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CURRENT CONTROVERSIES IN CRITICAL CARE |
Critical care units present particular challenges for meeting patients and families. Expert clinicians must learn how to "meet" and come to know patients who are often sedated and paralyzed or less than alert. Gadow1,2 developed the concept of existential advocacy even with silent patients. By existential advocacy, she means the kind of patient advocacy that respects the concerns and identity of the person.
In 2 studies of nursing practice in critical care units, my colleagues and I found that nurses have many practical strategies for knowing the silent patient.3,4 For example, nurses request personal information about patients and pictures of patients in their usual circumstances from families and friends.5,6 "Knowing a patient," "following the body’s lead," "preserving personhood," and "describing [to the patient] what happened during the period of sedation or unconsciousness" were described as strategies for meeting and recognizing the silent patient as a person and not just as an objectified body with a disease condition that excludes agency and personhood.7 All of these strategies are the opposite of other possible responses of objectifying and distancing oneself from the patient as a person. The concept of a nurse "knowing a patient" is illustrated in the following excerpt from an interview with a nurse:
I got to know her [the patient] in a semi-sedated level and paralyzed, on a level you get to know a lot of patients in the ICU. You still feel like you know them. . . . I feel like I get to know them differently than when they’re normal . . . but there’s some sense of who this person is. It’s like when you touch them, or when you do something to them, what happens on their monitors. Or maybe just to see what the effect of what you’re doing shows up in what’s happening to the patient, how they look, even when they’re paralyzed, just whether their features look a little different, something looks different about them, if they seem to be comfortable when you are there. You get to know them through talking to their family. . . . They give you all these stories. I contacted nurses who had taken care of her when she was a pediatric patient (because she had a lot of episodes down on Peds.) to find out how they had handled the parents and what she was like. . . . I felt like I really knew her.8
Upon awakening, this patient wanted to know what had happened to her during her time of sedation and paralysis, so the nurse described what had occurred. Knowing the patient in some sense is a basis for existential advocacy.
In interviews, other nurses described how they were meticulous in observing the feeding and handling preferences of premature infants in order to improve the infants’ rest and increase their tolerance of feedings. Grooming patients according to their usual habits and preferences is another strategy that nurses used to keep the dignity and personhood of the patient as intact as possible during a critical illness.
Immanuel Kant’s9 strongest notion of autonomy was that the person is never to be treated as a means, but always as an end. Also, to the extent possible, autonomy includes the notion that the person is entitled to determine his or her own ends. For Kant, the person’s autonomy is bound up with his or her conscious will as the primary source of moral self-determination or autonomy. However, individual autonomy and assertions require recognition and caring practices of other human beings for their development and social efficacy. The need for recognition and caring practices of others becomes even more apparent for the silent patient. These nurses, through following the body’s lead and through knowing the patient, upheld the dignity and personhood of critically ill patients.
Extending Kant’s notion of autonomy and agency to include the embodied self that perceives and opens the person to the world enlarges our vision of personhood and moral agency.10–12 The skillful and sentient embodied person is also vulnerable, requiring the care of others. At the very least, the embodied person has motor intentionality, habituated styles, skills, practices and tendencies, and an embodied identity.9,12,13 This view of embodied persons as ends in themselves is supported by these critical care nurses’ sense of fiduciary responsibility to critically ill silent patients. Their examples demonstrate what it means to respect silent patients’ personhood and meet them as embodied persons with preferences and identities currently constrained by their illness. At all times, our identity and social existence are dependent on the social spaces in which we are heard, seen, and met. The skills of meeting the critically ill patient call for extraordinary attentiveness, attunement, and respect.
As human beings, we are all interdependent. Our very social existence depends on the recognition of our personhood and our ability to be recognized and understood by others. Therefore, the conditions of possibility of human agency and autonomy depend on the social spaces we create.14 The African saying "Ubuntu" (I am because we are) captures this ethical wisdom and social reality. In our more extreme forms of individualism, we imagine that our moral agency depends solely on our self-determination, but no one is a self without the recognition, dialogue, and nurturance of others. This is easy to recognize in childhood and infancy, but it is equally apparent in these nurses’ recognition practices that attempt to recover the personhood, dignity, and embodied agency of the critically ill silent patient.
"Following the body’s lead" accords respect to the embodied tendencies of the person and includes the response to touch, preferences for positioning and for being addressed, rituals and symbols of identity, the sense of belonging accorded by family and friends, and more. All of these ways of meeting the silent patient help to preserve the personhood of the patient. One of the social dangers of the environments of critical care units is that the busyness and sense of urgency for medical treatments can cause exclusion of family and friends of the patient and that the silent patient, or the patient with impaired communication skills, will not be met and respected. Sometimes informal cultures in critical care units will promote the myth that the urgency of critical care precludes humanizing the environment or the patient; however, this is a dangerous myth because critically ill patients can be easily damaged by fear, stress, fatigue, and lack of comfort measures. This myth is even more suspect ethically because the agency and autonomy of people as ends in themselves are violated in disrespectful social spaces. A critical care nurse states this ethic of care in positive terms:
I have always been awed and still am that I can adjust a little machine and with the flick of my finger somebody’s body does some horrendous thing. Their blood pressure will go up and down by what I say. It is just awesome. It’s such a respectful thing, that if you can’t have respect for what you’re impinging on this other human body, then I don’t see how you can do it. I am not saying that everyone has to have a religious belief, it’s just respecting the human body and realizing that you really do determine how this body will respond. . . . You have the ability and responsibility to manipulate the finest portions of this person’s body, and it should be scary.15
This nurse extends her understanding of her relationship to the patient and the impact of her decisions on how the therapies she administers impinge on the person’s body. There are many threats in a highly technical environment that will cause the person to be objectified and become a body-machine, as shown in the following excerpt from an interview with a nurse:
I refused to take him off sedation just to keep his blood pressure up. That’s the other thing I fought for. It is not fair. He is also somebody. I knew him. His is somebody that is just so agitated. He is going to work himself up to another MI if he is not kept restful.10
In the telling, this nurse’s ethical stance seems obvious, but in actual practice, there are many occasions when the environmental press of a critical care unit may push for subjugating the body and treating it as a passive, depersonalized, objectified body instead of a sentient, embodied person. Those who work in critical care would do well to learn from nurses who have enhanced their abilities in meeting critically ill persons, following the body’s lead, and advocating for the silent patient. I invite readers to send in examples that illustrate these everyday caring practices.
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