The F word


It’s staggering to realize in our lives what a few attempts and a few failures allows you to do for yourself; refocus, redirect, and redefine.

We use the word failure in critical care to punctuate almost every person’s medical history: heart failure, kidney failure, liver failure, respiratory failure, failure to wean, failure to thrive… you get the point. The idea of failure is so permanent, final, and definitive.  You can see it in the eyes and the effort of patients that are struggling with their new medical diagnosis.  It’s hard to turn the corner from failure.  It’s hard to move on from failure.  It’s hard to smile with failure.

For the wife of one of my patient’s, Sarah, talking about her husband’s acute onset of kidney failure was her focus.  Every morning and afternoon seeking, searching, and grasping on to the newest creatinine level that was checked.  While he was in the ICU his renal perfusion and function had taken a hit and his creatinine climbed significantly.  Was it from medication, was it from fluid, was it from the OR? It was hard to comb out the details and the timing to determine the exact cause.  Nonetheless, we worked to correct it and part of that work was giving him time.  His body continued to make urine, and over time his serum creatinine rose and plateaued.  He never needed dialysis and while his renal failure would transition in label from acute to chronic; his spirit became more lively.  I’m not sure she ever noticed that. It was easy to see the obvious distraught that she had faced, I couldn’t decide where in her personal life this distress was based.  Was it over past experiences with dialysis in another family member, or over the word failure paired with a different organ system?  I couldn’t tell and I didn’t have the heart to ask.  All I knew was that over the time he was in the ICU, she was never able to see past the word.  She could see the word plastered everywhere.  It blocked her from seeing the successes he made in healing and strength building.  It limited her ability to laugh when he made jokes about being in the ICU.  It stressed her out when the case managers and social workers would talk about discharging him home. He had given a new face to renal failure and was able to redefine what living with it looked like.  I was proud of him.

Sam, one of my favorite patients, newly diagnosed with heart failure after an infection. He was spunky, honest, and talked frequently about how much he lived his wife; whom he had been married to for 20 years (since high school graduation).  He had done everything right in his life and was facing down the barrel of a terminal diagnosis.  He was being talked to about and worked up for a heart transplant.  One night, as I was going about my assessment/ vital signs business, he asked if I had a minute to talk.  I did.  He talked and asked questions in circles about the process, the cost, and the challenges of living with a heart transplant.  A few questions I was able to answer, many were out of my scope of experience and professional judgement.  A few were not my place to insert an opinion.  His biggest concern revolved around money.  He had a comfortable savings account and had built a great business. He was afraid of bankrupting his daughters’ futures.  I had never heard a patient state it quite like that and all I could tell him was that he was in the right state of mind to make a decision and I knew he would make the decision that was right for him and his family.  I had never heard anyone redirect their fear and anxiety in quite a positive light.  I was breathless.

A sweet elderly patient in her mid-nineties, whose care I was part of years ago, quickly assumed the diagnosis of failure to thrive.  The discussion began with her family about comfort and trying to clarify what her wishes in a situation such as this would be.  Her nephew didn’t quite know her wishes but he could tell us what in her life brought her joy and laughter.  Failure to thrive is a tough diagnosis.  I don’t really like it.  It’s is very commonly used in young newborns and children.  Geriatric failure to thrive is becoming a bit more specific.  When you read the medical definition, it sounds like what perhaps is inevitable for all of us as we approach the end of a long and hopefully happy life on earth.   Her breathing had declined and we weren’t able to get her off of the ventilator; her kidney function and heart function showed signs of a significant slow down; and her eyes were vacant and withdrawn. Without much discussion her nephew made the selfless and unprompted decision to withdraw life-support. I know what I would want for myself as a patient in this situation, but I would have to work to find the strength to be as selfless and caring making this decision about the life and death of someone I loved.   He showed me early on in my career the gift of refocusing attention on comfort rather than cure.

These are stories of patients I cared for so long ago.  Though so many of my patients and families have demonstrated to me that failure in life and health isn’t always insurmountable.  With time, the ability to refocus, redirect, and redefine your goals make success possible; they just may not look the same as you thought they would when you started chasing after them.



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