Finding Meaning in the ICU

A patient’s wife beckoned over to me after saying goodbye to her husband for the final time. It was a challenging week, and we had withdrawn care a few hours before. Before leaving, she wanted me to see what her husband looked like. Not the version of him that I knew in the intensive care unit (ICU) (intubated, alternatively agitated or sedated), the real him. She scrolled through photos on her phone and I saw him wearing pajamas on a comfy lounge chair, a goofy grin on his face and a twinkle in his eyes. It was an utterly humanizing moment of connection.

 

It was this moment that came to mind when I read about the 3 Wishes Project in the January issue of Annals. Vanstone and colleagues described a wholly patient-centered intervention—asking patients in the ICU and their families for end-of-life wishes and executing them—yet the effect extended to the entire medical team (1). In reporting qualitative outcomes, the authors noted that the project helped ICU clinicians add meaning to their work. A nurse shared how the project helped her feel more connected to patients and families, and a social worker commented that the project may prevent burnout by bringing people closer.

 

My internal medicine coresidents and I frequently discuss the challenges of ICU rotations. We brave 28-hour call cycles, and sleep is elusive. Yet, the emotional demands of the ICU are sometimes the hardest. Our job is not just to place central lines and start norepinephrine bitartrate drips, it’s to help patients and families navigate what may be the final moments of life. We talk on rounds not just on how to manage acute respiratory distress syndrome but how to share difficult news with families.

 

The 3 Wishes Project was implemented differently at different sites, yet it provided a structure for augmenting end-of-life care via discussions of wishes. The structure then facilitated the types of humanizing experiences both patients and clinicians cherish. Most of the wishes in the study had no cost associated. Although funding and infrastructure is needed to carry out such a project, we can start by being more intentional in our conversations. We can make a point to get to know our patients as people and elicit values. If that patient’s wife hadn’t beckoned me over, I would have stayed at my computer, finished a progress note, and missed a moment of meaning. 

 

References 

1. Vanstone M, Neville TH, Clarke FJ, et al. Compassionate end-of-life care: mixed-methods multisite evaluation of the 3 Wishes Project. Ann Intern Med. 2020;172:1-11. [PMID: 31711111] doi:10.7326/M19-2438