In the ICU we see our fair share of loss, most the result of unplanned tragedy both for the patients and their families. As healthcare providers we work as part of a high functioning team always working to provide exemplary patient-centred care. We maintain a calm cool demeanor, approachable and open to suggestions and feedback from families, as we care for our patients and families alike through this highly stressful and emotional time. Stressful for all? Yes… but it is what we do. But sometimes despite our best efforts, it is a fight that just can’t be won. And our goals shift from talks of airway, breathing and circulation to talks of patient values, quality of life and death with dignity.
When this talk happens, I tell the families that there are many things we do well in the ICU, but there are two we excel at. First being to provide aggressive, life-sustaining care including cardiopulmonary resuscitation (CPR), defibrillation, blood products and vasopressors. And when that is proving to be futile the other thing we do is provide a peaceful and comfortable passing. Once families realise that they will not be bringing their loved one home the only thing they want to know is that their passing will be comfortable.
In our ICU we wanted to extend that comfort to the families and loved ones as well. We came up with the idea to create a comfort cart. When the time has come where having the code cart with the epinephrine and defibrillator is no longer appropriate we trade it out for our end-of-life comfort cart. With donations from families and money from fundraisers we purchased a portable kitchen island. This was important for us as we didn’t want the institutional look of the code carts found throughout our unit. We wanted the presence of the cart to bring peace and not anxiety. We equipped it with a coffee maker, water bottles, granola bars and other snacks. In one drawer there is a portable CD/MP3 player with cords and even phone chargers so that their choice of music can be played. In another drawer we have rubbing stones etched with different words: ‘family’ ‘peace’ ‘love’… I have seen these used time and time again while loved ones sit vigil at the bedside. I have heard from families who then had them made into charms for necklaces and keychains. In one of the cupboards we have an assortment of books and pamphlets on dealing with grief and spiritual care resources. In another cupboard we have scrapbook supplies and a digital camera. We will often do photos of hand holding or provide an ECG rhythm strip. For the ECG strip we take a screen shot (or scroll through for best possible rhythm of that day), cut out a small section of their rhythm, and roll it into a memory bottle. When presented to the families we tell them they will always have a piece of their loved one’s heart. These resources are inexpensive (can be purchased at dollar stores) but provide a priceless gift that families cling to.
There are colouring books and crayons for when children are present. In separate storage drawers we have a vast amount of craft and colouring supplies, so we can replenish what was used. Families often bring in their young children for various reasons: no childcare, from out of town or they want to provide them the opportunity to say goodbye. What they often don’t realise is the amount of time they will be present at the bedside. For children first coming into the ICU we have ‘ICU dolls’ that we bring out to discuss with them things to expect in the room and with their loved one. Parents have found these resources we provide for their children invaluable as it provides a distraction and allows them to focus on their loved one and their grieving process.
As with any ICU there is often ongoing commotion at any given time. A surgical team is consulting, the ICU team is rounding, the nurses are collaborating, cleaners are emptying the room next door, a patient is arresting... We try to communicate before team members enter the bay that there is an end-of-life ‘comfort care’ case happening so they can use hushed tones. However, since we do not post a guard at the end of the bay and with nurses busy caring for their own patient assignment, this message often does not get relayed. So we came up with the idea to place large battery-operated candles. One at the main charge nurse desk to make all staff aware of a comfort case. The second candle is placed at the end of the bay and the third on the cart outside the patient’s room. This sends a silent but powerful message to maintain respectful tones, be mindful of the words being spoken and has been well received and practised by all staff members.
As healthcare professionals we take pride in the care we deliver. When a patient gets admitted into our ICU it is always with the intent to return that patient to a meaningful quality of life. When our goals shift from cure to comfort we strive to do it with compassion, grace and respect. Having developed the comfort cart, we are able to provide a meaningful and family-centred care experience. They may not remember our names or even 80% of the information we gave them, but they will forever remember that they were wholly cared for.