By Dorrie Fontaine, RN, DNSc, FAAN
President, American Association of Critical-Care Nurses
Rising Above: New Questions, New
Opening the Door, Just a Crack
Two events caught my attention during December. One
was exceptionally tragic. The other was tremendously uplifting.
On Dec. 12, a man walked into an ICU, shot his
74-year old wife who had lung cancer, then turned the gun on himself.1 Both died
instantly. Although the national media was focused on other violence across the
globe, this tragedy rocked the world of critical care.
About the same time, I attended a workshop presented
by Miami-based Project Yes. (www.projectyes.org) The workshop centered on
generating dialogue that can begin to dissolve fears and encourage actions that
protect all youth. I learned an essential skill: how to "be with" people as a
first step to authentic communication.
What Don't You Know?
I sensed a link between these seemingly unrelated
events. But what? There were so many unanswered questions that I hesitated to
take the plunge and write about it. Then, I remembered an op-ed piece titled
"My Dunno Sheet" by New York Times columnist William
Safire.2 He wrote, "Don't just write what you know,' a great editor once
instructed me about reporting an emerging story. �Make a list of what you don't
Safire goes on to reflect that "[this advice] is
again a useful reminder of how much is going on about which we have yet to learn...Because the answers are hidden does not mean the answers do not exist. One by
one, they will all spill out, in glorious or infuriating detail." In a manner of
speaking, Safire could have been writing about rising above-posing new questions
and hunting for new opportunities.
Here's a short dunno sheet for you to consider-some
questions followed by some possibilities:
� Do I keep silent because I have no answers?
Unanswered questions are part of life. Not accessories, but part of the basic
package. If I take to heart the lesson that Connie Barden, our past president,
taught us about bold voices, then I am compelled to recognize that one person's
voice-mine-may soon be joined by others who seek answers.
� How do I hunt for answers when I sometimes feel
like there's barely enough time to attend to "the basics"? Finding answers is
basic. Unanswered questions are doors waiting to be knocked on, opened. By
opening a door even a tiny a crack, I start to move toward possibility.
� Why did I hesitate to even mention what the police
called a "mercy-killing" incident? Would it look like I know more than I do?
Could it appear I'm laying blame? Neither is the truth. By making even one
important point about end-of-life care, might I honor the excellent nurses,
physicians and their colleagues at this and every hospital? Might I respect the
family of the tragically deceased couple? I believe so.
Open the Door to Palliative Care
I am opening the door just a crack to palliative and
end-of-life in critical care units. Through that crack, I am slipping AACN's
bold statements, joining so many others in calling for major change in
end-of-life care. AACN states that an association goal for this year is starting
to tackle the challenge of making certain that critically ill patients and
families who need palliative and end-of-life care receive it. No matter where
they are. Do we need more proof of this than the tragic deaths of Dec. 12?
Here is where we get stuck. We know "palliative care
is not what nurses do when they have finished doing everything else," as Cynda
Rushton, cochair of AACN's Ethics Work Group, often reminds us. But we have too
few nurses and not enough time. We are uncomfortable standing at the bedside
alongside those who are experiencing unspoken grief. Our words don't feel right.
It seems so much easier and "productive" to do a physical activity, then rush
off-or sheepishly slink away-to turn the person in the next room or answer a
In fact, what we have done is collide with the door
of doing versus being. Open it a crack, and we notice that critical care nurses
often care simultaneously for patients headed in different directions. Some
probably will live, some definitely will die. We tell ourselves that we're only
caring for those who will die "until they find a bed somewhere else." By doing
so, we essentially abandon them, denying the care they require and deserve.
Balance �Doing' and �Being'
This care involves integrating and balancing the
dimensions of "doing" and "being." As Cynda and her colleagues tell us,3 "the
main activity of this approach is being fully present in the relationship with
the patient to ascertain their needs, determine appropriate responses to needs,
and assure that [the care] encompasses �being with' patients and not merely
�doing' things to them."
You're right. It means providing holistic care,
something we know a great deal about. But in end-of-life care, being with
assumes a more critical and essential role. Today, this is harder than ever to
accomplish, yet we have no choice. We are challenged-I challenge us-to "be with"
those who make us uncomfortable. Those who gaze at us after we have sought to
lessen the pain with medication.
I find myself needing to start another dunno sheet.
� How will I believe that end-of-life care is equal
to life-saving care? How will I change my thinking so that someone who requires
palliative care isn't just someone waiting to be transferred?
� How do I reconcile with AACN's vision when I
haven't identified essential needs? This vision is one of a healthcare system
driven by the needs of patients and families. What if the only way to find out
essential needs is to stand beside and "be with"?
� What would happen in my unit if I said, "I need to
be in this room for a few hours to �be with' this family and patient"? Will you
watch my other patient so I can do this? The magic of being with is in the
understanding that emerges.
Love and Longing Are the Link
I wasn't sure at first how two tragic deaths and a
communications workshop were linked. Now, I see that they are linked by love and
longing. The love family members feel toward a patient who hurts and is dying.
The longing they feel for a miracle or a peaceful death. The longing played out
as they anticipate the grief of their loss.
Love and longing also point to the love and passion
that critical care nurses bring to the work of meeting needs of patients and
families at the end of life. To how nurses everywhere long to make a difference
and to meet the many needs of all who tug at our hearts each day.
Finding and making time, seeing the resulting magic
of "being with," is complicated work. And it is loving work. I am thinking of
you trying to make it happen for yourself, your patients and their families.
Would you let me know how you have learned to "be with" by sending me a note at
1. Hettena S. Husband and Wife Die in Shooting at
Chula Vista Hospital. San Francisco Chronicle. December 12, 2003.
2. Safire W. My Dunno Sheet. New York Times. October
3. Rushton CH, Williams MA, Sabatier KH. The
integration of palliative care and critical care: one vision, one voice. Crit
Care Nurs Clin N Am. 2002;14:133-140.