Families in the intensive care unit a guide to understanding engaging and supporting at the bedside
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The Beginner’s Guide to Intensive Care : a Handbook for Junior Doctors and Allied Professionals Arora
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To my family that planted my roots, nurtured me, and guided me upwards; and to my family that nourishes and grows me yet.
Foreword
Margaret Atwood once wrote [1]:
I would like to give you the silver branch, the small white flower, the one word that will protect you from the grief at the center of your dream, from the grief at the center. I would like to follow you up the long stairway again & become the boat that would row you back
In the ICU, we enact these beautiful metaphors hourly—trying to pull patients back from the sadness and sometimes horror of death and suffering.
In doing so, we increasingly partner deeply not just interprofessionally but with patients’ families. This partnership involves an often unnatural intensity, and an interdependency that can develop within minutes and hours. That interdependency evolves as we work to save the patient’s life or to recognize that it is not within our power to save—or that the patient would not want their life saved at the cost that must be imposed by our limitations.
Partnership at this level requires honesty and frankness. It means understanding what our partner can do at any given moment, but also what cannot—ought not—be asked of them.
This is a book to help us, as clinicians, understand what our patients’ families may experience. It provides us a set of tools to understand the ways in which the ICU experience can reshape—and, yes, can deform and scar—family members. It can help us understand the ways in which the ICU experience may limit a family’s ability to be their best self. It can help us learn what our partners are going through.
The authors of this book provide insights into what we may be doing that might make things worse for our partners, the families of our patients. They demonstrate that there are pervasive system issues that at best benignly neglect the needs of families—but sometimes may not be so benign.
The authors teach us paths forward, from broad philosophies of care to simple tips for engaging the family in bedside physical therapy. They suggest ways in which we can more effectively partner with families to transform critical care. There is much to learn here, and I hope dog-eared copies of this book will be found at ICU work rooms and nursing stations for years to come.
Ann Arbor, MI, USA
Theodore J. Iwashyna, MD, PhD
Reference
1. Atwood M. Selected poems II: 1976–1986 2nd ed. New York: Mariner Books; 1987.
Preface
After 12 days at my mother’s bedside, I had reached the end of my rope, physically and emotionally. She’d had three craniotomies and was spiking a fever, and the neurosurgery resident arrived to perform the lumbar puncture. I walked out of her room in the intensive care unit (ICU), trying to figure out how to hold back the sobs welling up inside me. “Would you like a cup of coffee?” a nurse asked. It wasn’t long before a Styrofoam cup of burnt, terrible machine coffee steamed in my hand. It was the greatest cup of coffee I had ever tasted.
That moment was miraculous even as it was unremarkable. A wise and caring nurse had reached out to a fellow human being who was suffering and poured a helping of pure and selfless kindness. This small act helped me more fully understand that while the hurt of families in the ICU was deeper and more jagged than I had realized, the power of a simple gesture of support and kindness was more powerful than I could have imagined.
My mother returned home a week later to begin her recovery. However, when I came back to the ICU, filled with gratitude, I brought with me an awareness that changed the way I viewed every facet of critical care. Now as I look at family faces in the waiting rooms, it reminds me of being there as a loved one—nauseous from days of junk food, bleary from sleep deprivation, and distraught and exhausted from the whirlwind of it all. Seeing them takes me back to being at my mother’s bedside, anxious and waiting for cardiologists, cardiac surgeons, neurosurgeons, and ICU physicians. It was a raw epiphany that opened me to a truth I could now personally understand and relate to the feelings of those sitting across from me. I could no longer cloak myself in a white coat to escape the now-obvious truth that if I were to truly care for critically ill human beings in their totality, I owed their loved ones the same dedication I was giving them.
This realization brought to mind the words of the Chassidic philosopher Rebbe Nachman of Breslov [1]:
As the hand held before the eye conceals the greatest mountain, so the little earthly life hides from the glance the enormous lights and mysteries, of which the earth is full, and he who can draw it away from before his eyes, as one draws away a hand, beholds the great shining of the inner worlds.
The science of today’s ICU medicine is dazzling. We practice in a fortunate era, using technology and evidence to take better care of our patients than any time in history. At the same time, it’s easy to lose sight that this is a human endeavor. Those for whom we care are individual souls, not bags of organs and collections of maladies. They and their families have entrusted us with this most precious thing, their very being. To save lives and ease suffering, our minds and efforts make our work in the ICU the highest calling. But kindness must be integral to this, elevating it from the noble to the sacred. We then illuminate the world around us.
For those of us in healthcare and research whose lives have been touched personally by critical illness, we are transformed. We want to see the ICU made human, not only for our patients and their families but for ourselves as well. But this endeavor requires more than just good intentions.
Our first task is to recognize that families are suffering with their loved ones in the ICU. But this, in and of itself, is not enough. We need to know how this suffering occurs and how it impacts their abilities to advocate and make the often difficult decisions frequently encountered in the ICU. Only then can we best create and assess the potential interventions that might support and guide them. Then will come the changes in the way we engage and work with families.
This book seeks to do these things: for us to describe what families are going through, what mechanisms may be driving their suffering, how we rise up to this great and noble challenge now, and how we may continue to rise up to meet it.
Baltimore, MD, USA
Reference
Giora Netzer, MD, MSCE
1. Buber M. Tales of the Hasidim. New York: Schocken Books; 1991.
Acknowledgments
For me, the Hippocratic Oath’s exhortation to honor one’s teachers has been a delight, as I’ve been blessed with so many superb mentors throughout my path in medicine, including Thomas Shaffer, Gregory Tino, John Hansen-Flaschen, John Hess, Dale Needham, Anthony Harris, Michael Terrin, and Chuck Callahan. Jason Christie guided and launched me on my path and continues to generously provide his wisdom. I’ve tried to pay it forward. It’s been my honor to work with amazing mentees, whose work, ideas, and talent have made so much exciting research possible. Thank you: Tessy Paul, Ann Parker, Xinggang Liu, Michael Dallman, Aaron Hess, Majid Afshar, Matthew Barrett, Sahar Mansoor, Mario Fusaro, Jona Ludmir, Niki Leiter, Danielle Glick, Stephen Biederman, and Sara Viola. I’m especially grateful to Don Sullivan, together with whom I developed the core concepts guiding my work on families.
Jack Iwashyna has been a collaborator, guide, foil, and friend since our time as residents. Jack’s mark is apparent throughout this book; I am indebted to his thoughtful comments and guidance in its structure and approach. I hope the book’s introduction conveys just how inspirational working with Judy Davidson has been— she’s my ICU family hero, as is Sam Brown, who brings great grace and rigor to thinking about humanizing the ICU. Mark Mikkelsen has led the charge in addressing the challenges of ICU survivors and their families, and I’m fortunate to work and think with him.
My thanks to the Division of Pulmonary and Critical Care Medicine at the University of Maryland School of Medicine, where I work with some terrific friends and researchers, as well as the Department of Epidemiology and Public Health, whose work studying older caregivers has helped to inform my own work. I am grateful to the leadership of the University of Maryland Medical Center and the University of Maryland Medical System for their support in improving familycentered care across its ICUs. I’m honored and proud to be a member of the Society of Critical Care Medicine. The Society of Critical Care Medicine has taken a leadership position in advocating for patient- and family-centeredness in critical care with
its state-of-the-art guidelines, and also the well-being of survivors and families after the ICU with its THRIVE Initiative (where Adair Andrews has worked tirelessly to make the world a better place).
For me, the inspiration to write a book about family comes from the love of my own. Thank you to my parents for their selflessness and my sister for her bravery. My wife and partner, Alison, and my children, Hannah, David, and Jacob, breathe life into my soul each day.
My thanks to Andy Kwan at Springer Press for his enthusiasm and vision for this project and also to Prakash Jagnnathan for his efforts in making it possible.
Samuel M. Brown, Michael E. Wilson, Chris Benda, Negin Hajizadeh, and Ramona O. Hopkins
Arunmozhi Aravagiri, Waqas Bhatti, Jetina Okereke, and Avelino C. Verceles
Judy Elisa Davidson, Janet Marty Mendis, Truong-Giang Huynh, Samantha Gambles Farr, Suzette Jernigan, Steffanie A. Strathdee, and Thomas Patterson
16 Strategies to Facilitate Communication with Families in the ICU
Andre Carlos Kajdacsy-Balla Amaral
Jennifer L. McAdam 18 The Integrative Approach to Supporting Families in the ICU
Simon Lasair and Shane
Linehan and Giora Netzer
Kimberley Haines
Erin K. Kross and Catherine L. Hough
Child Life in the Adult ICU: Including the Youngest Members of the Family
Jaime E. Bruce and Kathleen McCue
How to Study the Family ICU Syndrome: A Basic Approach to Research Methodology
Christiane S. Hartog
Contributors
Andre Carlos Kajdacsy-Balla Amaral Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
Bree Andrews Section of Neonatology, The University of Chicago Medicine Comer Children’s Hospital, Chicago, IL, USA
Department of Pediatrics, The University of Chicago, Chicago, IL, USA
Arunmozhi Aravagiri Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
Sarah J. Beesley Division of Pulmonary and Critical Care, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
Pulmonary Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, Murray, UT, USA
Chris Benda Intensive Care Unit Patient-Family Advisory Council, Intermountain Medical Center, Murray, UT, USA
Waqas Bhatti Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
O. Joseph Bienvenu Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
A. Doran Bostwick Division of Pulmonary and Critical Care, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
Samuel M. Brown Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA
Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
Intermountain Medical Center, Shock Trauma Intensive Care Unit, Murray, UT, USA
Jaime E. Bruce Middle Tennessee State University, College of Behavioral and Health Sciences, Murfreesboro, TN, USA
Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Child Life and Volunteer Services, Nashville, TN, USA
Morgan Bunting School of Medicine, Division of Gerontology, University of Maryland-Baltimore, Baltimore, MD, USA
John G. Cagle University of Maryland, Baltimore, School of Social Work, Baltimore, MD, USA
Delia Chiaramonte University of Maryland School of Medicine, Center for Integrative Medicine, Baltimore, MD, USA
Sal Colianni ARDS Patient, Northbrook, IL, USA
Christopher E. Cox Department of Medicine, Division of Pulmonary & Critical Care Medicine, Duke University, Durham, NC, USA
Program to Support People and Enhance Recovery, Duke University, Durham, NC, USA
Judy Elisa Davidson University of California, San Diego Health, San Diego, CA, USA
Samantha Gambles Farr Surgical Intensive Care, University of California, San Diego Health, San Diego, CA, USA
Kimberley Haines Western Health, Australia and New Zealand Intensive Care Society Research Center, Monash University, Clayton, VIC, Australia
Negin Hajizadeh Center for Health Innovations and Outcomes Research (CHIOR), Hofstra Northwell School of Medicine and Northwell Health, Manhasset, NY, USA
Scott D. Halpern Department of Medicine, Palliative and Advanced Illness Research Center, Philadelphia, PA, USA
Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute of Health Economics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
Joanna L. Hart Department of Medicine, Palliative and Advanced Illness Research Center, Philadelphia, PA, USA
Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute of Health Economics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
Christiane S. Hartog Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
Ramona O. Hopkins Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA
Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT, USA
Catherine L. Hough Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
Truong-Giang Huynh Medical-Surgical ICU, University of California, San Diego Health, San Diego, CA, USA
James C. Jackson Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA
Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
Stuti J. Jaiswa The Scripps Research Institute, La Jolla, CA, USA
Suzette Jernigan Burn ICU, Burn Special Care, University of California, San Diego Health, San Diego, CA, USA
Erin K. Kross Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
Simon Lasair Compassion Research Lab, Faculty of Nursing, University of Calgary, Calgary, AB, Canada
Deborah Linehan University of Maryland Medical Center, Department of Respiratory Care, Baltimore, MD, USA
Jason H. Maley Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Jennifer L. McAdam School of Nursing, Samuel Merritt University, Oakland, CA, USA
Kathleen McCue Children’s Program, The Gathering Place, Cleveland, OH, USA
Janet Marty Mendis NICU, University of California, San Diego Health, San Diego, CA, USA
Mark E. Mikkelsen Medical Intensive Care Unit, Penn Presbyterian Medical Center, Philadelphia, PA, USA
Critical Care Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
Giora Netzer Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
Jetina Okereke Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
Robert L. Owens Pulmonary, Critical Care and Sleep Medicine Division, University of California San Diego, La Jolla, CA, USA
Thomas Patterson University of California, San Diego Department of Psychiatry, San Diego, CA, USA
Neethi Pinto Section of Pediatric Critical Care, The University of Chicago Medicine Comer Children’s Hospital, Chicago, IL, USA
Department of Pediatrics, The University of Chicago, Chicago, IL, USA
Margaret A. Pisani Yale University, New Haven, CT, USA
Nilu Rahman Child Life Department, Johns Hopkins Children’s Center, Baltimore, MA, USA
Nicole Roeder Yale University, New Haven, CT, USA
Julie Rogan Medical Intensive Care Unit, Penn Presbyterian Medical Center, Philadelphia, PA, USA
Eileen Rubin ARDS Foundation, Northbrook, IL, USA
Henry J. Silverman University of Maryland Baltimore, Baltimore, MD, USA
Shane Sinclair Compassion Research Lab, Faculty of Nursing, University of Calgary, Calgary, AB, Canada
Kristina Stepanovic Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
Joanna L. Stollings Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
Steffanie A. Strathdee University of California, San Diego Department of Medicine, San Diego, CA, USA
Julie Van Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
Avelino C. Verceles Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
Michael E. Wilson Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
Donald L. Zimmerman Healthcare Management, University of New Orleans, New Orleans, LA, USA
Chapter 1
An Introduction and Overview of Why Families Matter in the Intensive Care Unit
Giora Netzer
Defining Family
Ab ovo, please note that the term “family” is defined and used inclusively to reflect what makes us human and wonderful. The definition for family used here and throughout this book is that used by the Society of Critical Care Medicine’s 2017 guidelines on family-centered care [1]:
Family is defined by the patient or, in the case of minors or those without decision-making capacity, by their surrogates. In this context, the family may be related or unrelated to the patient. They are individuals who provide support and with whom the patient has a significant relationship.
Thinking About and Naming the Challenge
Traditionally, we have viewed the task of engaging families in the ICU as one of communication. This model emphasizes the need to improve our efforts at communication (the transmitter) but assumes the existence of a normally functioning receiver (the families). Observational data make a clear association between the quality of perceived communication and families’ psychological state, including anxiety, depression, and post-traumatic stress disorder (PTSD) [2–5]. However, early, multicenter studies employing the logic of increased communication with families all failed to improve families’ or their loved ones’ outcomes [6–9]. Superficially addressing one symptom of a complex pathophysiology was not going to cut it.
G. Netzer
Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
G. Netzer (ed.), Families in the Intensive Care Unit, https://doi.org/10.1007/978-3-319-94337-4_1
Broadly, families living the nightmare of their loved one being close to death are barraged with high-intensity emotions. They are stressed, anxious, and depressed [10, 11]. Many have PTSD before even leaving the ICU [12]. Sleep deprivation further torments them [13]. Unable to process these insults, they may turn to maladaptive coping, further exacerbating their suffering [14]. Thinking about the possible death of their loved ones further deteriorates their social problem-solving skills [15]. Presented with data, they suffer the same biases we all do in daily life but now with greater consequences [16, 17]. As they gather together, families grapple with the agonizing process of having to speak for their loved one in a unified voice, despite often being wracked by disagreement [18].
The challenges faced by families after their ICU stay, caring for survivors of critical illness or mourning their loss, was defined in 2012 [19]. This definition recognized the psychological morbidity incurred during the ICU course on family members as they returned home. However, the suffering of families while still in the ICU was not discussed (speaking with Judy Davidson, it seems the authors intended it to encompass both during and after the ICU; if I encroached inappropriately on this term, I am truly sorry). Additionally, what family members experienced seemed to extend beyond just suffering described in this syndrome, to also include obstacles to cognition, threatening their ability to advocate and care for their loved ones.
We termed this constellation the Family Intensive Care Unit Syndrome (FICUS) (Fig. 1.1) [20]. While FICUS may not have been the catchiest acronym, we hoped to capture the symbolism of the Ficus carica, the fig tree. Just as illness and suffering are shared by all people, the Ficus tree plays an important role across the world’s Maladpative Reasoning
religions, from its multiple appearances in the Pentateuch and New Testament, to the Quran (including Sura 95, “The Fig”), and to Buddha’s enlightenment under the Bodhi tree (itself a fig).
Harnessing the Best of our Human Instinct
At the time, putting these thoughts to text, the task seemed overwhelming. I looked at prior negative studies that worked to support families, the enormous hurt of families, and I sometimes despaired. But being at the bedside, caring for patients in the medical ICU, and meeting with their families reminded me of the most important variable, though perhaps the hardest to measure: love.
It’s said that more than the calf wants to suckle, the cow wants to nurse [21]. A parent’s instinct is to give. Families have a natural instinct to protect those they love [22]. They ask us what they can do to help [23]. The first time I read Judy Davidson’s theory of facilitated sensemaking, I was simply struck; this approach both encourages and nurtures the instinct to give. By communicating with and caring for families, valuing their presence, and engaging them in bedside activities, we help them to make sense of the situation and their new role [24].
Previously, I had felt uneasy as I tried to reconcile my two worlds. Outcomedriven medicine was the thesis; all efforts should be directed toward rigorously tested processes that improve outcomes. The antithesis, in my mind, was my humanistic concern for families and their well-being. But as data accumulated, engaging families at the bedside was very clearly recognized as the synthesis. Doing so both improved the families’ lot while helping their loved ones do better clinically (Fig. 1.2).
Family Engagement Improves Patient Outcomes
In short, putting families to work helps our patients while simultaneously bringing meaning and coping to the families themselves. For example:
• Families can increase rates of early mobilization, reducing the length of mechanical ventilation and ICU length of stay [25, 26].
• Liberalizing family presence at the bedside reduces ICU delirium [27].
• With families joining bedside rounds, ICU throughput improves [28].
• When parents participate in care in the neonatal ICU, their infants gain more weight and are more likely to breastfeed at discharge [29].
• Families participating in care have reduced anxiety levels [30].
• Families can keep an ICU diary, reducing their loved one’s PTSD symptoms [31].
• Families are far more effective at detecting errors and adverse events than hospital safety systems [32].
We Need Families for the Health of ICU Survivors and of our Community as a Whole
As Jack Iwashyna predicted, survivorship is indeed the defining challenge of critical care in the twenty-first century [33]. A large proportion of ICU survivors require family caregiving for the activities of daily living [34, 35]. Moreover, families are key determinants in whether the physical limitations incurred during critical illness result in disability [36]. In one example, the support provided by families, both instrumental and emotional, is significantly associated with the degree of recovery after stroke [37]. In the United States, (conservatively) 200,000 older survivors are our neighbors [38], not even counting younger survivors. Given the role that families play in caring for our ICU patients after discharge and modifying their post-ICU trajectories, as ICU clinicians, we must recognize that caring for families in the ICU is caring for the community itself [39].
Family Engagement Is Good for Us as a Healthcare Team
While we embrace the ICU for its energy and excitement, burnout is a significant problem among ICU providers [40]. When families are unsupported, conflict is more likely; that conflict, in turn, further increases burnout risk [41, 42]. As Joe Bienvenu points out [43], an intervention of targeted communication with families reduces staffing burnout as well [44]. In this sense, engaging families may benefit us as much as it does our patients and their loved ones.
This Book as Springboard
Critical care medicine is a relatively young specialty. Our focus on family-centered care and the science of what happens to families in the ICU is even younger. In collecting ideas for this book, I am honored that this dynamic group of contributing clinicians, families, and researchers has created a nidus for further thought, debate, and research. It’s my hope that these pages also provide both better understanding and care for our patients’ families in ICUs today. This approach to care is a winwin-win for our patients, our patients’ families, and ourselves.
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18. Schenker Y, Crowley-Matoka M, Dohan D, Tiver GA, Arnold RM, White DB. I don’t want to be the one saying ‘we should just let him die’: intrapersonal tensions experienced by surrogate decision makers in the ICU. J Gen Intern Med. 2012;27(12):1657–65.
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30. Skoog M, Milner KA, Gatti-Petito J, Dintyala K. The impact of family engagement on anxiety levels in a cardiothoracic intensive care unit. Crit Care Nurse. 2016;36(2):84–9.
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32. Khan A, Coffey M, Litterer KP, et al. Families as partners in hospital error and adverse event surveillance. JAMA Pediatr. 2017;171(4):372–81.
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Chapter 2 Family Voices from the Intensive Care Unit
Eileen Rubin and Sal Colianni
Eileen Rubin, JD, is an acute respiratory distress syndrome (ARDS) survivor and founder of the ARDS Foundation, the largest critical care patient- and familyadvocacy organization. She has worked to increase ARDS awareness among the public. Her activities include providing a patient voice and leadership in the American Thoracic Society and the Society of Critical Care Medicine, contributing to national guidelines, and engaging in Patient-Centered Outcomes Research Institute-sponsored research.
It is difficult to think of the intensive care unit as anything but an awful place. It is traumatic for patients and it is traumatic for their loved ones. No one asks to be there; for patients, it is because they are critically ill, and for families, it is because their loved one is so sick. Most people are unfamiliar with protocol, procedure, terminology, and proper behavior. I have experienced being both a critical care patient and also a family member of a critical care patient. In 1995, when I was 33 years old, I spent 9 weeks in the hospital with acute respiratory distress syndrome, a syndrome that causes widespread inflammation in the lungs as well as many other medical complications. At the time I was in the ICU, ARDS had a mortality rate of over 50%. Of those 9 weeks in the hospital, 8 were on the ventilator and 4 were in the ICU, mostly in a drug-induced coma. And in 2011, my father found himself in another ICU, diagnosed with acute lung injury. Though my parents and siblings were familiar with having a loved one in ICU, I was not. I knew right away that being on the other side of the bed was a completely different experience than being a patient, and even though there are many similarities, there are a tremendous number of aspects that make it more difficult, frustrating, and completely overwhelming.
G. Netzer (ed.), Families in the Intensive Care Unit, https://doi.org/10.1007/978-3-319-94337-4_2
E. Rubin and S. Colianni
In October, 2011, my father, 77 years old, had terrible ear pain. He was flying home from Florida the next day, so he visited the clinic at the pharmacy, where they said his ear was clear. Over the next few weeks, his ear and throat pain continued to worsen; he developed a constant cough and grew weaker. Multiple physician visits did not yield a diagnosis. Three trips to the emergency room and two inpatient admissions followed. A diagnosis of interstitial lung disease was entertained, and he was discharged home on steroids after the second hospitalization.
By Thanksgiving Day, he was in terrible condition, so weak he was barely able to stand. During the holiday weekend, someone always needed to be with him. Then, on Monday morning, my father sat up on his bed at 5:30 am and said twice, “I cannot get up.” My mother tried to help him but he slid right down the side of the bed. Paramedics took him to a local stroke center.
In the emergency room, we were frustrated by the delay in administering aspirin that was ordered after his electrocardiogram. The decision was made to transfer my dad to another hospital in the network.
My father was taken by ambulance to and admitted into the other hospital’s intensive care unit. My father was in the ICU for about 3 1/2 weeks. The ICU was an open one, without visiting hours. Family was able to come and go freely. Shortly after admission, the ICU staff became familiar with our family. They were helpful and friendly. When we met the attending intensivist, unfortunately, he was cold and aloof with my father, my mother, and our family. We felt he was not very forthcoming with information and that we were bothering him when we asked questions. By later in the week, his attitude changed and we felt more comfortable with him in charge of our father’s care. His attitude seemed to change as my father’s condition grew worse. From a former patient perspective, it was unfortunate that my father was unable to view this physician as a kind man, generously offering information with a more gentle attitude.
The nursing care was excellent. The nurses were kind and attentive, answered questions, and tried to make us as comfortable as possible. Nurses always introduced themselves to my father and to family. They answered questions, answered the call button quickly, and reacted to any situation appropriately. There was also a continuity of nursing care, as often my father had the same nurses on different days and most nurses worked 12 h shifts, long enough for us to get to know them and for them to get to know us. From a family perspective, the nurses seemed to have a vested interest in the care, comfort, and survival of my father.
They knew he had pneumonia but the antibiotics and steroids were not working. He had to have a procedure done involving his lungs and his heart. The day before the procedure, two of the doctors sat in a private room with my mother and now, as my sister had flown in from Arizona, all four of my father’s children, and they thoroughly explained the two-part procedure to us. They answered all of our questions and took as much time as we needed to repeat explanations. Although we were very worried, we felt comfortable with the surgeon and intensivist from the floor, who would also be present at surgery as they removed some of the uncertainty family feels when a loved one is going into surgery. The next day, after seeing my father off to surgery, our family waited in the surgical waiting area. Because his surgery took
longer than anticipated, we asked that his status be checked, which was done without complaint. A diagnosis of cryptogenic organizing pneumonia was made.
My father’s condition seemed to be getting worse. His voice was raspy and he was desperate to leave the hospital. He kept saying, “They are trying to kill me, get me out of here!” When I told him that I could not take him out, he said with anger, “You’re a lousy daughter!” He told he to call my older brother for him, which I did. On the phone, he begged my older brother to come to the hospital and take him home, repeating to him that “they were trying to kill him!” My father also kept asking my mother and sister to get him out of the hospital. He never asked the nurses, but of course, in his state of delirium, he felt that they were in on the plan to kill him. The time when a patient is experiencing this sort of delirium is one of the most upsetting times for the family. It seems like there is nothing we are able to do to make anything better for my father. Because we could not give in to his demands, he reacted with anger and frustration. During this time, my father also had moments of pure sweetness, which happened when he told my sister, “Tell Mom when I get out of here, I am going to marry her!” But the other moments were so disturbing and felt so real. We could see his anxiety, his fear, and his frustration. If there were any suggestions of how we could help him through this time, we were not given this information. But we felt that doctors and nurses were doing everything that they could, adjusting medications and trying to make him more comfortable, to lessen the delirium. When my father was reintubated again, it felt like a relief. He was again deeply medicated and no longer able to talk. As a former patient, I recall vividly the time when I was suffering from delirium. I remember not only how I felt but also how upset my family was, fearing I had suffered from brain damage. I also knew that there were two family members who saw me during that time who could never come back to visit me in the hospital afterwards because of how terrible I looked. When my father was intubated again, I felt extremely guilty; admittedly I felt a strong sense of relief but at the same time, the feeling of guilt was overwhelming.
The following day, they extubated him again. All day though, my father was declining. Later that day, we were told that he was losing blood, and, at some point, a nurse told us to go to the waiting room. My brothers showed up and all five of us waited for hours without information. In a small, private room to talk, three doctors told us that my father had already gone through eleven units of blood and they felt that surgery was the only option. They also said they did not believe that he would survive surgery. We saw our father for a few seconds before he was taken to surgery. We waited in the ICU waiting room for 5–6 h. The surgeon who performed the original surgery spoke to us. He admitted that he must have done something during the original surgery to cause the bleeding. He was very honest and comforting to our family and we had no anger or animosity.
The days after that surgery were among the most difficult for us as a family. We all had to forgo sleep, meals, showers, our work responsibilities, and our own spouses and children for days. But from that day forward, we started to see an improvement in my father. He was started on large amounts of steroids. A few days later, when they were getting near the time to extubate him, they told us that he had
E. Rubin and S. Colianni
been receiving different medications and hopefully his delirium would be reduced, which it was. He spent another week in the ICU, a total of about 3 1/2 weeks, and was stabilized, extubated, and moved to a cardiac step-down unit. From there, he spent 2 more weeks in the hospital inpatient rehabilitation.
During the time in the ICU, my father’s survival was a constant concern for his family. We worried that he was uncomfortable. We also felt exhausted all the time. We could not sleep but we were never fully alert. My mother, when she ate, had every meal in the hospital, often in my father’s hospital room. Sometimes, she had a meal in the waiting room. Occasionally, she went down to the hospital cafeteria. The rest of us often missed meals or ate fast food and, likewise, had too many in the hospital. Prior to discharge, the staff at the hospital arranged for him to see a visiting nurse, a physical therapist, an occupational therapist, and a speech therapist at home, which was extremely helpful.
My mother stopped working while my father was sick. She had a part-time job as a travel agent. My sister, a public defender in Arizona, took off time from work and flew into town to stay while my father was ill. I was working part time as a criminal defense attorney and did not work during this time. My older brother, a busy real estate attorney, cut his hours drastically, coming to the hospital several times within a day. My younger brother, an executive at a real estate company and also an attorney, also cut his work hours drastically and was at the hospital several times each day as well. My father, who managed real estate properties, was unable to work and therefore, both my brothers needed to attend to his work during and after his hospitalization.
The expenses associated with a loved ones stay in ICU are beyond just the parking expenses. For our family, with four or five cars coming from different locations at different times each day, they began to add up. The ICU vouchers to reduce the parking rate helped a bit. Also, after discharge, my mother needed help to care for my father at home. This cost for a home health aide was $200 a day, for 9 days.
After discharge, my mom’s new role was as a constant caregiver. She was unable to go back to work because she needed to be home all the time. Since my father was older, his recovery was slow. Family members and friends would come over to visit and also give my mother a break, but the reality was that all of the responsibility of being a caregiver fell on her. She had to schedule and make sure that my father was ready for his therapy appointments. She had to keep track of all of the medication that he was taking, including what to take, the time, and amount of medication. She also was responsible for filling and refilling medication. It was her responsibility to schedule and get my father to doctor appointments after his hospitalization. In addition, she had to make sure that the house had the types of foods that my father could eat, since he was on a specific diet after his hospitalization. At night, she always worried if he needed to get up to use the bathroom. Would he be able to get up? Would he fall? She knew she would be unable to get him up if that happened.
After spending 7 weeks in the hospital, 3 1/2 of them in ICU while my father was ill, my family believes that ICU clinicians talking to the patient’s family should provide as much information as possible, along with full explanations of medical
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in the Duke's following shed its last vestige of restraint. Opinions were divided between those who cried 'Miracle!' with the impious yet credulous Squarcia, and those who cried 'Witchcraft!' with Messer Francesco Lonate, the gentleman of the falcon.
In the Duke's own mind some fear began to stir. Whether of God or devil, only supernatural intervention could explain this portent.
He spurred forward, his followers moving with him, and Bellarion, as he looked upon the awe-stricken countenances of that ducal company, was moved to laughter. Reaction from his palsy of terror had come in a mental exaltation, like the glow that follows upon immersion in cold water. He was contemptuous of these fellows, and particularly of Squarcia and his grooms who, whilst presumably learned in the ways of dogs, were yet incapable of any surmise by which this miracle might be naturally explained. Mockery crept into that laugh of his, a laugh that brought the scowl still lower upon the countenance of the Duke.
'What spells do you weave, rascal? By what artifice do you do this?'
'Spells?' Bellarion stood boldly before him. He chose to be mysterious, to feed their superstition. He answered with a proverb that made play upon the name he had assumed. 'Did I not tell you that I am Cane? Dog will not eat dog. That is all the magic you have here.'
'An evasion,' said Lonate, like one who thinks aloud.
The Duke flashed him a sidelong glance of irritation. 'Do I need to be told?' Then to Bellarion: 'This is a trick, rogue. God's Blood! I am not to be fooled. What have you done to my dogs?'
'Deserved their love,' said Bellarion, waving a hand to the great beasts that still gambolled about him.
'Aye, aye, but how?'
'How? Does any one know how love is deserved of man or beast? Loose the rest of your pack. There's not a dog in it will do more than
lick my hands. Dogs,' he added, again with a hint of mysteries, 'have perceptions oft denied to men.'
'Perceptions, eh? But what do they perceive?'
And Bellarion yielding to his singular exaltation laughed again as he answered: 'Ah! Who shall say?'
The Duke empurpled. 'Do you mock me, filth?'
Lonate, who was afraid of wizardry, laid a hand upon his arm. But the Duke shook off that admonitory grasp. 'You shall yield me your secret. You shall so, by the Host!' He turned to the gaping Squarcia. 'Call off the dogs, and make the knave fast. Fetch him along.'
On that the Duke rode off with his gentlemen, leaving the grooms to carry out his orders. They stood off reluctantly, despite Squarcia's commands, so that in the end for all his repugnance the kennelmaster was constrained, himself, to take the task in hand. He whistled the dogs to heel, and left one of his knaves to leash them again. Then he approached Bellarion almost timidly
'You heard the orders of his highness,' he said in the resigned voice of one who does a thing because he must.
Bellarion proffered his wrists in silence. The Duke and his following had almost reached the wood, and were out of earshot.
'It is the Duke who does this,' that black-browed scoundrel excused himself. 'I am but the instrument of the Duke.' And cringing a little he proceeded to do the pinioning, but lightly so that the thong should not hurt the prisoner, a tenderness exercised probably for the first time in his career as the villainous servant of a villainous master. His hands trembled at the task, which again was a thing that had never happened yet. The truth is that Squarcia was inspired by another fear as great as his dread of the supernatural. On both counts he desired to stand well with this young man.
He cast a glance over his shoulder to satisfy himself that the grooms were out of earshot.
'Be sure,' he muttered in his dense black beard, 'that his excellency the Count of Biandrate shall know of your presence within
an hour of our arrival in Milan.'
CHAPTER II
FACINO CANE
On the ground that they had far to travel, but in reality to spare this unwelcome prisoner, Bellarion was mounted on the crupper of Squarcia's great horse, his lightly pinioned wrists permitting him to hang on by the kennelmaster's belt.
Thus he made his first entrance into the fair city of Milan as dusk was descending. Some impression of the size and strength of it Bellarion gathered when, a couple of miles away, they made a momentary halt on a slight eminence in the plain. And though instruction had prepared him for an imposing spectacle, it had not prepared for what he actually beheld. He gazed in wonder on the great spread of those massive red walls reflected in a broad navigable moat, which was a continuation of the Ticinello, and, soaring above these, the spires of a half-dozen churches, among which he was able from what he had read to identify the slender belfry of Sant' Eustorgio and the octagonal brick and marble tower, surmounted by its headless gilded angel, belonging to the church of Saint Gotthard, built in honour of the sainted protector of the gouty by the gout-ridden Azzo Visconti a hundred years ago.
They entered the city by the Porta Nuova, a vast gateway, some of whose stonework went back to Roman times, having survived Barbarossa's vindictive demolition nearly three centuries ago. Over the drawbridge and through the great archway they came upon a guard-house that was in itself a fortress, before whose portals lounged a group of brawny-bearded mercenaries, who talked loudly amongst themselves in the guttural German of the Cantons. Then along Borgo Nuovo, a long street in which palace stood shoulder to
shoulder with hovel, and which, though really narrow by comparison with other streets of Milan, appeared generously broad to Bellarion. The people moving in this thoroughfare were as oddly assorted as the dwellings that flanked it. Sedately well-nourished, opulent men of the merchant class, glittering nobles attended by armed lackeys with blazons on their breasts, some mounted, but more on foot, were mingled here with aproned artisans and with gaunt, ragged wretches of both sexes whose aspect bespoke want and hunger. For there was little of the old prosperity left in Milan under the rule of Gian Maria.
Noble and simple alike stood still to bare and incline their heads as the Duke rode past. But Bellarion, who was sharply using his eyes, perceived few faces upon which he did not catch a reflection, however fleeting, of hatred or of dread.
From this long street they emerged at length upon a great open space that was fringed with elms, on the northern side of which Bellarion beheld, amid a titanic entanglement of poles and scaffolding, a white architectural mass that was vast as a city in itself. He knew it at a glance for the great cathedral that was to be the wonder of the world. It was built on the site of the old basilica of Saint Ambrose, dedicated to Mariæ Nascenti: a votive offering to the Virgin Mother for the removal of that curse upon the motherhood of Milan, as a result of which the women bore no male children, or, if they bore them, could not bring them forth alive. Gian Galeazzo had imagined his first wife, the sterile Isabella of Valois, to lie under the curse. Bellarion wondered what Gian Galeazzo thought of the answer to that vast prayer in marble when his second wife Caterina brought forth Gian Maria. There are, Bellarion reflected, worse afflictions than sterility.
Gian Galeazzo had perished before his stupendous conception could be brought to full fruition, and under his degenerate son the work was languishing, and stood almost suspended, a monument as much to the latter's misrule as to his father's colossal ambition and indomitable will.
They crossed the great square, which to Bellarion, learned in the history of the place, was holy ground. Here in the now vanished basilica the great Saint Augustine had been baptised. Here Saint Ambrose, that Roman prefect upon whom the episcopate had been almost forced, had entrenched himself in his great struggle with the Empress Justina, which marked the beginnings of that strife between Church and Empire, still kept alive by Guelph and Ghibelline after the lapse of a thousand years.
Flanking the rising cathedral stood the Old Broletto, half palace, half stronghold, which from the days of Matteo Visconti had been the residence of the Lords of Milan.
They rode under the portcullis into the great courtyard of the Arrengo, which derived a claustral aspect from its surrounding porticoes, and passed into the inner quadrangle known as the Court of Saint Gotthard. Here the company dismounted, and to Lonate, who held his stirrup for him, Gian Maria issued his orders concerning the prisoner before entering the palace.
This bewitcher of dogs, he announced, should make entertainment for him after supper.
Bellarion was conducted to a stone cell underground, which was supplied with air and as much light as would make a twilight of high noon by a grating set high in the massive door. It was very cold and pervaded by a moist, unpleasant, fungoid odour The darkness and chill of the place struck through him gradually to his soul. He was very hungry, too, which did not help his courage, for he had eaten nothing since midday, and not so much as a crust of bread did his gaolers have the charity to offer him.
At long length—at the end of two hours or more—the Duke's magnificence came to visit him in person. He was attended by Messer Lonate and four men in leather jerkins, one of whom was Squarcia. His highness sought to make up in gaudiness of raiment for what he lacked of natural endowments. He wore a trailing, highnecked velvet houppelande, one half of which was white, the other red, caught about his waist by a long-tongued belt of fine gold mail that was studded with great rubies. From waist to ground the long
gown fell open as he moved showing his legs which were cased, the one in white, the other in scarlet. They were the colours of his house, colours from which he rarely departed in his wear, following in this the example set him by his illustrious sire. On his head he wore a bulging scarlet cap tufted at the side into a jagged, upright mass like a cock's comb.
His goggling eyes measured the prisoner with a glance which almost sent a shudder through Bellarion.
'Well, rogue? Will you talk now? Will you confess what was the magic that you used?'
'Lord Duke, I used no magic.'
The Duke smiled. 'You need a lenten penance to bring you to a proper frame of mind. Have you never heard of the Lent of my invention? It lasts for forty days, and is a little more severe than mere fasting. But very salutary with obstinate or offending rogues, and it teaches them such a contempt of life that in the end they are usually glad to die. We'll make a beginning with you now. I dare make oath you'll be as sorry that you killed my dogs as that my dogs did not kill you.' He turned to Squarcia. 'Bring him along,' he commanded, and stalked stiffly out.
They dragged Bellarion into a larger stone chamber that was as anteroom to the cell. Here he now beheld a long wooden engine, standing high as a table, and composed of two oblong wooden frames, one enclosed within the other and connected by colossal wooden screws. Cords trailed from the inner frame.
The Duke growled an order.
'Lay the rogue stark.'
Without waiting to untruss his points, two of the grooms ripped away his tunic, so that in a moment he was naked to the waist. Squarcia stood aloof, seeking to dissemble his superstitious awe, and expecting calamity or intervention at any moment.
The intervention came. Not only was it of a natural order, but it was precisely the intervention Squarcia should have been expecting,
since it resulted from the message he had secretly carried.
The heavy studded door at the top of a flight of three stone steps swung slowly open behind the Duke, and a man of commanding aspect paused on the threshold. Although close upon fifty years of age, his moderately tall and vigorous, shapely frame, his tanned, shaven face, squarely cut with prominent bone structures, his lively, dark eyes, and his thick, fulvid hair, gave him the appearance of no more than forty. A gown of mulberry velvet edged with brown fur was loosely worn over a dress of great richness, a figured tunic of deep purple and gold with hose of the colour of wine.
A moment he stood at gaze, then spoke, in a pleasant, resonant voice, its tone faintly sardonic.
'Upon what beastliness is your highness now engaged?'
The Duke span round; the grooms stood arrested in their labours. The gentleman came sedately down the steps. 'Who bade you hither?' the Duke raged at him.
'The voice of duty. First there is my duty as your governor, to see that ...'
'My governor!' Sheer fury rang in the echoing words. 'My governor! You do not govern me, my lord, though you may govern Milan. And you govern that at my pleasure, you'll remember. I am the master here. It is I who am Duke. You'll be wise not to forget it.'
'Perhaps I am not wise. Who shall say what is wisdom?' The tone continued level, easy, faintly mocking. Here was a man very sure of himself. Too sure of himself to trouble to engage in argument. 'But there is another duty whose voice I have obeyed. Parental duty. For they tell me that this prisoner with whom you are proposing to be merry after your fashion claims to be my son.'
'They tell you? Who told you?' There was a threat to that unknown person in the inquiry.
'Can I remember? A court is a place of gossip. When men and women discover a piece of unusual knowledge they must be airing it. It doesn't matter. What matters to me is whether you, too, had heard
of this. Had you?' The pleasant voice was suddenly hard; it was the voice of the master, of the man who holds the whip. And it intimidated, for whilst the young Duke stormed and blustered and swore, yet he did so in a measure of defence.
'By the bones of Saint Ambrose! Did you not hear that he slew my dogs? Slew three of them, and bewitched the others.'
'He must have bewitched you, Lord Duke, at the same time, since, although you heard him claim to be my son, yet you venture to practise upon him without so much as sending me word.'
'Is it not my right? Am I not lord of life and death in my dominions?'
The dark eyes flashed in that square, shaven face. 'You are ...' He checked. He waved an imperious hand towards Squarcia Giramo. 'Go, you, and your curs with you.'
'They are here in attendance upon me,' the Duke reminded him.
'But they are required no longer.'
'God's Light! You grow daily more presumptuous, Facino.'
'If you will dismiss them, you may think differently.'
The Duke's prominent eyes engaged the other's stern glance, until, beaten by it, he swung sullenly to his knaves: 'Away with you! Leave us!' Thus he owned defeat.
Facino waited until the men had gone, then quietly admonished the Duke.
'You set too much store by your dogs. And the sport you make with them is as dangerous as it is bestial. I have warned your highness before. One of these fine days the dogs of Milan will turn upon you and tear out your throat.'
'The dogs of Milan? On me?' His highness almost choked.
'On you, who account yourself lord of life and death. To be Duke of Milan is not quite the same thing as to be God. You should
remember it.' Then he changed his tone. 'That man you were hunting to-day beyond Abbiate was Francesco da Pusterla, I am told.'
'And this rogue who calls himself your son attempted to rescue him, and slew three of my best dogs....'
'He was doing you good service, Lord Duke. It would have been better if Pusterla had escaped. As long as you hunt poor miscreants, guilty of theft or violence or of no worse crime than being needy and hungry, retribution may move slowly against you. But when you set your dogs upon the sons of a great house, you walk the edge of an abyss.'
'Do I so? Do I so? Well, well, my good Facino, as long as a Pusterla remains aboveground, so long shall my hounds be active. I don't forget that a Pusterla was castellan of Monza when my mother died there. And you, that hear so much gossip about the town and court, must have heard what is openly said: that the scoundrel poisoned her.'
Facino looked at him with such grim significance that the Duke's high colour faded under the glance. His face grew ashen. 'By the Bones of God!' he was beginning, when Facino interrupted.
'This young man here was not to know your motives. Indeed, he did not know you were the leader of that vile hunt. All that he saw was a fellow-creature inhumanly pursued by dogs. None would call me a gentle, humane man. But I give you my word, Lord Duke, that he did what in his place I hope I should have had the courage to do, myself. I honour him for it. Apart from that, he told you that his name was Cane. It is a name that deserves some respect in Milan, even from the Duke.' His voice grew cold and hard as steel. 'Hunt the Pusterla all you please, magnificent, and at your own peril. But do not hunt the Cane without first giving me warning of the intention.'
He paused. The Duke, slow-witted ever, stood between shame and rage before him, silent. Facino turned to Bellarion, his tone and manner expressing contempt of his ducal master. 'Come, boy. His highness gives you leave. Put on your tunic and come with me.'
Bellarion had waited in a fascinated amazement that held a deal of fear, based on the conviction that he escaped Scylla to be wrecked upon Charybdis. For a long moment he gazed now into that indolently good-humoured, faintly mocking countenance. Then, with mechanical obedience, he took up the garment, which had been reduced almost to rags, and followed the Count of Biandrate from that stone chamber.
Sedately Facino went up the narrow staircase with no word for the young man who followed in uneasy wonder and dread speculation of what was now to follow.
In a fine room that was hung with Flemish tapestries, and otherwise furnished with a richness such as Bellarion had never yet beheld, lighted by great candles in massive gilt candlesticks that stood upon the ground, the masterful Facino dismissed a couple of waiting lackeys, and turned at last to bestow a leisurely scrutiny upon his companion.
'So you have the impudence to call yourself my son,' he said, between question and assertion. 'It seems I have more family than I suspected. But I felicitate you on your choice of a father. It remains for you to tell me upon whom I conferred the honour of being your mother.'
He threw himself into a chair, leaving Bellarion standing before him, a sorry figure in his tattered red tunic pulled loosely about him, his flesh showing in the gaps.
'To be frank, my lord, in my anxiety to avoid a violent death I overstated our relationship.'
'You overstated it?' The heavy eyebrows were raised. The humour of the countenance became more pronouncedly sardonic. 'Let me judge the extent of this overstatement.'
'I am your son by adoption only.'
Down came the eyebrows in a frown, and all humour passed from the face.
'Nay, now! That I know for a lie. I might have got me a son without knowing it. That is always possible. I was young once, faith, and a little careless of my kisses. But I could scarcely have adopted another man's child without being aware of it.'
And now Bellarion, judging his man, staked all upon the indolent good-nature, the humorous outlook upon life which he thought to perceive in Facino's face and voice. He answered him with a studied excess of frankness.
'The adoption, my lord, was mine; not yours.' And then, to temper the impudence of that, he added: 'I adopted you, my lord, in my hour of peril and of need, as we adopt a patron saint. My wits were at the end of their resources. I knew not how else to avert the torture and death to which wanton brutality exposed me, save by invoking a name in itself sufficiently powerful to protect me.'
There was a pause in which Facino considered him, half angrily, so that Bellarion's heart sank and he came to fear that in his bold throw with Fortune he had been defeated. Then Facino laughed outright, yet there was an edge to his laugh that was not quite friendly. 'And so you adopted me for your father. Why, sir, if every man could choose his parents ...' He broke off. 'Who are you, rogue? What is your name?'
'I am called Bellarion, my lord.'
'Bellarion? A queer name that. And what's your story? Continue to be frank with me, unless you would have me toss you back to the Duke for an impostor.'
At that Bellarion took heart, for the phrase implied that if he were frank this great soldier would befriend him at least to the extent of furthering his escape. And so Bellarion used an utter frankness. He told his tale, which was in all respects the true tale which he had told Lorenzaccio da Trino.
It was, when all is said, an engaging story, and it caught the fancy of the Lord Facino Cane, as Bellarion, closely watching him, perceived.
'And in your need you chose to think that this rider who befriended you was called Facino!' The condottiero smiled now, a little sardonically. 'It was certainly resourceful. But this business of the Duke's dogs? Tell me what happened there.'
Bellarion's tale had gone no farther than the point at which he had set out from Cigliano on his journey to Pavia. Nor now, in answer to this question, did he mention his adventure in Montferrat and the use he had made there already of Facino's name, but came straight to the events of that day in the meadows by Abbiategrasso. To this part of his narrative, and particularly to that of Bellarion's immunity from the fierce dogs, Facino listened in incredulity, although it agreed with the tale he had already heard.
'What patron did you adopt to protect you there?' he asked, between seriousness and derision. 'Or did you use magic, as they say.'
'I answered the Duke on that score with more literal truth than he suspected when I told him that dog does not eat dog.'
'How? You pretend that the mere name of Cane ...?'
'Oh, no. I reeked, I stank of dog. The great hound I had ripped up when it was upon me had left me in that condition, and the other hounds scented nothing but dog in me. The explanation, my lord, lies between that and miracle.'
Facino slowly nodded. 'And you do not believe in miracles?' he asked.
'Your lordship's patience with me is the first miracle I have witnessed.'
'It is the miracle you hoped for when you adopted me for your father?'
'Nay, my lord. My hope was that you would never hear of the adoption.'
Facino laughed outright. 'You're a frank rogue,' said he, and heaved himself up. 'Yet it would have gone ill with you if I had not heard that a son had suddenly been given to me.' To Bellarion's
amazement the great soldier came to set a hand upon his shoulder, the dark eyes, whose expression could change so swiftly from humour to melancholy, looked deeply into his own. 'Your attempt to save Pusterla's life without counting the risk to yourself was a gallant thing, for which I honour you, and for which you deserve well of me. And they are to make a monk of you, you say?'
'That is the Abbot's hope.' Bellarion had flushed a little under the sudden, unexpected praise and the softening of the voice that bestowed it. 'And it may follow,' he added, 'when I return from Pavia.'
'The Abbot's hope? But is it your own?'
'I begin to fear that it is not.'
'By Saint Gotthard, you do not look a likely priest. But that is your own affair.' The hand fell from his shoulder, Facino turned, and sauntered away in the direction of the loggia, beyond which the night glowed luminously blue as a sapphire. 'From me you shall have the protection you invoked when you adopted me, and to-morrow, wellaccredited and equipped, you shall resume the road to Pavia and your studies.'
'You establish, my lord, my faith in miracles,' said Bellarion.
Facino smiled as he beat his hands together. Lackeys in his blueand-white liveries appeared at once in answer to that summons. His orders were that Bellarion should be washed and fed, whereafter they would talk again.
CHAPTER III
THE COUNTESS OF BIANDRATE
Facino Cane and Bellarion talked long together on the night of their first meeting, and as a result the road to Pavia was not resumed upon the morrow, nor yet upon the morrow's morrow. It was written
that some years were yet to pass before Bellarion should see Pavia, and then not at all with the eyes of the student seeking a seat of learning.
Facino believed that he discovered in the lad certain likenesses to himself: a rather whimsical, philosophical outlook, a readiness of wit, and an admirable command of his person such as was unusual amongst even the most cultured quattrocentists. He discovered in him, too, a depth and diversity of learning, which inspired respect in one whose own education went little beyond the arts of reading and writing, but who was of an intelligence to perceive the great realms that lie open to conquest by the mind. He admired also the lad's long, clean-limbed grace and his boldly handsome, vivid countenance. Had God given him a son, he could not have desired him other than he found Bellarion. From such a thought in this childless man—thrust upon him, perhaps, by the very manner of Bellarion's advent—it was but a step to the desire to bind the boy to himself by those ties of adoption which Bellarion had so impudently claimed. That step Facino took with the impulsiveness and assurance that were his chief characteristics. He took it on the third day of Bellarion's coming, at the end of a frank and detailed narrative by Bellarion of the events in Montferrat. He had for audience on that occasion not only Facino, but Facino's young and languidly beautiful countess. His tale moved them sometimes to laughter, sometimes to awe, but always to admiration of Bellarion's shrewdness, resource, and address.
'A sly fox the Marquis Theodore,' Facino had commented. 'Subtlety curbs ambition in him. Yet his ambition is such that one of these days it will curb his subtlety, and then Messer Theodore may reap his deserts. I know him well. Indeed, it was in his father's service that I learnt the trade of arms. And that's a better trade for a man than priesthood.'
Thus from the subject of Theodore he leapt abruptly to the subject of Bellarion, and became direct at once. 'With those limbs and those wits of yours, you should agree with that. Will you let them run to waste in cloisters?'
Bellarion sighed thoughtfully He scented the inspiration of that question, which fell so naturally into place in this dream in which for three days he had been living. It was all so different, so contrary to anything that he could have imagined at the hands of this man with whose name he had made free, this man who daily bade him postpone the resumption of his journey until the morrow.
Softly now, in answer to that question, he quoted the abbot: '"Pax multa in cella, foris autem plurima bella." And yet ... And yet is the peace of the cloisters really better than the strife of the world? Is there not as much service to be done in righting wrongs? Is not peace stagnation? Are not activity and strife the means by which a man may make his soul?' He sighed again. His mention of righting wrongs was no vague expression, as it seemed, of an ideal. He had a particular wrong very vividly in mind.
Facino, watching him almost hungrily, was swift to argue.
'Is not he who immures himself to save his soul akin to the steward who buried his talents?'
He developed the argument, and passed from it to talk of feats of arms, of great causes rescued, of nations liberated, of fainting right upheld and made triumphant.
From broad principles his talk turned, as talk will, to details. He described encounters and actions, broad tactical movements and shrewd stratagems. And then to his amazement the subject was caught up, like a ball that is tossed, by Bellarion; and Bellarion the student was discoursing to him, the veteran of a score of campaigns and a hundred battles, upon the great art of war. He was detailing, from Thucydides, the action of the Thebans against Platæa, and condemning the foolish risk taken by Eurymachus, showing how the disastrous result of that operation should have been foreseen by a commander of any real military sense. Next he was pointing the moral to be drawn from the Spartan invasion of Attica which left the Peloponnesus uncovered to the attack of the Athenians. From that instance of disastrous impetuosity he passed to another of a different kind and of recent date in the battle of Tagliacozzo, and, revealing a close acquaintance with Primatus and Bouquet, he showed how a
great army when it thrust too deeply into hostile territory must do so always at the risk of being unable to extricate itself in safety. Then from the broad field of strategy, he ran on, aglow now with a subject of his predilection, to discourse upon tactics, and chiefly to advocate and defend the more general use of infantry, to enlarge upon the value of the hedgehog for defensive purposes against cavalry, supporting his assertions by instancing the battle of Sempach and other recent actions of the Swiss.
It could not be expected that a great leader like Facino, who had depended all his life upon the use of cavalry, should agree with such views as these. But the knowledge displayed by this convent-reared youngster, and the shrewd force and lucidity with which Bellarion, who had never seen a pitched battle, argued upon matters that were regarded as mysteries hidden from all but the initiates in the difficult science of arms, amazed him so profoundly that he forgot to argue at all.
Facino had learnt the trade of war by actual practice in a long and hard apprenticeship. It had never even occurred to him that there was a theory to be learnt in the quiet of the study, to be culled from the records of past failure and achievement in the field. Nor now that this was revealed to him was he disposed to attach to it any considerable importance. He regarded the young man's disquisitions merely in the light of interesting mental exercises. But at the same time he concluded that one who showed such understanding and critical appreciation of strategy and tactics should, given the other qualities by Facino considered necessary, be quick to gather experience and learn the complex military art. Now every man who truly loves the trade by which he lives is eager to welcome a neophyte of real aptitude. And thus between Facino and Bellarion another link was forged.
Deep down in Bellarion's soul there was that vague desire, amounting as yet to little more than a fantastic hope, to consummate his service to that brave Princess of Montferrat. It was a dream, shadowy, indefinite, almost elusive to his own consciousness. But the door Facino now held so invitingly open might certainly lead to its ultimately becoming a reality.
They were occupying at the time the loggia of Facino's apartments above the court of Saint Gotthard. Facino and his lady were seated, one at each end of that open space. Bellarion stood equidistant from either, leaning against one of the loggia's slender pillars that were painted red and white, his back to the courtyard, which lay peaceful now in the bright sunlight and almost forsaken, for it was the rest hour of early afternoon. He was dressed in very courtly fashion in a suit of purple which Facino's wardrobe had supplied. The kilted tunic was caught about his waist by a belt of violet leather with gold trimmings, and his long black hair had been carefully combed and perfumed by one of Facino's servants. He made a brave figure, and the languid sapphire eyes of the Countess as they surveyed him confirmed for her the conviction already gathered from his frank and smoothly told tale that between himself and her husband there existed no relationship such as she had at first suspected, and such as the world in general would presently presume.
'My Lord Count advises you shrewdly, Ser Bellarion,' she ventured, seeing him thoughtful and wavering. 'You make it very plain that you are not meant for cloisters.'
She was a handsome woman of not more than thirty, of middle height with something feline in her beautifully proportioned litheness, and something feline too in the blue-green eyes that looked with sleepy arrogance from out of her smoothly pallid face set within a straight frame of ebony black hair.
Bellarion considered her, and the bold, direct, appraising glance of his hazel eyes, which seemed oddly golden in that light, stirred an unaccountable uneasiness in this proud daughter of the Count of Tenda who had married out of ambition a man so much older than herself. Languidly she moved her fan of peacock feathers, languidly surveyed herself in the mirror set in the heart of it.
'If I were to await further persuasions I must become ridiculous,' said Bellarion.
'A courtly speech, sir,' she replied with her slow smile. Slowly she rose. 'You should make something of him, Facino.'
Facino set about it without delay He was never dilatory when once he had taken a resolve. They removed themselves next day— Facino, his lady, his household, and Bellarion—to the ducal huntingpalace at Abbiategrasso, and there the secular education of Bellarion was at once begun, and continued until close upon Christmastide, by when some of the sense of unreality, of dream experiences, began at last to fade from Bellarion's mind.
He was taught horsemanship, and all that concerns the management of horses. Followed a training in the use of arms, arduous daily exercises in the tilt-yard supervised by Facino himself, superficially boisterous, impatient, at times even irascible in his zeal, but fundamentally of an infinite patience. He was taught such crude swordsmanship as then obtained, an art which was three parts brute force and one part trickery; he was instructed in ballistics, trained in marksmanship with the crossbow, informed in the technicalities of the mangonel, and even initiated into the mysteries of that still novel weapon the cannon, an instrument whose effects were moral rather than physical, serving to terrify by its noise and stench rather than actually to maim. A Swiss captain in Facino's service named Stoffel taught him the uses of the short but formidable Swiss halbert, and from a Spaniard named de Soto he learnt some tricks with a dagger.
At the same time he was taken in hand by the Countess for instruction in more peaceful arts. An hour each evening was devoted to the dance, and there were days when she would ride forth with him in the open meadows about the Ticino to give him lessons in falconry, a pursuit in which she was greatly skilled; too skilled and too cruelly eager, he thought, for womanhood, which should be compassionate.
One autumn day when a northerly wind from the distant snows brought a sting which the bright sunshine scarcely sufficed to temper, Bellarion and the Countess Beatrice, following the flight of a falcon that had been sent soaring to bring down a strong-winged heron, came to the edge of an affluent of the Ticino, now brown and swollen from recent rains, on the very spot where Duke Gian Maria had loosed his hounds upon Bellarion.
They brought up there perforce just as overhead the hawk stooped for the third time. Twice before it had raked wide, but now a hoarse cry from the heron announced the strike almost before it could be seen, then both birds plumbed down to earth, the spread of the falcon's great wings, steadying the fall.
One of the four grooms that followed sprang down, lure in hand, to recapture the hawk and retrieve the game.
Bellarion looked on in silence with brooding eyes, heedless of the satisfaction the Countess was expressing with almost childish delight.
'A brave kill! A brave kill!' she reiterated, and looked to him in vain for agreement. A frown descended upon the white brow of that petulant beauty, rendered by vanity too easily sensitive to disapproval and too readily resentful. Directly she challenged him. 'Was it not a brave kill, Bellarion?'
He roused himself from his abstraction, and smiled a little. He found her petulance amusing ever, and commonly provoked her by the display of that amusement.
'I was thinking of another heron that almost fell a victim here.' And he told her that this was the spot on which he had met the dogs.
'So that we're on holy ground,' said she, enough resentment abiding to provoke the sneer.
But it went unheeded. 'And from that my thoughts ran on to other things.' He pointed across the river. 'That way I came from Montferrat.'
'And why so gloomy about that? You've surely no cause to regret your coming?'
'All cause, indeed, for thankfulness. But one day I shall hope to return, and in strength enough to hood a hawk that's stooping there.'
'That day is not yet. Besides, the sun is sinking, and we're far from home. So if you're at the end of your dreams we had best be moving.'
There was a tartness in her tone that did not escape him. It had been present lately whenever Montferrat was mentioned. It arose, he conceived, from some misunderstanding which he could not fathom. Either to fathom or to dispel it, he talked now as they rode, unfolding all that was in his mind, more than he knew was in his mind, until actual utterance discovered it for him.
'Are you telling me that you have left your heart in Montferrat?' she asked him.
'My heart?' He looked at her and laughed. 'In a sense you may say that. I have left a tangle which I desire one day to unravel. If that is to have left my heart there ...' He paused.
'A Perseus to deliver Andromeda from the dragon! A complete knight-errant aflame to ride in the service of beauty in duress! Oh, you shall yet live in an epic.'
'But why so bitter, lady?' wondered Bellarion.
'Bitter? I? I laugh, sir, that is all.'
'You laugh. And the matter is one for tears, I think.'
'The matter of your love-sickness for Valeria of Montferrat?'
'My ...' He gasped and checked, and then he, who a moment ago had gently chided her for laughing, himself laughed freely.
'You are merry on a sudden, sir!'
'You paint a comic picture, dear madonna, and I must laugh. Bellarion the nameless in love with a princess! Have you discovered any other signs of madness in me?'
He was too genuinely merry for deceit, she thought, and looked at him sideways under her long lashes.
'If it is not love that moves you to these dreams, what then?'
His answer came very soberly, austerely, 'Whatever it may be, love it certainly is not, unless it be love of my own self. What should I know of love? What have I to do with love?'
