JOURNAL
OF SURGICAL
RESEARCH
26,494-498 (1979)
Neglected
Components
A. GERSON GREENBURG,
of Intensive
Care
M.D., PH.D. ,* JOSEPH M. CIVETTA, AND GEORGE BARNHILL, M.S.t
M.D. ,’
* Departments ofsurgery, University of California, San Diego, and the Veterans Administration Medical Center, San Diego, California 92161, and fDepartment of Surgery, University of Miami School of Medicine, Miami, Florida 33124 Presented at the Annual Meeting of the Association for Academic Surgery, Cleveland, Ohio, November 12-15, 1978
A great deal of literature exists about intensive care units in general and surgical intensive care units in particular. References regarding what to monitor, how to monitor, and when to monitor are abundant. Reports on interpretation of monitored data, errors in the data acquisition, and how to use specific data in decision making are similarly available. Intensive care unit architecture and design details, as well as staffing requirements, have been described. One could go on. Despite all our “scientific” methodology and applied medical knowledge there are still areas of intensive care that seem to be neglected. What do we know about the reasons behind the high turnover of skilled nursing personnel? What are the effects of the high turnover rate on the quality of care delivered or the quantity of system/effort possible? What effect does this loss have on personnel morale? Do we really know the effort we ask of nursing personnel in terms of nurse utilization -minutes of time per hour or per shift-when we write routine orders? What data do we have that will help us allocate precious and limited resources to an appropriate end? Can an appropriate end be defined? Finally, are there identifiable stress factors that need to be dealt with which produce the fear, anxiety, anger, and often low morale in these high-tension, rapidaction, volatile clinical situations? These are not rhetorical issues! They are real issues and questions present in all in0022-4804i79/050494-05$1.00/O Copyright 0 1979 by Academic Press, Inc. All rights of reproduction in any form reserved.
494
tensive care units. These issues must be addressed for they are all pervasive in instilling and, more critically, altering attitudinal positions. Once sensitized to these issues the surgeon develops insight into the unit’s true internal environment as well as its interfaces with the rest of the care delivery system. Can the clinician predict death? If one could accurately predict this stress-producing event, two benefits would accrue. First, we would be able to rationally allocate our scarce intensive care resources and second, we could prepare psychologically both staff and family for the event. Unfortunately we cannot accurately predict death. Furthermore, it is the uncertainty of predicting the event that eventually, if the patient lives long enough, produces stress. This stress is manifest upon the staff regarding the patient, the rest of the staff, and in the staff’s response to the patient’s family. The result is multifactorial and its impact unpredictable. Because we have little scientific evidence to use in predicting death we are left to rely on clinical judgment as the basis for major decisions regarding resource allocation. Our ability to predict a survivor is at least 90%, while our ability to predict a nonsurvivor “based on clinical judgment” is never more than 60%. The discrepancy is so great we must bias our allocation based on an objective that says: “Everyone will live.” This high level of predictive uncertainty,
GREENBURG,
CIVETTA,
AND BARNHILL:
entropy, is both anxiety provoking and threatening to unit personnel. When this uncertainty of survival is coupled with the uncertainty of the random appearance of catastrophic events, the unpredictable clinical crisis, one begins to appreciate the basis for the high-tension environment. The point is simple: Uncertainty produces anxiety and anxiety readily translates to stress. Surviving patients reside in the ICU for less time than nonsurvivors. The longer a patient stays in the ICU the more uncertain the outcome. It is no wonder that nurses become concerned and attached to the longterm patients and develop a “protective” reaction. On the other hand, the staff may develop an “aversion reaction” to a particularly long-term patient. They feel death is likely and distance becomes a good defense. Furthermore, they may feel they have effected a “save” and believe no one else can care for the patient. They thus become reluctant to discharge the patient to the care of nurses or physicians in a less intensive environment who know him/her less well. The net result is yet another stress-producing situation! These are not orchestrated scenarios. This process occurs daily and is, in fact, fueled by our inability to accurately predict who will live and who will die. Our clinical judgment is generally bad, and we have little scientific methodology to rely on. As a result, we stress our system by using resources and we stress our personnel because the outcome is uncertain. There are stress-producing factors related to resource allocation that also need to be investigated. There are the questions of physical stress or demands on nurse time in the ICU that also need to be addressed. If the nursing personnel are physically stressed, the effect in combination with emotional stress resulting from uncertainty may be synergistic. What demands do our orders place on available nursing personnel time? Utilizing the management science technique of systems analysis to identify and quantitate tusks performed in the ICU,
INTENSIVE
CARE
495
we were able to generate 15 categories of tasks that consume time. Furthermore, these tasks can be subcategorized into observation, therapeutic, hotel, or clerical groups. Even further, each task can be quantitated and a finite segment of time identified for completion. The tasks to be performed are generated by physician’s orders and system overhead, so the physician directly controls nurse utilization. The task categories are shown in Table 1, and an example of detailed tasks for a category is shown in Table 2. In all, 108 tasks, each consuming 6-7 min of nursing time, are identified. Thus, with 8 hr per nurse per shift, 480 min are available, and if one desires to operate at 80% nurse utilization, only 380 min are available for patientdirected tasks less the overhead (nurse’s notes, reports, etc.). All of the tasks have been presented elsewhere [2] and indeed, we have converted the task requests to a NISS Score (Nursing Intervention Score System) that clearly and explicitly defines how much time the nurse must spend performing the requested tasks. For a single patient, a NISS score of 60 or more indicates more than one nurse will be required to carry out all those tasks. Using this score daily or at each shift change, one has a managerial assessment of the functional capacity of a given unit. Closing beds or recruiting extra help can be based on data and information necessary to support the action. Were one to constantly and continuously place demands for time in excess of those reasonably available a stressed system and eroded emotions would result. The futility and frustration resulting from trying to be complete can be destructive physically and emotionally on the unit. Can computers help in the ICU? This is a truly difficult question to answer. Using digital simulation technology we have designed and evaluated a model ICU within which we can vary patient load by number and state of health, nurse:patient ratio, and system configuration and define the effects
496
JOURNAL
OF SURGICAL
RESEARCH:
of these changes on nurse utilization [l]! That the model can rapidly execute 154 variations and provide useful and usable data implies that computers can help ICU functional analysis and indicate potentially viable solutions for further real-life evaluation. What did the model’s output indicate? Interestingly enough, even an idealized fully automated computerized system does not decrease nurse utilization for the most seriously ill patients. In fact, for these patients reasonable and appropriate utilization only begins to appear when the nurse: patient ratio approaches 2: 1. In addition, a “turnkey” computerized monitoring system is no better for the medium-range patient than a well-tuned ICU. This tends to indicate that these predefined systems will be of questionable cost effectiveness if utilized as delivered. The incremental cost attendant on full computerization may likewise not be cost effective for when it is most needed, it has the least impact. Figure 1 shows the simulation model output for four states of health (l-4), four different systems, and a variety of nurse:patient ratios. It is significant to note that even with full computerization for the most seriously ill TABLE
1
NISS TASK CATEGORIESAND NUMBER OF TASKS PERCATEGORY Monitoring Intravenous lines Medication Fluid intake Blood therapy Fluid output Metabolic management Respiratory management GI tract management Wound, skin care Miscellaneous therapy Miscellaneous task Patient events Non-KU services Nursing factors
13 5 14 6 4 11 10 13 4 3 10 15 4” 3” 2”
a Not storable, no points assigned.
108 - 9 117 Total
VOL. 26, NO. 5, MAY
1979
TABLE 2 MONITORINGTASKS Task
No. of points
ECG, rate Vital signs, QlH Vital signs, Q30M Vital signs, Q 15M Peripheral arterial line, BP CVP Pulmonary arterial line, pressures Neuro vital signs Measurement of cardiac output Left atria1 pressure Intracranial pressure Peripheral pulses, Doppler ECG, rhythm
1 1 3 4 1 2 3 3 4” 3 4 3 2
a Dye dilution; 2 if thermal.
patients, a ratio of nurse to patient of more than 1: 1 is needed. The overlap of our current system and a turnkey system is also apparent. Thus the decrease in nurse utilization anticipated from computerization where it is most needed can be better effected by more personnel. For a state of health of 2 a fully computerized system is helpful. Most open-heart and seriously ill patients, however, are l’s for up to 24 hr. The computer is thus helpful for administrative and managerial function but there are little data to support its general application directly in the ICU. Potential application as an adjunct to unit process, data interpretation and relief from clerical tasks exists but has not been demonstrated. The real impact is thus unknown. In addition, when introduced into the ICU, computers can create a stressful situation by stimulating anxiety in the staff. If the staff is not included in the planning and implementation the system may go unused as a staff reaction. A desirable goal is to decrease staff anxiety over all issues, and one accomplishes that by decreasing uncertainty. Health care professionals deal with the threat of death, and the inability to cure dying patients is a constant source of frustration. This frustration often becomes trans-
GREENBURG, CIVETTA, AND BARNHILL:
INTENSIVE
497
CARE
100 90
-
a0 x F l-i 2 2 I=
7060-
fi2
40-
50STATE
aQ
OF HEALTH
= 1
30 - OIST. EXP. 20 - b.---a
.
10 - &--
0’
Manual
.... current A
Turn
’ ’ ’ .!i 1.0 1.5
Kev
’
2.0
’
2.5
’
’
3.0
3.5
’
.5
4.0
1.0
1.5
RN:PT
loo STATE
2.0
2.5
3.0
3.5
4.0
RN:PT
r
OF HEALTH=3 90-
80 -
.5
’ 1.0
Turn Key Best Compurerkd ’ ’ 1.5 2.0
60-
;
40-
STATE
70-
OF HEALTH=4
50-
2 30a@. 20 -
20-o-.--.a Manual ,.........AC”,e”f ,,-, -b------o 0 ’
g I= 2 ? 5
10 1
I
3.0
4.0
FlN:PT
01
OIST.
.5
1.0
EXP.
1.5
2.0
3.0
4.0
RN:PT
FIG. 1. Nurse utilization as a function of nurse:patient ratio for four states of health under four ICU system configurations. See text for explanation.
lated to stress and anxiety and is manifest by low morale and poor interpersonal relations. The constant threat of death, the uncertainty of when it will occur, and its impact on the patient and his family, physician, and nurses deserve consideration, for this threat is what keeps us treating our patients. Since we cannot accurately predict death, and since most seriously ill patients place a great demand on personnel time, the potential frustration resulting from physical and emotional stress must be recognized. “Death is not necessarily a failure” only if everyone recognizes and is prepared for the event.
Caring for a dying patient is frustrating. The feelings engendered may lead any of us to anger for each death reminds us of our inability to cure all disease and of our own fallibility. Depression, anxiety, and anger are the unpleasant feelings that result. The illness involves anxiety and reminds us of our inability to control all situations. Rather than deal with the anxiety, anger results and we direct it toward the patient and his family, or more often toward fellow staff members and colleagues. How do we react to a patient’s death? Withdrawal from family and staff, each going its own way, usually occurs. The staff
498
JOURNAL OF SURGICAL RESEARCH: VOL. 26, NO. 5, MAY 1979
feels they have failed, and the family feels rejected. They isolate themselves and cut off the one useful option: open and honest communication. We must recognize that the cause of death, the character of death, and the duration of dying have changed with advances in technology. The patient is often dehumanized as the staff pays more attention to physiological requirements than emotional needs. By turning their backs on the patient’s emotional needs, the physicians often fail to realize this, and the burden falls upon the nursing staff. The net result is a high degree of tension more often than not manifest as anger. Could there be specific stress factors identified that account for the high turnover of ICU nurses? We all recognize the problem in terms of the economic input attendant on the loss of skilled, trained personnel, but do we recognize the stress factors that produce the problem? Health professionals at all levels harbor above average fears and anxiety pertaining to death. This subjective dread may lead to rejection of the dying patient. We must recognize that the hospital is not only an institution for restoring health, it is the place where Americans die. In America 70% of all deaths occur in hospitals or nursing homes; little wonder there is high anxiety! Dying occurs in an impersonal environment and the ICU, being technologically oriented, is perhaps the most impersonal. Not surprising, most physicians and nurses judge their success or failure by whether their patient lives or dies. When a patient dies it is taken as a sign of failure. Physicians are little prepared to deal with death, and it often comes as a shock reminding them of their own fallibility or mortality. This is particularly true when dealing with the younger patient. Physicians and other health professionals must realize that patients are going to die but that death does not have to mean failure and loss of self-esteem. Physicians are mortal and are entitled to emotional oscilla-
tions and often need support and understanding. Involvement with a dying patient is stressful and denial of this stress has a deep emotional impact. Open, frank communication among staff and between staff and family decreases anxiety by not allowing denial to get too far. Artificial maintenance of a sense of hope is counterproductive. If we recognize the reality of death and the reality of our humanness as physicians, then dealing with death should lose some of its personal destructiveness and the cascade of angry feelings often observed should be eliminated. Neglected interfaces in the ICU are multiple. The uncertainty of events and the inability to predict death with the resultant philosophy that everyone gets maximum care is a stress-producing situation. Couple this with a potential for physical overload in terms of tasks requested and the stress increases. Dealing with the dying patient produces anxiety and fear and the frustration and sense of betrayal often strain interpersonal relationships in a negative manner. Only open communication and sharing of feelings can alleviate some of the detrimental effects of these responses. The surgeon must be aware of these factors and incorporate them into his day-to-day practice in the ICU. A little thought and consideration to these neglected interfaces could yield great dividends in the arena of improved ICU function. REFERENCES Greenburg, A. G., and Goldberg, M. Alternative surgical intensive care unit configurations: Evaluation by simulation. In D. B. Shires and H. K. Wolff (Eds.), Proceedings, MEDINFO ‘77, World Conference on Medical Information Amsterdam: North-Holland, 1977. P. 437. Greenburg, A. G., McClure, D. K., Janus, C. A., and Stubbs, J. A. Nursing intervention scoring system: A concept for management, research, and communication. In Lindberg and Reichertz (Eds.), Lecture Notes in Medical Informatics (Medical Informatics Europe ‘78), New YorWBerlimSpringerVerlag. P. 728.
OF SURGICAL
RESEARCH
26,494-498 (1979)
Neglected
Components
A. GERSON GREENBURG,
of Intensive
Care
M.D., PH.D. ,* JOSEPH M. CIVETTA, AND GEORGE BARNHILL, M.S.t
M.D. ,’
* Departments ofsurgery, University of California, San Diego, and the Veterans Administration Medical Center, San Diego, California 92161, and fDepartment of Surgery, University of Miami School of Medicine, Miami, Florida 33124 Presented at the Annual Meeting of the Association for Academic Surgery, Cleveland, Ohio, November 12-15, 1978
A great deal of literature exists about intensive care units in general and surgical intensive care units in particular. References regarding what to monitor, how to monitor, and when to monitor are abundant. Reports on interpretation of monitored data, errors in the data acquisition, and how to use specific data in decision making are similarly available. Intensive care unit architecture and design details, as well as staffing requirements, have been described. One could go on. Despite all our “scientific” methodology and applied medical knowledge there are still areas of intensive care that seem to be neglected. What do we know about the reasons behind the high turnover of skilled nursing personnel? What are the effects of the high turnover rate on the quality of care delivered or the quantity of system/effort possible? What effect does this loss have on personnel morale? Do we really know the effort we ask of nursing personnel in terms of nurse utilization -minutes of time per hour or per shift-when we write routine orders? What data do we have that will help us allocate precious and limited resources to an appropriate end? Can an appropriate end be defined? Finally, are there identifiable stress factors that need to be dealt with which produce the fear, anxiety, anger, and often low morale in these high-tension, rapidaction, volatile clinical situations? These are not rhetorical issues! They are real issues and questions present in all in0022-4804i79/050494-05$1.00/O Copyright 0 1979 by Academic Press, Inc. All rights of reproduction in any form reserved.
494
tensive care units. These issues must be addressed for they are all pervasive in instilling and, more critically, altering attitudinal positions. Once sensitized to these issues the surgeon develops insight into the unit’s true internal environment as well as its interfaces with the rest of the care delivery system. Can the clinician predict death? If one could accurately predict this stress-producing event, two benefits would accrue. First, we would be able to rationally allocate our scarce intensive care resources and second, we could prepare psychologically both staff and family for the event. Unfortunately we cannot accurately predict death. Furthermore, it is the uncertainty of predicting the event that eventually, if the patient lives long enough, produces stress. This stress is manifest upon the staff regarding the patient, the rest of the staff, and in the staff’s response to the patient’s family. The result is multifactorial and its impact unpredictable. Because we have little scientific evidence to use in predicting death we are left to rely on clinical judgment as the basis for major decisions regarding resource allocation. Our ability to predict a survivor is at least 90%, while our ability to predict a nonsurvivor “based on clinical judgment” is never more than 60%. The discrepancy is so great we must bias our allocation based on an objective that says: “Everyone will live.” This high level of predictive uncertainty,
GREENBURG,
CIVETTA,
AND BARNHILL:
entropy, is both anxiety provoking and threatening to unit personnel. When this uncertainty of survival is coupled with the uncertainty of the random appearance of catastrophic events, the unpredictable clinical crisis, one begins to appreciate the basis for the high-tension environment. The point is simple: Uncertainty produces anxiety and anxiety readily translates to stress. Surviving patients reside in the ICU for less time than nonsurvivors. The longer a patient stays in the ICU the more uncertain the outcome. It is no wonder that nurses become concerned and attached to the longterm patients and develop a “protective” reaction. On the other hand, the staff may develop an “aversion reaction” to a particularly long-term patient. They feel death is likely and distance becomes a good defense. Furthermore, they may feel they have effected a “save” and believe no one else can care for the patient. They thus become reluctant to discharge the patient to the care of nurses or physicians in a less intensive environment who know him/her less well. The net result is yet another stress-producing situation! These are not orchestrated scenarios. This process occurs daily and is, in fact, fueled by our inability to accurately predict who will live and who will die. Our clinical judgment is generally bad, and we have little scientific methodology to rely on. As a result, we stress our system by using resources and we stress our personnel because the outcome is uncertain. There are stress-producing factors related to resource allocation that also need to be investigated. There are the questions of physical stress or demands on nurse time in the ICU that also need to be addressed. If the nursing personnel are physically stressed, the effect in combination with emotional stress resulting from uncertainty may be synergistic. What demands do our orders place on available nursing personnel time? Utilizing the management science technique of systems analysis to identify and quantitate tusks performed in the ICU,
INTENSIVE
CARE
495
we were able to generate 15 categories of tasks that consume time. Furthermore, these tasks can be subcategorized into observation, therapeutic, hotel, or clerical groups. Even further, each task can be quantitated and a finite segment of time identified for completion. The tasks to be performed are generated by physician’s orders and system overhead, so the physician directly controls nurse utilization. The task categories are shown in Table 1, and an example of detailed tasks for a category is shown in Table 2. In all, 108 tasks, each consuming 6-7 min of nursing time, are identified. Thus, with 8 hr per nurse per shift, 480 min are available, and if one desires to operate at 80% nurse utilization, only 380 min are available for patientdirected tasks less the overhead (nurse’s notes, reports, etc.). All of the tasks have been presented elsewhere [2] and indeed, we have converted the task requests to a NISS Score (Nursing Intervention Score System) that clearly and explicitly defines how much time the nurse must spend performing the requested tasks. For a single patient, a NISS score of 60 or more indicates more than one nurse will be required to carry out all those tasks. Using this score daily or at each shift change, one has a managerial assessment of the functional capacity of a given unit. Closing beds or recruiting extra help can be based on data and information necessary to support the action. Were one to constantly and continuously place demands for time in excess of those reasonably available a stressed system and eroded emotions would result. The futility and frustration resulting from trying to be complete can be destructive physically and emotionally on the unit. Can computers help in the ICU? This is a truly difficult question to answer. Using digital simulation technology we have designed and evaluated a model ICU within which we can vary patient load by number and state of health, nurse:patient ratio, and system configuration and define the effects
496
JOURNAL
OF SURGICAL
RESEARCH:
of these changes on nurse utilization [l]! That the model can rapidly execute 154 variations and provide useful and usable data implies that computers can help ICU functional analysis and indicate potentially viable solutions for further real-life evaluation. What did the model’s output indicate? Interestingly enough, even an idealized fully automated computerized system does not decrease nurse utilization for the most seriously ill patients. In fact, for these patients reasonable and appropriate utilization only begins to appear when the nurse: patient ratio approaches 2: 1. In addition, a “turnkey” computerized monitoring system is no better for the medium-range patient than a well-tuned ICU. This tends to indicate that these predefined systems will be of questionable cost effectiveness if utilized as delivered. The incremental cost attendant on full computerization may likewise not be cost effective for when it is most needed, it has the least impact. Figure 1 shows the simulation model output for four states of health (l-4), four different systems, and a variety of nurse:patient ratios. It is significant to note that even with full computerization for the most seriously ill TABLE
1
NISS TASK CATEGORIESAND NUMBER OF TASKS PERCATEGORY Monitoring Intravenous lines Medication Fluid intake Blood therapy Fluid output Metabolic management Respiratory management GI tract management Wound, skin care Miscellaneous therapy Miscellaneous task Patient events Non-KU services Nursing factors
13 5 14 6 4 11 10 13 4 3 10 15 4” 3” 2”
a Not storable, no points assigned.
108 - 9 117 Total
VOL. 26, NO. 5, MAY
1979
TABLE 2 MONITORINGTASKS Task
No. of points
ECG, rate Vital signs, QlH Vital signs, Q30M Vital signs, Q 15M Peripheral arterial line, BP CVP Pulmonary arterial line, pressures Neuro vital signs Measurement of cardiac output Left atria1 pressure Intracranial pressure Peripheral pulses, Doppler ECG, rhythm
1 1 3 4 1 2 3 3 4” 3 4 3 2
a Dye dilution; 2 if thermal.
patients, a ratio of nurse to patient of more than 1: 1 is needed. The overlap of our current system and a turnkey system is also apparent. Thus the decrease in nurse utilization anticipated from computerization where it is most needed can be better effected by more personnel. For a state of health of 2 a fully computerized system is helpful. Most open-heart and seriously ill patients, however, are l’s for up to 24 hr. The computer is thus helpful for administrative and managerial function but there are little data to support its general application directly in the ICU. Potential application as an adjunct to unit process, data interpretation and relief from clerical tasks exists but has not been demonstrated. The real impact is thus unknown. In addition, when introduced into the ICU, computers can create a stressful situation by stimulating anxiety in the staff. If the staff is not included in the planning and implementation the system may go unused as a staff reaction. A desirable goal is to decrease staff anxiety over all issues, and one accomplishes that by decreasing uncertainty. Health care professionals deal with the threat of death, and the inability to cure dying patients is a constant source of frustration. This frustration often becomes trans-
GREENBURG, CIVETTA, AND BARNHILL:
INTENSIVE
497
CARE
100 90
-
a0 x F l-i 2 2 I=
7060-
fi2
40-
50STATE
aQ
OF HEALTH
= 1
30 - OIST. EXP. 20 - b.---a
.
10 - &--
0’
Manual
.... current A
Turn
’ ’ ’ .!i 1.0 1.5
Kev
’
2.0
’
2.5
’
’
3.0
3.5
’
.5
4.0
1.0
1.5
RN:PT
loo STATE
2.0
2.5
3.0
3.5
4.0
RN:PT
r
OF HEALTH=3 90-
80 -
.5
’ 1.0
Turn Key Best Compurerkd ’ ’ 1.5 2.0
60-
;
40-
STATE
70-
OF HEALTH=4
50-
2 30a@. 20 -
20-o-.--.a Manual ,.........AC”,e”f ,,-, -b------o 0 ’
g I= 2 ? 5
10 1
I
3.0
4.0
FlN:PT
01
OIST.
.5
1.0
EXP.
1.5
2.0
3.0
4.0
RN:PT
FIG. 1. Nurse utilization as a function of nurse:patient ratio for four states of health under four ICU system configurations. See text for explanation.
lated to stress and anxiety and is manifest by low morale and poor interpersonal relations. The constant threat of death, the uncertainty of when it will occur, and its impact on the patient and his family, physician, and nurses deserve consideration, for this threat is what keeps us treating our patients. Since we cannot accurately predict death, and since most seriously ill patients place a great demand on personnel time, the potential frustration resulting from physical and emotional stress must be recognized. “Death is not necessarily a failure” only if everyone recognizes and is prepared for the event.
Caring for a dying patient is frustrating. The feelings engendered may lead any of us to anger for each death reminds us of our inability to cure all disease and of our own fallibility. Depression, anxiety, and anger are the unpleasant feelings that result. The illness involves anxiety and reminds us of our inability to control all situations. Rather than deal with the anxiety, anger results and we direct it toward the patient and his family, or more often toward fellow staff members and colleagues. How do we react to a patient’s death? Withdrawal from family and staff, each going its own way, usually occurs. The staff
498
JOURNAL OF SURGICAL RESEARCH: VOL. 26, NO. 5, MAY 1979
feels they have failed, and the family feels rejected. They isolate themselves and cut off the one useful option: open and honest communication. We must recognize that the cause of death, the character of death, and the duration of dying have changed with advances in technology. The patient is often dehumanized as the staff pays more attention to physiological requirements than emotional needs. By turning their backs on the patient’s emotional needs, the physicians often fail to realize this, and the burden falls upon the nursing staff. The net result is a high degree of tension more often than not manifest as anger. Could there be specific stress factors identified that account for the high turnover of ICU nurses? We all recognize the problem in terms of the economic input attendant on the loss of skilled, trained personnel, but do we recognize the stress factors that produce the problem? Health professionals at all levels harbor above average fears and anxiety pertaining to death. This subjective dread may lead to rejection of the dying patient. We must recognize that the hospital is not only an institution for restoring health, it is the place where Americans die. In America 70% of all deaths occur in hospitals or nursing homes; little wonder there is high anxiety! Dying occurs in an impersonal environment and the ICU, being technologically oriented, is perhaps the most impersonal. Not surprising, most physicians and nurses judge their success or failure by whether their patient lives or dies. When a patient dies it is taken as a sign of failure. Physicians are little prepared to deal with death, and it often comes as a shock reminding them of their own fallibility or mortality. This is particularly true when dealing with the younger patient. Physicians and other health professionals must realize that patients are going to die but that death does not have to mean failure and loss of self-esteem. Physicians are mortal and are entitled to emotional oscilla-
tions and often need support and understanding. Involvement with a dying patient is stressful and denial of this stress has a deep emotional impact. Open, frank communication among staff and between staff and family decreases anxiety by not allowing denial to get too far. Artificial maintenance of a sense of hope is counterproductive. If we recognize the reality of death and the reality of our humanness as physicians, then dealing with death should lose some of its personal destructiveness and the cascade of angry feelings often observed should be eliminated. Neglected interfaces in the ICU are multiple. The uncertainty of events and the inability to predict death with the resultant philosophy that everyone gets maximum care is a stress-producing situation. Couple this with a potential for physical overload in terms of tasks requested and the stress increases. Dealing with the dying patient produces anxiety and fear and the frustration and sense of betrayal often strain interpersonal relationships in a negative manner. Only open communication and sharing of feelings can alleviate some of the detrimental effects of these responses. The surgeon must be aware of these factors and incorporate them into his day-to-day practice in the ICU. A little thought and consideration to these neglected interfaces could yield great dividends in the arena of improved ICU function. REFERENCES Greenburg, A. G., and Goldberg, M. Alternative surgical intensive care unit configurations: Evaluation by simulation. In D. B. Shires and H. K. Wolff (Eds.), Proceedings, MEDINFO ‘77, World Conference on Medical Information Amsterdam: North-Holland, 1977. P. 437. Greenburg, A. G., McClure, D. K., Janus, C. A., and Stubbs, J. A. Nursing intervention scoring system: A concept for management, research, and communication. In Lindberg and Reichertz (Eds.), Lecture Notes in Medical Informatics (Medical Informatics Europe ‘78), New YorWBerlimSpringerVerlag. P. 728.
