Life - Hospitals - Vicious Cycles - Anticipation
Stability is an illusion. Every aspect of a person's existence (both internal and external) fluctuates. Frequency and amplitude vary within individuals, between individuals and over time, e.g., hormonal flux, physical fitness, degree of "success," etc. On a larger scale, I perceive life as a series of background, though frequently dominant, vicious cycles. Often viewed (and sounding) negative, I define these as sequences of reciprocal causes and effects in which two or more elements intensify and amplify each other endlessly unless "broken." They can be positive or negative. If this sounds similar to the theory of biorhythms, a "pseudoscientific" fad popular in the 1970’s which applied mathematical formulas to three oscillating variables (emotional, physical, intellectual) to make daily predictions based on birth date, I must admit I was probably the only 8 year old kid whose favorite part of the newspaper (except for the sports section) was the biorhythm chart!
In life the intensity of cycling often correlates with self-esteem. In the extreme, a "glass half-empty" type will perceive every challenge as insurmountable, every oversight as a personal affront. Increased stress and negative internal feelings result. A constant frown and quick temper increase isolation. The cycle turns. A "glass half-full" type will feed off random fortuitous events, increasing personal satisfaction and confidence. Energetic and sociable, interactions with the world reinforce positive sense of self. For most of us, maintaining a balance of "yin and yang" is the goal. When "bad" became "worse" for me, my mom used to say "this too shall pass."
As an ICU physician, I utilize the vicious cycle concept when teaching about basic pathophysiology (e.g., in Type 2 diabetes, insulin resistance lead to hyperglycemia which can impair pancreatic beta cell function and exacerbate insulin resistance...) and clinical disease (e.g., Sickle crisis - sickling of red cells impairs rheology causing vasocclusion leading to local hypoxia promoting further sickling, etc.). In addition, it is often the best (and most accurate) way to help confused and distressed family members understand why their loved one, so vital on admission, will not survive. A "negative" vicious cycle defines the last days, weeks, etc. of most prolonged hospitalizations with an unhappy ending. Unless the original insult is self-limited (e.g., a viral infection) or is interrupted by expeditious, appropriate diagnosis and treatment in "time" to avoid the next derangement, the patient will be caught in a vortex. Age, comorbidity, and quality of care are relevant variables. Hospitals are notoriously harsh environments. Patients are subject to multiple local or systemic insults (e.g., device-related infection, inactivity, poor nutrition) that prolong hospitalization. Common hospital-associated events result in, or potentiate, further physical and emotional sequela such as generalized weakness, loss of gut and skin integrity, stress, depression, etc. Redundant and pernicious cycles carry the patient further and further from the premorbid state despite some expected variability ("good days and bad"). There is a variable but relatively narrow "window' of time before a given patient enters the "hospital viscous cycle." Though measures can be taken to forestall entry or break a cycle, a long enough hospital course makes the phenomenon nearly inevitable. A brief and “uncomplicated” hospital stay "ages" even a previously healthy and young patient. With the exception of many elective surgical admissions, it is rare to be discharged without requiring substantial time to regain previous vigor.
Like the works of a prolific romance novelist, the cast of characters, setting, and plot are unique, but a familiar theme marks the course of each patient that succumbs to the "cycle." A typical case begins when a reasonably healthy elderly man, Mr. X, slips, sustaining a hip fracture. Despite appropriate perioperative support and expeditious surgery the patient enters a downward spiral leading to death in the near-term or, often worse, in the intermediate-term without returning home or regaining significant function. Though Mr. X initially does well and discharge planning has begun, on postoperative day 2 he runs a low-grade fever attributed to an infiltrated intravenous line. He is tired and anxious, uncooperative with physical therapy and refuses lunch. Mr. X is prescribed a low dose benzodiazapine as a sleep aid. Paradoxically (but not surprisingly) he becomes delirious that night, requiring more medication. He becomes dehydrated as the care team fails to anticipate his need for water. Now somnolent, in bed and quite weak, his voice is "wet" and his cough is inadequate to clear tenacious lung secretions. A new chest radiograph reveals partial left lung collapse as retained mucus plug blocks an airway. A new fever, rising white blood cell count and green sputum are suggestive of hospital-acquired pneumonia. Cultures are done and antibiotics are started empirically. Despite this, Mr. X continues to decline. He remains in bed, either sleeping or confused. He is swollen and pale. His breathing becomes labored and irregular. He is immune to the encouraging words and increasingly frantic exhortations of his family. Intermittent moans and restlessness speak to his discomfort. His family is called together by the Palliative Care Team joined by his primary physician and his bedside nurse. The decision to initiate "comfort" care is made. Mr. X is transferred to a hospice facility where he passes away.
The scenario described (and all its permutations) is played out daily in every hospital. Restoring "health" while minimizing hospital "exposure" should be the combined focus of the health care team. To a large degree, the outcome of a majority of patients admitted to an acute care hospital is predetermined or relatively independent of the care provided. Attention to the "little things" (Table 1), commonly overshadowed initially by the dominant issue, is often the key to escaping the "cycle" for the minority of vulnerable but viable patients. Provision of adequate food, water, activity and sleep while minimizing local external stressors (e.g., excessive ambient noise and unnecessary disruptions to the sleep-wake cycle) and avoiding any medical errors is both a substantial challenge and essential for this cohort.
On a happier note, occasionally a patient clearly trending in the wrong direction will rally. In the absence of a definite terminal diagnosis, refractory pain or a specific directive, provision of meticulous care may allow a sustained period of "good" days (sufficient calories, exercise, no new insults), initiating a positive cycle. I will work earnestly to enhance the chance that the patient can complete the climb out of a "deep hole." Though reversal of the cycle allowing complete recovery is rare, it is truly precious!
Table 1: "Little Things" that make a big difference. It’s all about ANTICIPATION!
Whenever appropriate and possible- ensure adequate caloric intake using the gut
Watch for early "soft" signs of sepsis, e.g., myoclonus, hypothermia, tachpnea
Ensure adequate hydration
Remove any unnecessary lines and catheters ASAP
Use measures to ensure adequate sedation but avoid oversedation
Utilize physical therapists early and often - communicate needs
Utilize PharmDs if available - they are indispensible
Handwashing
If welcomed, use alternative therapies to decrease stress, e.g., music therapy, touch therapy, etc.
Do everything possible to avoid skin breakdown
Be very cautious when prescribing psychoactive medications to the elderly
Use appropriate prophylaxis, e.g., VTE, stress ulcer
Thin lung secretions (guaifenisin, hydration) and utilize cough training when appropriate
Be parsimonious with blood transfusion
Foresee rather than react, e.g., replete potassium and magnesium as you diurese prior to atrial fibrillation
Value and improve the mechanisms to transfer patients to a lower level of care and be discharged
Utilize pre-ICU or pre-"code" teams - e.g., Medical Response Teams