How to die in intensive care. The condition is serious, stable. What are the goodbyes...

What happens to a person in the intensive care unit

A person who is in intensive care may be conscious, or may be in a coma, including medication. With severe traumatic brain injury and increased intracranial pressure the patient is usually given barbiturates (that is, they are put into a state of barbituric coma) so that the brain finds resources for recovery - it takes too much energy to stay conscious.

Usually in the intensive care unit, patients lie without clothes. If a person is able to stand up, then they can give him a shirt. “In intensive care, patients are connected to life support systems and tracking equipment (various monitors), - explains Elena Aleshchenko, head of the intensive care unit of the European Medical Center. - For medicines in one of the central blood vessels a catheter is placed. If the patient is not very heavy, then the catheter is placed in peripheral vein(for example, in a vein of the arm. - Note. ed.). If artificial ventilation of the lungs is required, then a tube is installed in the trachea, which is connected through a hose system to the apparatus. For feeding, a thin tube is inserted into the stomach - a probe. AT bladder a catheter is inserted for urine and accounting for its amount. The patient can be tied to the bed with special soft ties so that he does not remove the catheters and sensors when excited.

The body is treated with fluid to prevent bedsores daily. They treat their ears, wash their hair, cut their nails - everything is as in normal life, except that hygiene procedures doing medical worker". But if the patient is conscious, they may be allowed to do it on their own.

To prevent bedsores, patients are regularly turned in bed. This is done every two hours. According to the Ministry of Health, in public hospitals, there should be two patients per nurse. However, this is almost never the case: there are usually more patients and fewer nurses. “Most often, nurses are overwhelmed,” says Olga Germanenko, director of the SMA Families (spinal muscular atrophy) charity foundation, Alina’s mother, who has been diagnosed with this disease. - But even if they are not overloaded, sisterly hands are still always lacking. And if one of the patients becomes destabilized, then he will receive more attention at the expense of another patient. This means that the other one will be turned later, fed later, etc.”

Why are relatives not allowed into intensive care?

According to the law, parents should also be allowed to see their children (it is generally allowed here cohabitation), and close to adults (Article 6 323-FZ). This possibility in pediatric ICUs (intensive care unit) is also mentioned in two letters from the Ministry of Health (dated 07/09/2014 and 06/21/2013), for some reason duplicating what is approved in federal law. But nevertheless, there is a classic set of reasons why relatives are refused to be allowed into intensive care: special sanitary conditions, lack of space, too huge pressure on the staff, the fear that a relative will harm, will begin to “pull out the tubes”, “the patient is unconscious - what will you do there?”, “The internal rules of the hospital prohibit”. It has long been clear that if the leadership wishes, none of these circumstances becomes an obstacle to the admission of relatives. All arguments and counterarguments are analyzed in detail in a study conducted by the Children's Palliative Foundation. For example, the story that you can bring terrible bacteria into the department does not look convincing, because the nosocomial flora has seen a lot of antibiotics, acquired resistance to them and has become much more dangerous than what you can bring from the street. Can a doctor be fired for violating hospital rules? "Not. Exists Labor Code. It is he, and not local hospital orders, that regulates the interaction between the employer and the employee,” explains Denis Protsenko, chief specialist in anesthesiology and resuscitation of the Moscow Health Department.

“Often, doctors say: you create normal conditions for us, build spacious premises, then we will let them in,” says Karina Vartanova, director of the Children's Palliative Foundation. - But if you look at the departments where there is a permit, it turns out that this is not such a fundamental reason. If there is a management decision, then the conditions do not matter. The most important and difficult reason is mental attitudes, stereotypes, traditions. Neither doctors nor patients have an understanding that the main people in the hospital are the patient and his environment, so everything should be built around them.”

All uncomfortable moments that can actually interfere are removed by a clear formulation of the rules. “If you let everyone in at once, of course, it will be chaos,” says Denis Protsenko. - Therefore, in any case, you need to regulate. We in Pervaya Gradskaya start one by one, let us down and tell at the same time. If the relative is adequate, we leave him under the control of the nursing staff, we go for the next one. On the third or fourth day, you perfectly understand what kind of person this is, contact is established with him. Even then, you can leave them with the patient, because you have already explained everything to them about the tubes and devices for connecting the life support system.”

“Abroad, talk about admission to intensive care began about 60 years ago,” says Karina Vartanova. - So do not count on the fact that our healthcare will be inspired together and will do everything tomorrow. A forceful decision, an order, can spoil a lot. The decisions that are made in each hospital about whether or not to let in, as a rule, are a reflection of management's attitudes. There is a law. But the fact that it is not massively performed is an indicator that individual doctors, and the system as a whole are not yet ready.”

Why is the presence of relatives 24 hours a day impossible even in the most democratic intensive care units? In the morning, various manipulations and hygiene procedures are actively carried out in the department. At this time, the presence of an outsider is highly undesirable. During the rounds and during the transfer of the shift, relatives should also not be present: this will at least violate medical secrecy. At resuscitation relatives are asked to leave in any country in the world.

The resuscitator of one of the US university clinics, who wished not to give his name, says that their patient is left without visitors only in rare cases: "AT exceptional cases anyone’s access to the patient is limited - for example, if there is a danger to the patient’s life from visitors (usually these are situations of a criminal nature), if the patient is a prisoner and the state prohibits visits (for seriously ill patients, an exception is often made at the request of a doctor or nurse), if the patient has a suspected/confirmed diagnosis of a particularly dangerous infectious disease(Ebola virus, for example) and, of course, if the patient himself asks that no one be allowed in.”

Children in adult resuscitation they try not to let them in either here or abroad.

What to do to get you into intensive care

“The very first step is to ask if it is possible to go to the intensive care unit,” says Olga Germanenko. A lot of people don't really ask. Most likely, it’s in their head that they can’t go to intensive care.” If you asked, and the doctor says that it’s impossible, that the department is closed, then you definitely shouldn’t make a fuss. “Conflict is always useless,” explains Karina Vartanova. “If you immediately start stomping your feet and shouting that I will rot you all here, I will complain, there will be no result.” And money doesn't solve the problem. “No matter how much we interview relatives, money does not change the situation at all,” says Karina Vartanova.

“It makes no sense to talk about admission with nurses or the doctor on duty. If the attending physician takes the position “not allowed”, you must behave calmly and confidently, try to negotiate, - says Olga Germanenko. - No need to threaten to appeal to the Ministry of Health. You calmly explain your position: “It will be easier for the child if I am there. I will help. Pipes don't scare me. You said that with the child - I can roughly imagine what I will see. I know the situation is difficult.' The doctor will not think that this is a hysterical mother who can pull out her tubes and yell at the nurses.

If you are denied at this level, where do you go next? “If the department is closed to relatives, communication with the head will not give anything,” says Denis Protsenko. - Therefore, you need to go to the deputy chief physician for medical work. If he does not give the opportunity to visit, then go to the head physician. In fact, that's where it ends." Olga Germanenko adds: “You need to ask the head physician for a written explanation of the reasons why they are not letting you in, and with this explanation go to the local health authorities, insurance companies, the prosecutor’s office, supervisory authorities- anywhere. But imagine how long it will take. It's a bureaucracy."

However, Lida Moniava, so to speak, is reassuring: “When a child lies in bed for a long time, mothers are already being let in. In almost all intensive care units, a couple of weeks after hospitalization, they begin to let in, gradually increasing the duration of the visit.

Director of the Department of Public Health and Communications of the Ministry of Health Oleg Salagay contact his insurance, which, in theory, is responsible for the quality of medical care and respect for the rights of the patient. However, as it turned out, companies have no experience in dealing with such situations. Moreover, not everyone is ready to support relatives (“Resuscitation is not created for dates, here they are fighting for human life, as long as there is at least some hope left. And no one should distract either doctors or patients from this struggle, who need to mobilize everything their strength in order to survive,” the correspondent was told “ Posters Daily at one of the insurance companies). The responses of some companies are full of confusion due to supposedly conflicting legislation, but nonetheless, someone is ready to "respond quickly."

When there is objective reasons not to let a relative into the ICU? If you are frankly ill and can infect others, if you are in a state of alcoholic or drug intoxication - in these cases you will rightly not be allowed into the department, no matter how hard you try.

“If there is quarantine in the hospital, then no certificate will help you get to the department,” explains Denis Protsenko.

How to understand that everything is in order

“If you are not allowed into intensive care, you will never know if everything is being done for your relative,” says Olga Germanenko. - A doctor can just give little information, but actually do everything that is needed. And someone, on the contrary, will paint the smallest details of your relative's treatment - what they did, what they are going to do, but in fact the patient will receive less treatment. Perhaps you can ask discharge summary. But they won’t give it just like that - you need to say that you want to show it to a specific doctor.

It is generally accepted that the admission of relatives to the intensive care unit will complicate the life of the staff. However, in reality, this reduces the number of conflicts precisely on the basis of the quality of medical care. “Of course, parental presence is an additional quality control,” says Karina Vartanova. - If we take a situation where the child had no chance to survive (for example, he fell from the 12th floor), the parents were not allowed, and he died, then, of course, they will think that the doctors left something unfinished, overlooked. If they were allowed in, there would be no such thoughts, they would also thank the doctors for fighting to the end.”

“If you suspect that your relative is being treated poorly, invite a consultant,” suggests Denis Protsenko. “For a self-respecting, self-confident doctor, a second opinion is absolutely normal.”

“For rare diseases, only narrow specialists know that some drugs cannot be prescribed, some can, but certain indicators need to be monitored, so sometimes resuscitators themselves actually need consultants,” explains Olga Germanenko. - True, the choice of a specialist must be approached carefully so that he does not talk down to local doctors and does not intimidate you: “You will be killed here. There are such stupid things here.

“When you tell your doctor that you want a second opinion, it often sounds something like this: you are treating incorrectly, we see that the condition is getting worse, so we want to bring a consultant who will teach you how to treat you properly,” says the psychiatrist, head of the Clinic of Psychiatry and psychotherapy at the European Medical Center Natalya Rivkina. - It is better to convey such an idea: it is very important for us to understand all the possibilities that exist. We are ready to use all our resources to help. We would like to ask you to get a second opinion. We know that you are our main doctor, we have no plan to go elsewhere. But it is important for us to understand that we are doing everything that is necessary. We have an idea who we would like to contact. Maybe you have other suggestions. This kind of conversation can be more comfortable for the doctor. You just need to rehearse, write down the wording. No need to go with the fear that you are breaking some rules. It is your right to get a second opinion.

How to help

“Doctors are forbidden to say that they do not have any drugs, consumables,” explains the deputy director children's hospice"House with a lighthouse" Lida Moniava. - And out of fear they can convince you that they have everything, although in reality it will not be so. If the doctor voices the needs, thank him very much. Relatives are not required to bring everything, but thanks to those doctors who are not afraid to speak.” The problem is that it is considered: if something is missing in the hospital, then the management does not know how to allocate resources. And relatives do not always understand the position of the doctor, so they can complain to the Department of Health or the Ministry of Health: “We have free medicine, but they force me to buy medicines, return the money, here are the checks.” Fearing such consequences, ICU staff may even use their own money to buy good drugs and expendable materials. Therefore, try to convince the doctor that you are ready to purchase everything you need, and you have no complaints about this.

Spinal surgeon Alexei Kashcheev also ask the attending physician whether it would be useful for the patient's current condition to hire an individual nurse.

How to behave in intensive care

If you are allowed into intensive care, it is important to remember that there are rules (in writing or spoken by a doctor), and they are designed so that doctors can do their job.

Even in those intensive care units where you can come even in outerwear, there is a rule: treat your hands with an antiseptic before visiting the patient. In other hospitals (including those in the West) they may be asked to wear shoe covers, a gown, not to wear woolen clothes and not to walk with loose hair. By the way, remember that visiting the intensive care unit, you expose yourself to certain risks. First of all, the risk of infection with local bacteria resistant to many antibiotics.

You must imagine where you are going and what you will see

If you have a tantrum, faint or feel sick, you will attract the attention of the intensive care unit staff, which is potentially dangerous. There are other subtle moments that Denis Protsenko talks about: “I know cases when a guy came to his girlfriend, saw her disfigured face and never returned. It happened the other way around: the girls could not cope with such a spectacle. In my experience, it is not uncommon for relatives who volunteer to help quickly disappear. Just imagine: you turn your husband on his side, and he has gases or a bowel movement. Patients vomit involuntary urination“Are you sure you will react normally to this?”

You can't cry in the ICU

“Usually, the first visits to the department by relatives are the most difficult,” says Elena Aleshchenko. “It is very difficult to prepare and not cry,” says Karina Vartanova. - It helps someone to take a deep breath, someone is better off crying on the sidelines, you need to talk to someone, someone should not even be touched. You can learn to be calm in the intensive care unit if you remember that the patient's condition largely depends on your calmness. Some hospitals employ clinical psychologists to help manage emotions.

Ask how you can help and don't be selfish

“A mother can change a diaper, turn it over, wash it, give a massage - all this is especially necessary for heavy children,” says Olga Germanenko. “It is clear that nurses, with the current workload, cannot do all this to the extent that is needed.”

Being in the intensive care unit around the clock is not only pointless, but also harmful

“You can visit us at any time, you can stay with the patient for 24 hours in a row,” says Elena Aleshchenko. Whether it is necessary is another matter. People then themselves understand that this is useless, that they are doing it more for themselves. When a person is in intensive care, he is sick, he also needs to rest. Olga Germanenko confirms this idea: “Sleeping in the intensive care unit special meaning no. In fact, no one will sit for more than four hours in a row (unless, of course, we are talking about a dying child). After all, everyone has their own things to do." A day in intensive care is hard not only physically, but also mentally: “What will happen to a relative after 24 hours in the intensive care unit? - says Denis Protsenko. - Corpses will be taken out several times past him, he will become a witness cardiopulmonary resuscitation, suddenly developed psychosis in another patient. I'm not sure that the relative will survive this calmly.

Negotiate with other relatives

“In one of the intensive care units where I ended up with my daughter, the children were in boxes for two,” says Olga Germanenko. - That is, if a nurse comes, and there are two more parents, then do not turn around. And her presence may be needed at any moment. So we agreed to come to different time. And the children were always supervised.

Respect the wishes of the patient

“When a person regains consciousness, the first question we ask him is: do you want to see relatives? There are situations when the answer is “no,” says Denis Protsenko. “Many clinics around the world have such programs for natural dying, when a patient and his family discuss how he will die,” says Natalia Rivkina. - This happens a month and a half before his death. The task is for a person to die with dignity and in the way he would like. There are parents who do not want their children to see the process of dying. There are wives who do not want their husbands to see the process of dying. Perhaps they will look ugly. There are those who want to be with their loved ones at the time of death. We must respect all these decisions. If a person wants to make the transition himself, this does not mean that he does not want to see loved ones. It means he wants to protect you. You shouldn't force your choice on him."

Respect other patients

“Speak to your child as quietly as possible, do not turn on loud music, do not use mobile phone in the department. If your child is conscious, then he can watch cartoons or listen to music using a tablet and headphones so as not to disturb others. Do not use strong-smelling perfume, ”writes Nadezhda Pashchenko in, published by the Children's Palliative Foundation,“ Together with Mom.

Do not conflict with doctors and nurses

“The work of the ICU staff is quite difficult, very intensive, energy-consuming,” Yulia Logunova writes in the same brochure. - This must be understood. And in no case should you conflict with someone, even if you see a negative attitude, it’s better to keep silent, it’s better to take a break in communicating with this person. And if the conversation turns to raised voices, the following phrase always works: I thought that you and I had one goal - to save my child, to help him, so let's act together. I have not had a single case when it did not work and did not transfer the conversation to another plane.

How to talk to a doctor

Firstly, it is advisable to talk with the attending physician, and not with the person on duty, who changes every day. He will definitely have more information. That is why in those intensive care units in which the time for visiting and communicating with the doctor is limited, it falls on uncomfortable hours - from 14.00 to 16.00: at 15.45 the shift of the attending physician ends, and until 14.00 he will most likely be busy with patients. It is not worth discussing treatment and prognosis with nurses. “Nurses carry out doctor's orders,” writes Nadezhda Pashchenko in the booklet Together with Mom. “It’s pointless to ask them about what exactly they give your child, since the nurse cannot say anything about the child’s condition and the essence of medical prescriptions without the doctor’s permission.”

Abroad and paid medical centers you can get information by phone: when you draw up the paperwork, you will approve the code word for this. In public hospitals, in rare cases, doctors can give their mobile.

“In a situation where someone close is in intensive care, especially when it is associated with a sudden onset of the disease, relatives may be in a state of acute reaction to stress. In these states people
experiencing confusion, difficulty concentrating, forgetfulness - it is difficult for them to get together, ask right question- explains Natalya Rivkina. - But doctors may simply not physically have time to build a dialogue with relatives who have such difficulties. I encourage family members to write down questions throughout the day to prepare for their appointment with the doctor.

If you ask "How is he/she?", the doctor may give two responses: "Everything is good" or "Everything is bad." This is unproductive. Therefore, it is necessary to formulate clearer questions: what is the patient's condition at this moment, what symptoms does he have, what are his plans for treatment. Unfortunately, in Russia there is still a paternalistic approach to communication with the patient and relatives. It is believed that they do not need to have information about the treatment. “You are not a doctor”, “You still will not understand anything.” Relatives should always be aware that by law they must be informed about the treatment being carried out. They have the right to insist on it.

Doctors react very nervously when frightened relatives come and say: “What are you doing? We read on the internet that this drug kills.” It is better to ask this question like this: “Tell me, please, what side effects have you seen from this medicine?” If the doctor does not want to answer this question, ask: “What do you think about this side effect? That way you don't attack or criticize. Any criticism causes resistance in people.

A common question in intensive care, especially when it comes to cancer patients: "Is that all?" or “How long does he/she have to live?” This is a question that has no answer. A properly trained doctor will answer it. A doctor who has no time will say, "God only knows." Therefore, I always teach relatives to ask this question in this way: “What is the worst and best prognosis?” or “What is the minimum and maximum duration life can be according to the statistics of such states?

Sometimes I insist that people leave and rest. No matter how wild and cynical it may be. If it is obvious that they cannot do anything for the patient now, they will not be allowed in one hundred percent, they cannot make any decisions, influence the process, then you can be distracted. Many people are sure that at this moment they should grieve. Going out to drink tea with friends in a cafe is to break the whole logic of the universe. They are so fixated on the mountain that they reject any resources that could support them. When it comes to a child, any mother will say, “How can I afford this?” or "I'll sit there and think about the baby." Sit and think. At least you will do it in a cafe, and not in the intensive care corridor.

Very often, in situations where one of the relatives is in intensive care, people become isolated and stop sharing their experiences. They try so hard to protect each other that at some point they just lose each other. People should speak openly. This is a very important step for the future. Children are a special category. Unfortunately, very often they hide from children that one of the parents is in intensive care. This situation is very bad for their future. Proven fact: the later children learn the truth, the higher the risk of severe post-stress disorders. If we want to protect a child, we must talk to him. This should be done by relatives, not a psychologist. But it is better that they get professional support first. Communicate in a comfortable environment. It should be understood that children of 4-6 years old are much more adequate to the issues of death and dying than adults. They at this time have a fairly clear philosophy regarding what death and dying are. Later, many different stigmas and myths are superimposed on this, and we are already starting to relate to this in a different way. There is another problem: adults try not to show their emotions, while children feel and experience this experience as a rejection.

It is also important to understand that different members families different variants adaptation to stress and different need in support. We react the way we react. This is a very individual thing. There is no one correct reaction for such an event. There are people who need to be stroked on the head, and there are people who get together and say: "Everything will be fine." Now imagine that they are husband and wife. The wife understands that a catastrophe is happening, and the husband is sure that you need to clench your teeth and not cry. As a result, when the wife starts crying, he says, "Stop crying." And she is sure that he is soulless. We often see family conflicts related to this. In this case, the woman becomes isolated, and it seems to the man that she simply does not want to fight. Or vice versa. And it is very important to explain to family members that everyone needs different support in such a situation, and to encourage them to give each other the support that everyone needs.

When people do not allow themselves to cry and kind of squeeze their emotions, this is called dissociation. Many relatives described this to me: in intensive care, they seem to see themselves from the outside, and they are horrified by the fact that they do not experience any emotions - no love, no fear, no tenderness. They are like robots doing what needs to be done. And it scares them. It is important to explain to them that it is absolutely normal reaction. But we must remember that these people have a higher risk of delayed reactions. Expect that after 3-4 weeks you will have disturbed sleep, there will be anxiety attacks, maybe even panic.

Where to look for information

“I always strongly advise relatives and patients to go to the official websites of clinics,” says Natalya Rivkina. - But if you speak English, it's much easier for you. For example, the Mayo Clinic website has great text across the board. There are very few such texts in Russian. I ask relatives not to enter the Russian-language patient forums. Sometimes there you can get misleading information that is not always related to reality.

Basic information in English about what happens in the intensive care unit can be found here:.

What to expect

“Within a few days after the patient is in intensive care, the doctor will tell you how long the person will stay in the ICU,” says Denis Protsenko.

After resuscitation, as soon as the need for intensive observation is no longer necessary and the patient can breathe on his own, he will most likely be transferred to a regular ward. If it is known for sure that a person needs lifelong artificial ventilation lungs (ventilator), but in general he does not require the help of resuscitators, he can be discharged home with a ventilator. You can buy it only at your own expense or at the expense of philanthropists (from the state

This topic is rarely discussed, but doctors also die. And they don't die like other people. It's amazing how rarely doctors seek medical help. when it comes to an end. Doctors fight death when it comes to their patients, but they are very calm about own death. . They know what options they have. They can afford any kind of treatment. But they leave quietly.

We leave quietly

Many years ago, Charlie, a respected orthopedic surgeon and my mentor, discovered a lump in his stomach. He underwent exploratory surgery. Pancreatic cancer confirmed.

The diagnosis was made by one of the best surgeons countries. He offered Charlie treatment and surgery, which would triple his life expectancy with this diagnosis, although the quality of life would be poor.

Charlie was not interested in this offer. He left the hospital the next day, closed his medical practice, and never returned to the hospital. Instead, he devoted all of his remaining time to his family. His health was as good as can be for a cancer diagnosis. Charlie was not treated with chemotherapy or radiation. A few months later he died at home.

Naturally, doctors do not want to die.

Doctors want to make sure that when their time comes, no one will heroically save them from death by breaking their ribs in an attempt to revive them with chest compressions (which is exactly what happens when the massage is done correctly). Virtually all health care workers have at least once witnessed a "vain treatment" when there was no chance that a terminally ill patient would get better from the latest advances in medicine.

But the patient's stomach is cut open, tubes are stuck into it, connected to the apparatus and poisoned with drugs. This is what happens in intensive care and costs tens of thousands of dollars a day. With this money, people buy suffering that we will not inflict even on terrorists.

I've lost count of how many times my colleagues have said something like this to me: "Promise me that if you see me like this, you won't do anything." They say it in all seriousness. Some doctors wear pendants that say "Do not pump out" to prevent doctors from giving them chest compressions. I even saw one person who made himself such a tattoo.

I suspect that the forced infliction of suffering on patients at the request of families is one of the reasons high percentage alcoholism and depression among health workers compared with other professions.

For me personally, this was one of the reasons why I have not practiced in a hospital for the last ten years.

Doctor do everything

What happened? Why do doctors prescribe treatments they would never prescribe themselves? The answer, simple or not, is patients, doctors, and the medical system as a whole.

Imagine this situation: a person lost consciousness, and he was brought by ambulance to the hospital. No one foresaw this scenario, so it was not agreed in advance what to do in such a case. This situation is typical. Relatives are frightened, shocked and confused by the many treatment options. Head goes around.

The problem is that ordinary people often do not know what is reasonable and what is not. Confused and grieving, they may not ask or hear what the doctor says. But physicians who are told to “do everything” will do everything without considering whether it is reasonable or not.

Such situations happen all the time. The matter is aggravated by sometimes completely unrealistic expectations about the "power" of doctors. Many people think that artificial heart massage is a win-win way of resuscitation, although most people still die or survive with deep disabilities (if the brain is affected).

I received hundreds of patients who were brought to my hospital after resuscitation artificial massage hearts. Only one of them healthy man co healthy heart left the hospital on foot.

If the patient is seriously ill, old, has a fatal diagnosis, the probability of a good resuscitation outcome is almost non-existent, while the probability of suffering is almost 100%. Lack of knowledge and unrealistic expectations lead to bad decisions about treatment.

Of course, not only the relatives of patients are to blame for this situation. The doctors themselves do useless treatment possible.

The problem is that even doctors who hate futile treatment are forced to satisfy the desires of patients and their families.

The forced infliction of suffering on patients at the request of families is one of the reasons for the high percentage of alcoholism and depression among health workers compared to other professions.

Imagine: relatives brought an elderly person with poor prognosis to the hospital, crying and fighting in hysterics. For the first time they see a doctor who will treat their loved one.

To them, he is a mysterious stranger. In such conditions, it is extremely difficult to establish trusting relationships. And if the doctor starts discussing the issue of resuscitation, people tend to suspect him of not wanting to mess with a difficult case, saving money or his time, especially if the doctor does not advise continuing resuscitation.

Not all doctors know how to speak to patients in a clear language. Someone is very categorical, someone sins with snobbery. But all doctors face similar problems.

When I needed to explain to the patient's relatives about the various treatment options before death, I told them as early as possible only those options that were reasonable under the circumstances.

If relatives offered unrealistic options, I plain language communicated to them all the negative consequences of such treatment. If the family still insisted on treatment that I considered pointless and harmful, I offered to transfer them to another doctor or another hospital.

More on the topic in the continuation of the article

Do not hold back the one who leaves you. Otherwise, the one who comes to you will not come.

Vyacheslav Afonchikov leads the well-known clinical center of anesthesiology and resuscitation of the Research Institute of Emergency Medicine named after. Dzhanelidze. Every day, about two hundred patients are brought to this center, and in the very serious condition. They are brought from all over St. Petersburg, and also from the Leningrad region, from the North-West and from all over the country. Fewer patients die every year - mortality in the intensive care unit does not exceed 20 percent. The head of the center told what it is like to save lives every day and whether a dying person sees “the light at the end of the tunnel”.

About professional development

– Our course at the medical school was the first to have their distribution canceled. It would seem that here it is, freedom - settle down wherever you want. And we rushed around the city with our tongues hanging out in search of work, and we were not taken anywhere. Doctors suddenly became useless. Therefore, I jumped at the first vacancy that came across - a resuscitator at the Janelidze Research Institute. And today I have no regrets.

- I've always been impressed life path cosmonaut Georgy Beregovoy. Before the war, he began flying on a Po-2 plywood biplane, and just 30 years later he flew into space on a Soyuz-3. So, with me in resuscitation for 25 years, there was about the same breakthrough. In the 1990s, a ventilator had only two knobs and two indicators, one showing pressure, the other showing oxygen flow. And today, the control panel of such an apparatus is comparable to the cockpit of a fighter: 10 - 15 knobs, and 60 - 80 indicators are displayed on the display. Approximately the same difference as between Po-2 and Soyuz-3.

- A resuscitator - as a pilot, he simultaneously monitors 6-8 such devices.Previously, many lung lesions were considered a near-fatal diagnosis. If the patient needed more than three days artificial respiration, then the old devices did not allow it to be provided for so long without serious complications. And today, some patients are on mechanical ventilation for more than a month, and at the same time we manage to save their lungs. Now intelligent systems have already appeared that themselves analyze the state of a person and select the desired mode of delivering oxygen to the body and removing carbon dioxide.

“In the 1990s, a stroke was a death sentence.If after it a person survived at all, then he became a severely disabled person. And now hundreds of patients are leaving us on their own feet. Modern technologies diagnostics and treatment, if applied in time, can restore cerebral circulation before a significant part of the brain of a stroke patient dies, and in many cases a person is not even threatened with disability.

“Medicine is undergoing such rapid changes that it is sometimes difficult to comprehend them.For example, you read the memoirs of eyewitnesses about how Stalin was dying in 1953, and you subconsciously have a desire to intervene, tell the doctors to urgently intubate the patient, connect an artificial respiration apparatus, make a tomogram ... And if we step into the history of medicine another 50 years ago , then from the Doctor's Pocket Guide of 1900 we learn that the victim of a lightning strike must be covered with damp earth ... Medicine today has achieved impressive success, but at the same time I am sure that descendants will laugh at us just as we today laugh at Vershinin's textbook.

Where is the hardest place to work?

— It is difficult to work where the lethality is higher.And this severe sepsis and burns. Sepsis used to be called blood poisoning. But today, this concept includes not only infection, but also defects in human immunity. We, doctors, also come into contact with microbes that our patients suffer from, but unlike them, we do not get sick. Because some kind of catastrophe happened in their body. The focus of inflammation can be a perforated stomach, an inflamed pancreas, or even a torn barb on a finger. But the person no longer complains about the sore spot from which it all began. Inflammation does not capture a local area, but the entire body. We collect these patients from all over the city. And with burns, victims from all over the North-West are evacuated to us - from Pskov, Novgorod, Murmansk.

— When there was a fire in the Lame Horse club in Perm, people were brought from there en masse. Our burn center very well equipped. For example, for patients with a burnt back, beds are installed where they seem to float in weightlessness - in special fine sand, blown with air ... But it is psychologically difficult to work there. A patient is brought in with 80 percent of the skin affected. He is talking to you. Nothing hurts him (since everything that could hurt has already burned down). And you know that he can no longer be saved and in 48 hours this person will definitely die.

– Five years ago, we received about 60,000 people a year, today about 70 thousand. There are almost no empty beds, on the contrary, we often deploy additional ones. And the flow is growing. But there are several reasons for this. First, the population of St. Petersburg is increasing. From here, from the intensive care unit, we see that it, together with visiting students and migrants, has already reached 7.5-8 million people. The second reason is that the work of polyclinics has noticeably deteriorated. Previously, in Soviet medical universities, students at exams could be asked a simple question: “Who is the key link in healthcare?” Nowadays, many will say: “Ministry of Health”. But the correct answer is “district doctor”. All Soviet system health care was built from it. And today, at least half of our 70,000 patients could be helped in polyclinics - to look at someone's stomach, to do an X-ray. And then we would be able to devote one and a half times more time to other, really seriously ill patients.

– We have 90 doctors and 160 nurses for 108 intensive care beds.Is it a lot or a little? If we suddenly try to bring our staff to the standards recommended by the order of the Ministry of Health, we will have to recruit another 426 people. There will even be nowhere to place them and change clothes. No one works for us at one rate, mostly at one and a half. No more by law. There is an old anecdote explaining why in medicine everyone works exactly for one and a half rates: because there is nothing to eat for one, and there is no time for two.

Sobering-up station named after Janelidze

– This public, whatever one may say, demands expenses.The life of a drunk brought to us by ambulance is often not in danger, he just needs to sleep. But we must examine him: one should do a blood test, the other - an x-ray (what if he has some kind of hidden injury?). We also spend time on them with our flow, when every minute of an intensive care doctor is worth its weight in gold. One drunken violent patient can put everything on his ears admission department. Now we specifically hold a separate medical post for them. And divert resources from other patients. After all, people with severe poisoning come to our poison control center. With the bites of exotic snakes that people keep in their apartments. With jellyfish stings from somewhere in the Maldives. And, of course, with a drug overdose. Moreover, drugs are updated all the time, craftsmen are constantly changing their structural formulas, which sometimes take years for specialists from our toxico-chemical laboratory to decipher.

Miracles in intensive care

– In the years of my youth, many went to it to show heroism.But here, as in the army, there should be no feat. Because the feat of one person is always a consequence of the miscalculation of another. I teach and I know from my own experience that out of 8 students who come to the department to study as an anesthesiologist-resuscitator, 2-3 will inevitably drop out, because this profession is not for them. It should have a head on its shoulders. But not only. Very smart and intelligent doctors left us because they were "free artists". And here severe internal discipline is required. Colleagues who watched from the side how we work with the newly brought patient were amazed: “You didn’t say anything, you just raised your hand, and the nurse is already putting something into it.” At this job, the day is not 24 hours, but 1440 minutes. The score goes exactly for minutes, which means that the coherence of actions is very important. This is a command type of human activity.

— Dimensions are secondary.. Some nurses remember how thin I came to our clinic in 1992 - I could hide behind an IV. But when you are in constant stress day after day, you want to eat it. Eating releases endorphins and calms the mind. So many people eat up the dimensions here. I also had to smoke at this job. The cigarette creates a stupid illusion of distraction from problems.

– intuition - God's gift and demonic temptation for youth.Sometimes from the outside it may seem that an experienced doctor works intuitively. Instantly makes decisions depending on a particular situation. And if you ask him, he may even find it difficult to explain why he did it that way. But in fact, a person just studied a lot, practiced a lot and got to the point that his professional reaction has already turned into a reflex. This is not a miracle, not a gift from God, but an acquired skill, for which hard work. I generally do not like any incorrect definitions of our work. Both pretentious - "we save lives", and semi-official - "we provide medical services”(This phrase is very fond of medical officials). I am in favor of returning the normal human word "treat" to the doctor's lexicon.

– No black pipes and flights in space.I just had to read about it. There is one circumstance that, in my opinion, explains such stories. And here we are constantly meeting with him in intensive care. Our memory is not empty. If a person, for example, was hit on the head on Monday, and he woke up only on Thursday, then, of course, he does not remember what happened to him on Tuesday and Wednesday. This emptiness is very painful, it torments a person. And the brain begins to fill it with invented memories. This is how our consciousness works. These fictional stories are called confobulation.

– False memories, for example, occur in alcoholics. Coming out of a binge, they begin to tell how yesterday they went fishing with friends. Convince themselves of this, and then those around them. So many of our surviving patients then share all sorts of tales about their stay in intensive care, in which they themselves sincerely believe. Still, a person is scared to be here. And so that this negative information does not torment them all their lives, it is erased from their memory and replaced by another, more positive one. I admit that the people whose testimonies were collected in his famous book by Raymond Moody already had all these tunnels in their subconscious. Perhaps they were told something similar in childhood about a journey to the afterlife, and consciousness filled a hole in memory with just this information. And since our compatriots are mostly atheists, they don’t tell anything. By the way, we have a doctor working at our institute who has been in a state of clinical death. And I haven't seen anything like it either.

– Our profession cannot serve as proof of the existence of God.But if a resuscitator with more than five years of experience tells you that he does not believe in God, he is either a fool or lying. Sometimes, however, something extraordinary happens. And it is no coincidence that each department has its own signs. For example, you can not sit on an intensive care bed. You can not shave the patient. Because there were completely inexplicable cases - the patient was going to be discharged, relatives brought a razor so that he would put himself in order before going out. He shaved and instead of being discharged the next day, he suddenly died. And when this happens three times, on the fourth you send your relatives away with a razor. I cannot explain these cases, just as I cannot explain some examples of recovery. To cure a disease, it is necessary to make a diagnosis. But sometimes it fails. The patient's condition is getting worse, we don't know what's going on. But since we have a very intensive therapy, allowing to replace vital important features patient, we simply react to the symptoms. Then, at some point, a break occurs. A person recovers, recovers, is discharged, we see him off with a long questioning look. We cured him, but it is not known from what.

“Sometimes the relatives of the patient become the authors of miracles.In the struggle for their loved one in seemingly hopeless situations, they show amazing courage and resilience. It happened more than once: the patient survived, but became disabled - his brain was damaged, he was in a deep coma. And six months later he comes with a bouquet of flowers, a cake and a question: “Doctor, don’t you recognize me?” Good rehabilitation sometimes gives amazing results, and it largely depends on the efforts of relatives. From the strength of their will and love. Last year we had an absolutely hopeless patient. He was given to relatives in a coma, and after 8 months they sent us a video where he talks and eats with a spoon himself. It's a miracle.

Who is more likely to come out of a coma

– Coma – critical situation . Before the advent of resuscitation, people could not stay in it for a long time. Coma is a severe lesion of the cerebral cortex, for example, after a traumatic brain injury or stroke. According to materialistic theory, man is his brain. The brain died - the man died. But medicine has learned to maintain life in the body even with such a defeat. There is a certain period during which the patient can come out of the coma. I believe that it is equal to 18 months, especially when it comes to young man and even more so for a child. The old saying that nerve cells not restored, not quite correct. New nerve cells are formed before the age of 35. In addition, the brain is a very complex computer. If the connections in it turned out to be broken, they can be restored in a roundabout way - “along the bypass road” through other nerve cells. Therefore, sometimes many functions can be restarted. But if this has not happened in a year and a half, then it will almost certainly not happen in the future. Patients in this vegetative state are kept in special hospitals, where they are provided with care - feeding through a tube, fighting pressure sores, if oxygen is needed.

– Any general anesthesia is also a coma: we do not want the person to feel anything during the operation and put him to sleep. But it happens that we need to introduce medical anesthesia not for two hours, but for two weeks. To protect the brain. With hemorrhage or brain injury it is necessary that the diseased brain has minimal requirements for energy and oxygen. This can be compared to the application of a cast for a fracture. Rigidly fixing the hand, we create it comfortable conditions. At first, until the injured hand has healed, it should not move, it needs rest. In the same way, with the help of an artificial coma, we provide rest to the damaged brain for the first time. acute period, which, for example, with a traumatic brain injury is 5-15 days.

chronic death

– Man is a fairly perfect machine.But like any machine, the term of its “work” depends on the resource. There was a German pathologist Görlach. He distinguished three types of death: fast, slow (that is, delayed for several days under the influence of various factors) and chronic death. The latter concept is rarely found in other authors. But as a resuscitator, I see that chronic dying is a reality. For example, a person has chronic heart failure. His heart is getting worse and worse every day, but just a little bit. There are diseases that cannot be cured, they imperceptibly, slowly but surely lead a person to the end, and it is impossible to save him. Sometimes relatives of a deceased patient are outraged: “How is it? A week ago, grandfather walked around the apartment, stroking his grandson on the head, and suddenly died. This did not happen all of a sudden - grandfather had been ill for 20 years. He had problems all this time, and at some point their quantity turned into quality. It's like a phone's power supply. While it still has 5 percent charge, I can talk on it, and then suddenly the screen goes blank. A person also has a resource and it decreases. If there is a lot of initial resource and a person suddenly fell under a trolleybus, his health can be restored. But if it was sharpened before chronic illness, then the critical situation in which he found himself threatens to become fatal. We can start his heart, and in 10 minutes it will rise again. Because the body no longer has a charge left.

How to make money on medical errors

– Of course, lawsuits and complaints are filed against our institute.In 90 percent of cases, these are claims from the category “it was bad, I didn’t like it.” And the claim to the doctor should be specific - prescribing the wrong medicine, performing erroneous actions. But a doctor can treat incorrectly not at all because he does it maliciously or negligently. He may not have the equipment. For example, a patient with a traumatic brain injury was brought to a hospital where there is no CT scan. Therefore, the physician may miss hidden lesions.

– Referral of a non-core patient to an unequipped hospital- This is a mistake in the organization of first aid. There is no equipment, there are not enough medicines, tariffs are too low (normal complete treatment this disease costs a million, and for him, according to the so-called tariff agreement, they pay 80 thousand) - but the last one will still be a doctor who was not lucky enough to be on duty on a given particular night. So we have accepted.

– And another very important question: who can evaluate a doctor's mistake? If a plane crashes, the most experienced pilots will definitely be included in the composition of the commission for the investigation of flight accidents, among other experts. They will analyze the data from the "black box". Not so in medicine. At least in domestic medicine. And we have already encountered a systemic problem - the dishonesty of experts who deal with medical conflicts.

– How is it happening with us. If the lawsuit of a citizen with a clinic goes to the level of the prosecutor's office, she turns to the central bureau of forensic examination. An employee of the bureau, who was entrusted with the investigation, assembles a team, which necessarily includes a physician. That's just it may not be related to the field of medicine in question. Let's say that all his life he operated on the abdomen not in emergency, but in planned surgery, and he is given a story from the burn center for review. And here comes the question of ethics. I will never undertake to write a conclusion on conflict situation in which I am not an expert. And someone will take it, because money is paid for work in such a team. He dealt with several cases - he received a good increase in salary.

— Case Study: Our anesthetist was blamed for a complication that happened during the operation - the patient died. And the expert wrote a conclusion that “the doctor was wrong,” referring to a 1974 book. Sorry, but since then everything has changed ten times in anesthesiology. With the same success, one could refer to the 1952 Vershinin textbook I mentioned, which recommended cognac to be injected under the skin of the patient. As a result, we achieved repeated examinations and proved the innocence of our doctor. But it took a lot of time and effort - the epic lasted more than a year. All over the world, experts are appointed by a specialized public organization of doctors. For example, in the Federation of Anesthesiologists and Resuscitators, where I am a member, they know and can recommend the best specialists in this region. If a conflict related to childbirth is being dealt with, then it would be logical to contact public organization obstetricians. And so on. We have complete chaos in this matter.

Resuscitation - a passage yard?

– The Ministry of Health decided to let relatives into intensive careafter Khabensky's address to Putin during the annual direct line with the president. So now we have to do it. But I would like to get a clear explanation from the Ministry of Health. Relatives - who are they? Once, as part of a commission of the Ministry of Health, I came to the city of Aleksandrov, Vladimir province. This was due to the assistance program for victims of road accidents. We checked all the hospitals on major highways. We drive up, and bonfires are burning around the hospital. The chief doctor wildly apologized. It turned out that it was the gypsies who had set up a camp, because their baron had ended up in the hospital. They all considered him to be their relative. In this regard, the question is: if the same baron comes to me tomorrow, should I let the whole camp into intensive care? In the 90s, when there was shooting around, the wounded were often brought to us. And friends and relatives came to protect them. Sometimes they were so worried about their “bro” that, after using drugs, they fell asleep in the dryer or pantry, and left their pistols there.

— We used to not let bandits with guns into the ward, and now, after a letter from the Ministry of Health, they are obliged to do this? Or another situation - a relative comes drunk. But we can't examine him, force him to breathe into a tube, check his pockets. And he will take and drop drunk monitor worth 3 million rubles. This can happen very easily, because we are crowded. According to the sanitary norm, one patient should have 13 square meters of area. But in all hospitals built before the collapse of the USSR, this norm is not observed. At the same time, the resuscitation bed is equipped with expensive equipment. And if suddenly stranger something breaks, who will pay for it - the hospital or the visitor? Or will he catch the IV of a neighboring patient, to whom he has never been a relative, and harm him? The legal mechanism for such situations is not spelled out at all. There is only a declarative statement "let everyone in". I would like clear explanations.

— Another question: should the patient himself be asked? Maybe the person is against being seen with a slit stomach, and there is no way to know his will, since he is unconscious.Will we violate the patient's rights? I will say more: we used to let relatives in before. But in those cases when they were sure that it would benefit the patient, it would bring positive emotions. But situations are different. Maybe a meeting with the patient's relatives will only finish him off. Some of our patients don't even want to see their mom and dad. I'm not talking about potentially conflicting moments that will inevitably arise. Often relatives, once in the ward, begin to pull everyone: why is the nurse or doctor taking care of other patients, and not mine? Or, having read about the disease on the Internet, they try to teach the doctor how to treat it properly. As long as the relatives are behind the barrier, such conflicts do not arise. In general, this practice - to let relatives to the patient came from children's hospitals. It is very scary for small children to be there without their mother. But our parents were always allowed into children's hospitals anyway. And it’s one thing for a mother with a child, and another thing for friends who come to a drug addict with “goodies”, after using which he is again taken from an ordinary ward to intensive care with a diagnosis of “overdose”. By the way, this is a very real situation in our daily work.

- Yes, in the West they are allowed everywhere. But there, for starters, there is another monitoring system.There, even in the pantries where the nurse goes to get medicines, screens hang over the shelves, on which the indicators of the condition of all patients are displayed. Let's first provide this level of monitoring in our intensive care units. Let's bring the premises in line with sanitary standards. But this is difficult, as it requires serious costs. And writing the order “let everyone in” does not require anything. The worst thing is that when making this decision, no one even consulted or consulted with the medical community - the Federation of Anesthesiologists and Resuscitators, which includes leading representatives of this profession from all over the country. None of us were asked at all. And let me call the president next time and be indignant why they don’t let me into the Leningrad NPP or into the cockpit when I’m flying on an airplane? Well, I'm a taxpayer. So I have a right. This whole story is yet another illustration of the relationship between the authorities and professionals, who have once again been shown the place they occupy in the social hierarchy of our country.

After a couple of minutes, you begin to understand: life goes on here too, only very, very quietly. Here is some kind of device blinking buttons. Someone took a deep, long breath. People in green coats walk silently. It is not immediately clear that some of them are not doctors, but visitors. Out of the corner of my eye, I notice how two people help the man lie down comfortably, how the woman says something to the man on the other bed. But one step away from the patient's bed - and not a sound is heard.

Suddenly, in this unthinkable silence, you sharply understand the phrase "a matter of life and death." Now I will associate it not with tubes and droppers, but with this literally tangible silence.

Severe, stable condition

I am in intensive care just as a curious journalist, but as soon as I look around, I begin to think: what do people feel who lie in this motionless silence for days? What do their loved ones feel on the other side, behind the closed door?

“To understand this, try to sit, or rather lie down in a closed room for a day,” doctors, patients themselves, and their relatives advise. Without any connection with the outside world.

“The worst thing is not being able to see loved one, - Elena tells me, whose husband has been in intensive care for almost three weeks. - You understand that he is ill, not even just ill, he is in a serious condition. And of course, doctors are doing everything possible, but you are not a doctor and you can’t do anything, just hold your hand ... how important it is!

Alexei, Elena's husband, is connected to a ventilator, he does not speak, he only looks from me to his wife. Then he pulls her hand, and from his pained look it becomes clear: he does not want his wife to be distracted by someone else. He wants these short two hours that are allocated for communication, she was only with him.

“A year and a half ago, my husband was in intensive care in another hospital,” Elena continues a little later, already in the corridor. - Then the door slammed shut in front of me, they said: “The condition is serious, call tomorrow.” And until tomorrow, you still have to live and not torment yourself with all sorts of thoughts. I call the next day, again: the condition is serious and stable. And what exactly is unknown, think what you want.

A few days later, I managed to persuade the nurse to give her husband a note. Then another. Alexey later said that these notes were for him as proof that there is another world, outside the hospital, in which there is a wife, son, parents, friends. How much easier it would be for me, yes for all of us, if we could then get at least two words from Lesha in response.

And when this year he was brought by ambulance to Pervaya Gradskaya, and the doors of intensive care slammed in front of me, I thought: it can’t be, the nightmare is repeating ... I was getting ready to beg doctors and nurses for information. And suddenly they say to me: you can go to him for a while. Here are shoe covers, here is a robe. My husband is connected to a ventilator, he cannot speak yet, but the operation went well. I then just stood next to him for about half an hour somewhere, held his hand. And when I came home, it felt like we talked.”

“I wanted to tell my family: I’m alive!”

This thread connecting with the patient in intensive care is so important not only for healthy people. The person on the other side closed door, surrounded by devices and silence, also needs us. And he also worries - for his loved ones, who are in perfect health.

“The first time I was in intensive care about a year and a half ago,” recalls Lyubov. “Those were probably the worst four days of my life. It hurt a lot, it hurt physically, and I, adult woman, I just dreamed that my mother was next to me. Or a husband. Or at least someone from my family who would pat me on the head, straighten the blanket, give me a drink.

It was cancer hospital. Thank God I had a benign tumor. But there were oncological patients nearby - and this special people. They already exist in their own world. They need a completely different approach, by different standards. And there was one shift in intensive care - Lord, how they screamed at everyone. One man, in an unconscious state, constantly threw off his blanket. I also remember there was a woman who moaned very loudly all the time. And this shift was terribly angry with them and vented evil on others. I understand that doctors are people too, with their moods and problems. But it seems to me that you can’t give in to your mood in intensive care with helpless people. If then relatives were allowed to visit us, they would be indignant, complained. And so... What can a helpless person do?

When I ended up in intensive care again a year later, already in another hospital and already with a normal attitude, all those few days that I spent there, I was worried about my relatives. They remember how terrible the first time was. And I wanted to reassure them, to tell them that they are taking good care of me, that I feel tolerably.”

For some reason, little is thought about this - that a person in intensive care can worry not for himself, but for his loved ones. Although this is an obvious and completely natural need: when you come to your senses, realizing that you have remained in this world, think about your family.

How many unnecessary worries, conjectures and misunderstandings can be avoided if relatives had the opportunity to hear a little more than just “stable condition” over the telephone receiver.

“The phone was constantly torn at the post,” Lyubov recalls. - Probably, the nurses were exhausted endlessly picking up the phone, hearing the same question and answering the same thing. I missed my mobile. I wasn't going to talk, and I didn't have the strength to. But to tell my husband herself: “Don’t worry, I’m alive,” - I really missed this opportunity.

Why is it needed

There is a medical post at the entrance to the intensive care unit.

She is surprised:

And what do they interfere with? On the contrary, it is more pleasant for the patient if he is fed or washed by a relative. And the inconvenience ... In which case, you can always put up a screen.

Inconvenience is the last thing you think about in intensive care, says Elena. - When a person is on the verge of life and death, you are absolutely not up to it. Well, yes, someone after the operation is completely naked under the covers. A lot of people walk by: doctors, nurses. Nurses feed the sick and wash their buttocks. The feeling of shame is blurred here. And then ... Each patient is focused only on himself, and visitors see only their loved ones.

Perhaps this is true. Healthy terrifies: how so, some medical manipulations the patient is done in the presence of strangers? Or publicly have to solve toilet issues. But a person who was on the verge of life and death is not up to these “trifles”, he needs strength to get out. Other visitors with whom I was able to speak only confirmed this. Everyone spoke only about their loved ones fighting for their lives. And if doctors need to carry out some procedures, then everyone is simply asked to leave the ward. By at least, so arranged in the First Gradskaya.

“You need to understand that resuscitation, in general, medical institution- the same part of life as everything else, - says Alexey Svet, chief physician First City Hospital named after N.I. Pirogov. - Relatives should see relatives in intensive care. Doctors should talk to them, explain what is happening, why, what they will do. It's as much a part of our job as installing a coronary stent."

You remain the same person, and when you are in intensive care, when you feel bad. Of course, first of all, you need close people nearby. For us, it's all natural.
Alexey Svet
Chief Physician of the First City Hospital named after N. I. Pirogov

Closed doors are inhuman

Now the State Duma is considering a bill that should secure the right of loved ones to visit a patient in intensive care. So far, admission is only recommended by the corresponding letter from the Ministry of Health, so the decision remains with the chief physician. Opponents of "open resuscitation" cite infection and inadequate relatives as an argument that interfere with the work of medical staff. These arguments are broken down by the experience of hospitals where intensive care units are open to the public, for example, Pervaya Gradskaya.

The medical post controls visitors and will not let in anyone who is sneezing, drunk or hysterical. At the entrance, everything is explained to the person so that he is not afraid of all the tubes extended to his loved one. According to doctors, these are organizational issues that are resolved on the basis of elementary concepts of ethics and humanity.

“The position that no one should enter the intensive care unit is a stereotype of Soviet medicine,” says Marat Magomedov, deputy chief physician for anesthesiology and resuscitation at the Pirogov First City Hospital. - The doctor, the patient, his relatives are not competitors, we all have one task, so dialogue is necessary. And I always asked relatives to write notes to our patients. Because it's inhuman to keep in the dark. We always let moms into intensive care. Because mothers are the most persistent, most scrupulous people. They are ready to spend the night under the door, dutifully endure all hardships. Tell your mother that you need to swim across the Moscow River to save your son - and she will immediately throw herself into the water.

Not letting a mother see her child, no matter how old he is, how insensitive you must be!
Marat Magomedov
Deputy chief physician for anesthesiology and resuscitation of the First City Hospital named after N. I. Pirogov

“Or now we have a grandfather in the ward. His wife and grandson are always around him. The guy took a vacation. All the time it bothers: grandfather, get up, grandfather, you need to eat! This is of tremendous importance. The word also heals. Moreover, the word native person", says the doctor.

“Any classified information is a reason to think something, to fantasize,” emphasizes Alexei Svet. - There is such a thing as quality of life. And it rises when you experience peace. That's probably the most important thing."

Ecology of life. Health: Southern California MD Ken Murray explains why many doctors wear "Don't Pump Down" pendants and why they choose to die of cancer at home.

Southern California M.D. Ken Murray explains why many doctors wear "Don't Pump Down" pendants and why they choose to die of cancer at home

We leave quietly

Many years ago, Charlie, a respected orthopedic surgeon and my mentor, discovered a lump in his stomach. He underwent exploratory surgery. Pancreatic cancer confirmed.

Diagnosis was carried out by one of the best surgeons in the country. He offered Charlie treatment and surgery, which would triple his life expectancy with this diagnosis, although the quality of life would be poor.

This topic is rarely discussed, but doctors also die. And they don't die like other people. It's amazing how rarely doctors seek medical attention when the case is nearing its end. Doctors struggle with death when it comes to their patients, but they are very calm about their own death. They know exactly what will happen. They know what options they have. They can afford any kind of treatment. But they leave quietly.

Naturally, doctors do not want to die. They want to live. But they know enough about modern medicine to understand the limits of possibilities. They also know enough about death to understand what people fear most - death in agony and alone. Doctors talk about it with their families. Doctors want to make sure that when their time comes, no one will heroically save them from death by breaking their ribs in an attempt to revive them with chest compressions (which is exactly what happens when the massage is done correctly).

Virtually all health care workers have at least once witnessed a "vain treatment" when there was no chance that a terminally ill patient would get better from the latest advances in medicine. But the patient's stomach is cut open, tubes are stuck into it, connected to the apparatus and poisoned with drugs. This is what happens in intensive care and costs tens of thousands of dollars a day. With this money, people buy suffering that we will not inflict even on terrorists.

Doctors don't want to die. They want to live. But they know enough about modern medicine to understand the limits of possibilities.

Treating people by causing them suffering is painful. Doctors are taught not to show their feelings, but among themselves they discuss what they are going through. “How can people torture their relatives like that?” is a question that haunts many doctors. I suspect that the forced infliction of suffering on patients at the behest of families is one of the reasons for the high percentage of alcoholism and depression among health workers compared to other professions. For me personally, this was one of the reasons why I have not practiced in a hospital for the last ten years.

Doctor do everything

What happened? Why do doctors prescribe treatments they would never prescribe themselves? The answer, simple or not, is patients, doctors, and the medical system as a whole.

The patient's stomach is cut open, tubes are stuck into it and poisoned with drugs. This is what happens in intensive care and costs tens of thousands of dollars a day. With this money people buy suffering

When doctors ask “Do you want us to “do everything”?”, relatives say “yes”. And hell begins. Sometimes the family really wants to “do everything,” but more often than not, the family just wants everything to be done within reasonable limits. The problem is that ordinary people often do not know what is reasonable and what is not. Confused and grieving, they may not ask or hear what the doctor says. But physicians who are told to “do everything” will do everything without considering whether it is reasonable or not.

I have seen hundreds of patients who were brought to my hospital after resuscitation with artificial heart massage. Only one of them, a healthy man with a healthy heart, left the hospital on his own two feet. If the patient is seriously ill, old, has a fatal diagnosis, the probability of a good resuscitation outcome is almost non-existent, while the probability of suffering is almost 100%. Lack of knowledge and unrealistic expectations lead to poor treatment decisions.

Of course, not only the relatives of patients are to blame for this situation. Doctors themselves make useless treatments possible. The problem is that even doctors who hate futile treatment are forced to satisfy the desires of patients and their families.

The forced infliction of suffering on patients at the request of families is one of the reasons for the high percentage of alcoholism and depression among health workers compared to other professions.

Imagine: relatives brought an elderly person with an unfavorable prognosis to the hospital, sobbing and fighting in hysterics. For the first time they see a doctor who will treat their loved one. To them, he is a mysterious stranger. In such conditions, it is extremely difficult to establish trusting relationships. And if the doctor starts discussing the issue of resuscitation, people tend to suspect him of not wanting to mess with a difficult case, saving money or his time, especially if the doctor does not advise continuing resuscitation.

Not all doctors know how to speak to patients in a clear language. Someone is very categorical, someone sins with snobbery. But all doctors face similar problems. When I needed to explain to the patient's relatives about the various treatment options before death, I told them as early as possible only those options that were reasonable under the circumstances.

If the relatives offered unrealistic options, I conveyed to them in simple terms all the negative consequences of such treatment. If the family still insisted on treatment that I considered pointless and harmful, I offered to transfer them to another doctor or another hospital.

Doctors do not refuse treatment, but retreatment

Should I have been more assertive in persuading relatives not to treat terminally ill patients? Some of the cases where I refused to treat a patient and referred them to other doctors still haunt me.

One of my favorite patients was a lawyer from a prominent political clan. She had severe diabetes and terrible circulation. There is a painful wound on the leg. I tried to do everything to avoid hospitalization and surgery, realizing how dangerous hospitals and surgical intervention for her.

She nevertheless went to another doctor whom I did not know. That doctor almost did not know the history of the disease of this woman, so he decided to operate on her - bypass the thrombotic vessels in both legs. The operation did not help restore blood flow, but postoperative wounds did not heal. Gangrene went on her feet, and both legs were amputated to the woman. Two weeks later, she died in the famous hospital where she was treated.

Both physicians and patients are often victims of a system that encourages overtreatment. Physicians in some cases get paid for every procedure they do, so they do whatever they can, whether the procedure helps or hurts, just to make money. Much more often, however, doctors are afraid that the patient's family will sue, so they do everything that the family asks, without expressing their opinion to the patient's relatives, so that there are no problems.

Both physicians and patients are often victims of a system that encourages overtreatment. Doctors sometimes get paid for every procedure they do, so they do whatever they can, whether the procedure helps or hurts.

The system can devour the patient, even if he prepared in advance and signed the necessary papers, where he expressed his preferences for treatment before death. One of my patients, Jack, had been ill for many years and had 15 major surgeries. He was 78. After all the vicissitudes, Jack absolutely unequivocally told me that he never, under any circumstances, wants to be on a ventilator.

And then one day Jack had a stroke. He was taken to the hospital unconscious. The wife was not around. The doctors did everything possible to pump him out, and transferred him to the intensive care unit, where he was connected to a ventilator. Jack was afraid of this more than anything in his life! When I got to the hospital, I discussed Jack's wishes with the staff and his wife. On the basis of documents drawn up with Jack's participation and signed by him, I was able to disconnect him from the life-sustaining apparatus. Then I just sat down and sat with him. He died two hours later.

Even though Jack made up everything required documents He still didn't die the way he wanted. The system intervened. Moreover, as I found out later, one of the nurses slandered me for disconnecting Jack from the machines, which means that I committed murder. But since Jack wrote down all his wishes in advance, there was nothing for me.

Hospice caregivers live longer than people with the same illness who are treated in the hospital

Yet the threat of a police investigation strikes terror into any physician. It would be easier for me to leave Jack in the hospital on the equipment, which is clearly contrary to his wishes. I'd even make more money and the insurance company would get billed for an extra $500,000. No wonder doctors tend to overtreat.

But doctors still do not cure themselves. They see the consequences of retreatment every day. Almost everyone can find a way to die peacefully at home. We have many options to ease the pain. Hospice care helps terminally ill people spend last days life comfortably and with dignity, instead of suffering from vain treatment.

It is amazing that people who are cared for in a hospice live longer than people with the same illness who are treated in a hospital. I was pleasantly surprised when I heard on the radio that renowned journalist Tom Wicker "died peacefully at home surrounded by family." Such cases, thank God, are becoming more common.

A few years ago, my older cousin Torch (torch - lantern, burner; Torch was born at home by the light of a burner) had a cramp. As it turned out, he had lung cancer with brain metastases. I spoke to various doctors and we learned that when aggressive treatment, which meant three to five visits to the hospital for chemotherapy, he would live for about four months. Torch decided not to be treated, moved to live with me and only took pills for cerebral edema.

For the next eight months, we lived for our own pleasure, just like in childhood. For the first time in my life we went to Disneyland. We sat at home, watched sports programs and ate what I cooked. Torch even recovered on home grubs. He was not tormented by pain, and the mood was fighting. One day he didn't wake up. He slept in a coma for three days and then died.

Torch wasn't a doctor, but he knew he wanted to live, not exist. Don't we all want the same? As for me personally, my doctor is aware of my wishes. I'll quietly go into the night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors. published

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