist that we do all to keep them alive, it’s understood among the staff that the patient is a ‘slow code’ and no one hurries to get a crash cart. We do, of course, make the patient as comfortable as possible.”

Nurses work hard to give patients the best healthcare they can. But not every patient gets the same treatment. Respectful patients might get faster, kinder service than the pain-in-the-ass down the hall; grateful, thoughtful patients might get some additional perks: extra snacks, the newest DVD releases from the library, the best magazines from the waiting room, additional diapers in the postpartum ward. “I’m always happy to get something for the patient if it will make them more comfortable or make them smile,” said an Arizona pediatric nurse. “When an able-bodied parent asks me to fill the water pitcher because they don’t want to walk to the galley to fill it themselves, I get just a little pinched. The hospital is not a hotel, and I’m not your personal butler.”

The secret is simple. If you’re not nice, said a travel nurse in Colorado, “rest assured that every single person involved in your care will know about it. While we will never cut corners on medical care, you can be damn sure we won’t be doing you any favors or even acting as if we like you. You’ll get your extra cup of soda or warm blanket a lot quicker if you’re not a dick. Also, we won’t talk about you in the nursing station if you’re nice. We reserve the trash talk for the mean ones.”

Many hospitals treat VIPs better than the average patient, saving deluxe private rooms for celebrities and officials who know about them. While some luxury rooms are available to any patient who can pay, like those in the Johns Hopkins Hospital’s Marburg Pavilion, others are kept secret.

Nurses described accommodations that look more like spacious luxury hotel suites than hospital rooms, with kitchenettes, beautifully glass-tiled bathrooms, and other amenities. In one Washington State hospital, when a VIP comes in, the staff combines two rooms to make a large one. They are instructed to bring in a large-screen TV and the “VIP furniture.” After the VIP is discharged, a nurse there said, the furniture is removed and stored until the next VIP admission. “They do this for rich and influential people and we nurses are disgusted by it. Nurses are taught to treat each patient as an important person and to give our best care to each one of those patients. Personally, I find it insulting to our profession,” she said.

A Washington, DC, hospital has a VIP unit devoted to patients such as visiting foreign dignitaries, senators, and professional football players. “It doesn’t have typical hospital furnishings; the rooms are much bigger, with fancy bedspreads, decorative pillows, and lavish curtains,” said a Maryland nurse who used to work at the hospital. “The patients are served excellent food—much better than the food on the regular floors—and the nurses cater to their every whim. It’s a restricted floor, with no access from the regular elevators. Most people don’t even know this floor exists.”

In California, celebrities have been offered their own private nurse; one nurse said that her hospital “definitely bent over backward for anyone they considered important.” In other states, some administrators give nurses special instructions when VIPs arrive and will personally check in on the patient. When the nurses give report, they are supposed to remind the incoming nurse that the patient is a VIP.

VIP care becomes problematic when those patients unnecessarily take up resources that more critical patients need. “Sometimes they will get a one-on-one nurse or we are all told to give them extra-special treatment,” said a New Jersey nurse. “They can’t hold back a room in the ICU, but I have seen critical patients who should be next to the nursing station moved so that a relation of a board member, a big donor, or celebrity could have the better room even if their condition didn’t warrant that level of observation. At another local hospital they had an entire VIP section set aside; those rooms were not to be used for the riffraff.”

Every hospital at which a Virginia nurse has worked had “a couple of rooms, if not a floor, dedicated to VIPs, which is often hidden. At one hospital, there was a room specifically maintained only for the use of a very famous person with a very crappy heart. They’ll get the best food, the nicest rooms, the most accommodating physicians, and the nurses who are easiest to push over. The hospital left the VIP section completely empty unless a VIP was present. No intermingling. Politicians have such a warped sense of how the healthcare system works, because they never have to be part of the actual system.”

This discrepancy in care frustrates nurses, who observe firsthand when patients with similar health concerns have extremely different experiences. “Some people abuse the system and take up more of the doctor’s time, utilizing more resources and even taking up ICU beds. Sometimes they even dictate staying in the ICU extra days,” said a Washington, DC, pediatric nurse. “It doesn’t seem fair that one family is having a cushy experience, while the other is sleeping upright in a chair crammed in the corner just because they aren’t famous.”

Nurses want patients to remember that from the moment patients enter a hospital to the moment they leave, nurses—not doctors—will be more intimately involved with their care. “The doctor is at your bedside for all of three minutes unless you’re getting intubated or coding. The nurse is the one rapidly assessing you at the door, immediately determining what interventions need to be made, so that when the doctor does come into the room he has something more intelligent to say than, ‘Well, we’re going to get some labs and an X-ray,’ ” a North Carolina ER nurse said. “I get you undressed, on the monitor, cleaned up if needed. I will wash the blood and vomit out of your hair, and not gag or make you feel embarrassed that you’re sick. I’m the one who will go to the doctor and tell them you are having nausea, pain, or a neuro status change because suddenly you think it’s 1988. That will be the reason that you get a head CT, and we find a brain bleed and contact the neurosurgeon. And then I will be at your bedside for the next three hours while we wait, reassuring your mother. You will hardly ever see the doctor. You will always see the nurse.”

Nurses told me about regularly being expected to stay 30 minutes, an hour, or 90 minutes past the end of their shift without pay. But inclement weather is an entirely different beast. “Our last snowstorm, they wouldn’t release the nurses until enough of the next shift made it in to cover the hospital,” said a Midwestern nurse. “During these times, we work, sleep, and shower at the hospital just to work another couple of shifts. If we can’t make it in, they’ll get us with a snowmobile if they have to. They’ve had army reservists drive out in their Hummers to get us. They make us stay against our will. Sucks when you have kids at home or are a single mom without a strong support system.”

Nurses don’t necessarily choose to work fourteen- to sixteen-hour shifts. “When nurses have attempted to refuse this overtime, we have been told this would be considered ‘patient abandonment.’ Nurses are not willing to abandon our patients,” an Ontario nurse told the Canadian Federation of Nurses Unions.

Depending on the hospital, weekends and nights can be riskier for patients, some nurses said. “Half of this hospital is unavailable during those hours. A STAT echocardiogram isn’t always STAT,” said a Midwestern nurse. “There isn’t maintenance available, so you have to wait for Monday to get things fixed, which can be frustrating when it’s a procedure light that could help you out, or you have to move a patient because the monitor broke. If you run out of supplies, you have to make do until Monday.”

If a hospital’s technicians don’t work weekends, nurses might have to send special labs to outside techs, which can delay a patient’s care. Because some organizations’ housekeeping services are reduced on weekends, nurses have to take time away from patients to clean patient rooms or hunt down equipment themselves. If a hospital needs to work on the computers or the water system, the outages can also cause increased wait times. “It’s risky sometimes because of the staffing issues. We can’t staff for the what-ifs,” said a NICU nurse. “At night, our NICU nurses go to ER and Peds to draw labs and start IVs. That takes nurses off our unit and we’re temporarily understaffed. If there is a code or a delivery when this happens, it can be bad.”

If a patient with a history of alcohol abuse needs open heart surgery, a Maryland Cardiac Surgical ICU nurse said, he or she might get alcohol (supplied by the pharmacy) with hospital meals or through a feeding tube to prevent alcohol withdrawal symptoms such as elevated heart rate, anxiety, and shaking. A nurse in an Oklahoma cardiac unit who has administered this treatment to a patient said that, on physician’s orders, the pharmacy brought 60 ml of bourbon each night to the nurse and watched her pour it down a nasogastric tube. While this method is considered “old school”—hospitals more often give patients Ativan—“it is funny to say that you gave your patient a shot of bourbon as a medication order,” the nurse said.