When Time Won't Tell
- When Time Won't Tell
J.B. was unlucky. A thirty-two-year-old chance witness to a robbery, he was shot in the head and abdomen. When he arrived at the emergency room, gray matter protruded from his head, and he had lost a tremendous amount of blood. After cardiopulmonary resuscitation, the trauma team managed to restore his heartbeat and place a tracheostomy tube to stabilize his airway. He was then transferred to the hospital's intensive care unit.
For the next two months, he depended on a ventilator to breathe, and for the last six months, he has remained on humidified oxygen because of the tracheostomy tube. He has also remained a patient of the trauma team. Nurses regularly suction his secretions, neurology consultants are sometimes called in to assess his neurological status, and his mother watches over him steadfastly.
Lately, members of the trauma team have asked the nurses, "Do we need to round on J.B. today?" J.B. cannot stay in the ICU forever (and continued reimbursement for his care is uncertain), but discharge planning is complicated by his need for regular tracheostomy tube maintenance, which makes him ineligible for residence in most long-term care facilities. Attending physician Dr. Vinart talks regularly with J.B.'s mother. She confides that she cannot care for him and worries that he would not want to continue living this way.
Dr. Vinart has heard some of his residents express uncertainty about whether J.B. belongs in the ICU and doubt about whether "reviving" him in the trauma bay was appropriate. He calls an ethics consultation. How can he approach J.B.'s continued care and possible discharge?
- Commentary
A central issue in this case is how best to respond to patients whose needs might not be medically complex, but who still require sophisticated nursing care to remain stable. These "long-term acute care" cases raise an important question: What does it mean for a patient to "belong" in the hospital?
In examining this question, we might explore the grounds for justifying a patient's discharge from an ICU to a long term care facility. "He's been in the ICU for a long time" does not seem to be a good reason for discharge. According to the acute care mindset, patients in a hospital are expected to get better or die. When they do neither, they are sometimes called "outliers" (particularly in coding and reimbursement language), and the appropriateness of their "placement"—a word common in utilization review parlance—is questioned. Patients whose conditions do not improve or worsen can be perceived as a waste of resources (clinicians' time, hospitals' bed space). The derogatory term "frequent flyers" is occasionally applied to patients who return to the hospital repeatedly for treatment of recurring ailments, which are usually exacerbated by poverty, social marginalization, addictions, or chronic mental illnesses.
J.B. is different from "frequent flyers." He is not perceived as wasteful of resources—at least, not yet. But his long-term acute care needs cause puzzlement ("What do we do with this guy? Is this the right place for him?") and even regret ("Did we do right by 'saving' him?"). Like "frequent flyers," J.B. is an outlier. These patients dwell in a liminal state that is neither healthy nor imminently dangerous. Persistent uncertainty about their outcomes generates anxiety, frustration, regret about whether and where they should be "placed," and questions about fiscal and other resources, such as how much time is worth investing when responding to their needs, and whose time that should be.
In the health care context, "placement" is a proxy word for its kindred concept, "belonging." One way of assessing whether a patient belongs is by determining whether he is either "progressing" toward wellness or "deteriorating" toward death. This progress or deterioration is regularly assessed according to specific, measurable physiological outcomes. It directly influences caregivers' perceptions of just resource allocation—what patients in those categories deserve, and from whom. "Progressing" is obviously the privileged category. But even if a patient is not measurably deteriorating, the fact that he is also not measurably progressing is enough to put his belonging and just...
