Tuesday, October 09, 2007

Bloodless

Last night I took care of a patient who had recently undergone chemotherapy and radiation, and was admitted to the MICU with severe anemia. Specifically, his hematocrit on admission was 14. Then the next day it was 13, then 12, then 11. That's what we call Super Low (or critical, whatever) since the average male should have a hct of at least 45% and we would nearly always transfuse for hct of less than 25%. But this particular patient, due to his personal religious beliefs, refused any transfusion of any type of blood products. He was not confused, and quite oriented, and understood that he could die without a blood transfusion. His cancer is still treatable, but he could not have any more chemo or radiation until his blood counts were back into a safe range. I think I am usually very nonjudgemental of my patients lifestyles, religions, or personal beliefs, but I am having a lot of trouble with this one.

His wife stayed overnight in the room with him, despite it being against our unit policy. But other nurses had previously allowed her to, and once the precedent has been set I hate being the bitch who suddenly enforces the rules. So I agreed to it, but with the warning that if her presence interfered at all with nursing care, I would have to ask her to leave. She put his side rail down and pushed the chair-bed right next to his bed, but I constantly had to wake her up and push the chair aside in order to be able to access my patient. Since he had just received four liters of Golytely and required very frequent cleaning up, I needed to make her move quite a lot. Freakin' Golytely. At one point, upon seeing the entire bed transformed into a lake of dark brown foul-smelling liquid, she sighed and said, "Wow. Awww. Wow. I'm just so surprised, he's only had one little Ensure shake in the past few days." Umm...four liters of Golytely go in, four liters of Golytely must come back out. And then some. I wondered if dayshift had silently administered the Golytely into his feeding tube without explaining the outcome? And she hovered around while I cleaned him, at one point even patting me soothingly on the shoulder and saying, "Aww. Wow, you poor thing. Wow." I bristled. Good thing the lights were dim in the room, or she may have noticed me narrow my eyes and the little hairs on the back on my neck stand up. I'm a nurse, a highly trained and well-educated ICU nurse, this is my job, this is what I do, I'm being paid for it and I chose to be here. Don't pat me on the shoulder.

The patient was pale as a ghost, lethargic and very weak. I didn't draw labs on him since the docs didn't order any, and they want to minimize blood draws as much as possible, for obvious reasons, so I don't know what his hct was this morning. The charge nurse and I discussed possible transfer out of ICU to the medical floor...after all, what could we do for him? Yes, he was full code status, but we could not transfuse. We cannot treat his life-threatening anemia, except with epo shots and iron supplements. He is not a surgical candidate. He is not intubated and his other vital signs and pressures are stable. So it sort of makes sense, he doesn't need to be in the ICU. But it struck me that his status would be downgraded, to a different level of care, essentially because of his religious beliefs. Is that weird?

I'm still thinking about this one. I'm still having trouble with it, because it doesn't make sense to me and I have trouble accepting it. Sure, a lot of religious convictions and beliefs don't make sense to me, but usually I can accept the differences in belief and move on from there. But this just doesn't sit well with me. I can't wrap my little secular head around it. Why does that one specific thing in the bible, regarding blood, get translated and adhered to so literally? Why do they accept all of our other medical advice and interventions without investigation or comparison to scripture?

And I'm confused by myself...I left the same t-shirt (his garments?) on a Mormon patient in the ICU for days and days and worked around it, I carefully wrapped and re-wrapped a head scarf around a young Muslim woman each time before a male physician entered her room, I timed certain medications around prayer times so a Muslim patient could pray, I made fifteen-minute checks on a my Hasidic Jewish patient because after sundown on a Friday she could not use the call light, I've bent the unit policy and allowed more than the requisite number of visitors into a patient's room so they can pray together, and not one bit of any of these actions bothered me. Rather, I consider it to be a crucial part of a nurse's job, since I am caring for the whole patient. But at the same time, I guess none of those things ever compromised a patient's care or well-being, either.

So anyway. This is just a big old can of worms I might be opening. Perhaps this is a controversial topic, maybe I seem callous or judgmental. I sort of feel that way. But I just don't get it.

2 comments:

CleanDry&Intact said...

I could see how that would be mind-boggling. I've felt that way sometimes, too. Not to sound like a total cheeseball, but nursing seems like it's full of emotional tug-o-wars. Can be so draining. Your avatar looks sooo sad now! :(

girl_in_greenwood said...

I also find that particular refusal mystifying. I mean, I tend to be on the "live and let live" end of the spectrum when it comes to the choices that other people make... but it is much harder when you *know* you could help the patient, but they are refusing for what seems like arbitrary reasons. There are a couple of members of that particular religion in my class at nursing school, and although I've discussed the whole blood topic with them several times, I still don't get it. At least my classmates have acknowledged that they would be willing to transfuse someone else if they had to.