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Life And Death In Intensive Care

Joan Cassell
Copyright Date: 2005
Published by: Temple University Press
Pages: 248
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  • Book Info
    Life And Death In Intensive Care
    Book Description:

    Life and Death in Intensive Careoffers a unique portrait of the surgical intensive care unit (SICU), the place in medical centers and hospitals where patients with the gravest medical conditions-from comas to terminal illness-are treated. Author Joan Cassell employs the concept of "moral economies" to explain the dilemmas that patients, families, and medical staff confront in treatment. Drawing upon her fieldwork conducted in both the United States and New Zealand, Cassell compares the moral outlooks and underlying principles of SICU nurses, residents, intensivists, and surgeons. Using real life examples,Life and Death in Intensive Careclearly presents the logic and values behind the SICU as well as the personalities, procedures, and pressures that characterize every case. Ultimately, Cassell demonstrates the differing systems of values, and the way cultural definitions of medical treatment inform how we treat the critically ill.

    eISBN: 978-1-59213-337-6
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Acknowledgments
    (pp. ix-x)
  4. INTRODUCTION Moonscape: The Surgical Intensive Care Unit
    (pp. 1-15)

    I felt this way when I first visited an operating room (OR) in 1983. But the strangeness wore off. I learned how to dress (in fresh scrubs, with sterile cap, mask, and booties over my sneakers), where to position myself (next to the anesthesiologist on a few stacked stools during an operation), how to move (to keep sterility and not touch and thus contaminate a surgeon who has scrubbed). Although I never became fluent, I learned enough of the language to understand the exchanges between surgeons, residents, and nurses. The strangeness was domesticated, became familiar. I was able to joke...

  5. 1 A Caring Ethic: Nurses and the Dilemma of Powerlessness
    (pp. 16-32)

    When I first started studying the Midwest SICU, I was struck by the differences between the ways the nurses and doctors related to patients.

    The nurses caredaboutpatients as well asforthem. It was a nurse who waved at a conscious patient through the glass walls as he walked past the room. It was a nurse who held a patient’s hand when a painful procedure was carried out. (Only once, in almost 18 months of research in this SICU was a resident observed holding a patient’s hand, and that resident was an exceptional woman.) It was a nurse...

  6. 2 The Best of Times, the Worst of Times: The Residents
    (pp. 33-50)

    A changing cadre of first- and second-year residents helped care for the patients in the Midwest SICU.¹ An occasional senior resident who wanted to learn more about critical care would “rotate” through. Residents generally spent four to six weeks on SICU rotation, arriving for 7:30 a.m. morning rounds, and leaving approximately 30 hours later, when morning rounds on the following day were completed. At this time, they passed on the patients they had been caring for—each took responsibility for several—to the next resident. With few exceptions, the residents came from surgery, anesthesiology, and emergency medicine training programs at...

  7. 3 Diverse Universes of Medical Discourse: The Fellows
    (pp. 51-60)

    The moral economies of the sites where training programs are located affect the qualities that are valued in residents and sought in critical care fellows. A star system functions in prestigious American academic centers; authorities look for brilliant candidates who have been identified as outstanding residents. Smaller, less competitive academic centers and community hospitals focus on finding and training dedicated physicians willing to serve their communities by striving to save lives. The picture is different in Auckland, New Zealand, where stars tend to hide their light in order to blend into the group, and where caringaboutpatients is valued...

  8. 4 The Attendings
    (pp. 61-71)

    The seven critical care doctors who cared for patients in the Midwest SICU were all stars.¹ All had passed at least two qualifying boards, one for anesthesia or surgery, and another for critical care. Several had passed three, and at least one was “boarded”—as doctors say—in four specialties.² One intensivist was the chief of anesthesiology; another, who held an endowed chair in the medical school, was the head of trauma surgery. All conducted research. Two of the younger attendings had been granted five-year mentored career development awards from the National Institutes of Health (NIH) in recognition not only...

  9. 5 Is Death the Enemy, or Suffering?
    (pp. 72-84)

    The Midwest SICU is semi-closed. Responsibility for patient care is shared between the surgeon who operated on the patient (referred to as the primary attending) and the intensivist on call that particular week. Conflict erupted, on occasion, when an intensivist proposed to shift a patient from “cure” to “comfort care” against the adamant opposition of the patient’s surgeon.

    The surgeons, as a rule, hated to let a dying patient go. A surgeon might tell family members there was no reason to worry, when an intensivist had warned them that the patient’s condition was grave. I repeatedly witnessed disagreement between the...

  10. 6 Confronting Death in the Surgical Intensive Care Unit
    (pp. 85-104)

    Almost all the patients in the Midwest SICU were highly sedated.¹ Their awareness levels were measured by a “Ramsay Score,” rating a patient’s condition from “cooperative, oriented and tranquil,” through “anxious, or agitated and restless,” to “no response” or “unable to assess.”²

    The co-director of the SICU said that they administer narcotics and sedatives³ to relieve anxiety and put the patient to sleep. He argues that it is so excruciating to be awake in the SICU, attached to tubes and with a breathing tube down one’s throat, that it is kinder for the intensivists to sedate patients. Some of the...

  11. 7 Intensive Caring in New Zealand
    (pp. 105-117)

    When I compared the lower-tech Auckland, New Zealand ICU with its American counterparts, an attending responded: “It’s not technology that makes intensive care work, it’s people who intensively care.”

    Although resources were scarce in New Zealand, the people in the Auckland ICU did, indeed, intensively care. They obviously cared about preserving and restoring lives and, also, about the quality of the dying and the quality of the human relationships in each death.

    Contrasted with in New Zealand, the American medical system is characterized by abundance. The United States has 30.4 ICU beds per 100,000 population, while New Zealand has 5.3...

  12. 8 Going Gentle into that Good Night: Death in Auckland
    (pp. 118-140)

    In the mid-1990s, the Auckland ICU initiated a Survivor’s Follow-up Service to interview patients who had been in the unit. These interviews were originally designed as a quantitative “audit” of the effectiveness of ICU systems, service, and patients’ current health status. The feelings of former patients, however, became increasingly important to the nurse-interviewers and the doctors who received their reports. A Bereavement Follow-up Service was then initiated.

    In 2002, the Bereavement Follow-up Service had been operating for seven years. The nurses’ reports, which were circulated in the unit, described not only how the families felt and how they reacted to...

  13. 9 Focusing on the Bottom Line
    (pp. 141-154)

    While conducting research, I spent a day each with five administrators at the Midwest medical center: the Chief Executive Officer,¹ the Chief Nurse Executive, the Chief Medical Officer, the Chief Operating Officer, and the chief of Surgery (the Surgeon in Charge). I told them that I wanted to learn more about the people whose decisions affected the day-to-day operation of the SICU; this would help me to understand the context in which the unit functioned. I spelled out the rules beforehand: I would meet each administrator when and where he or she wished; they could introduce me as they wished...

  14. 10 The Dominion of Death
    (pp. 155-176)

    An American SICU is a miraculous place to be if you are a patient with reasonable odds of surviving. All the resources of technology, medical knowledge, and drugs, will be brought to bear to help you walk out of that door back into your life. If you are likely to die, however, an American ICU is a terrible place to depart, surrounded by machines, with tubes in every orifice, unable—because of sedation and the ventilator tube in your throat—to communicate with those you love and say good-bye.

    American doctors tend to be uncomfortable with dying patients. A British...

  15. APPENDIX “Hard” Science, “Soft” Science, Social Science: The Anxiety of Methods
    (pp. 177-190)
  16. Notes
    (pp. 191-216)
  17. References
    (pp. 217-228)
  18. Index
    (pp. 229-234)
  19. Back Matter
    (pp. 235-235)