Don't Let Her Die!

I found a blog written by an EMT. His most recent posting told the story of answering a 911 call and finding the patient already dead. His question was - do you feign trying to resuscitate the patient to make the family feel that everything possible was done for their loved one?

The scenario that this EMT described reminded me of a similar story - the in-patient equivalent. I had a patient who was dying of advanced metastic cancer. At start of shift, I checked in on her and her family. The patient wasn't having pain and was lying in bed comfortably. She had on an oxygen mask, as her cancer had metastasized to her lungs, making it difficult for her to breath and difficult for her to get enough oxygen. But she was still able to talk quietly and occasionally to her husband and two daughters who were at the bedside.

About a half-hour after I left her room, the husband ran out into the hallway and grabbed me.

"Help! She stopped breathing." He was clearly in a state of panic.

When I arrived in her room, one daughter was sitting at the foot of the bed, tapping firmly on their mother's feet. The other daughter was at her head rubbing her chest. Both were calling out, "Breathe, Mom! Breathe!"

She started to breathe about four resperations per minute on her own. And continued this so long as her daughters continued their cheering. Human willpower is amazing. This woman was clearly struggling. We cannot know what the patient was thinking, but we can take a few guesses. I'm certain this woman was very sad to leave her daughters. How could she not be? She'd been sick for a couple of months, however, and had probably accepted that she was dying. It must have been so painful to see her daughter's panic in her last moments. She certainly wouldn't want to leave them when it was so clear that they needed her. She tried so hard to hang on for their benefit.

The patient had signed DNR/DNI orders (do not resuscitate / do not intubate); however, the husband had durable power of attorney rights and could change the orders now that his wife was in a position where she could not speak for herself. (See my August 24th posting on physician-assisted suicide for a similar story of spouses changing code statuses as in the case of my Aunt Abby).

If you read that story, you'll realize this scenario was a bit of a hot topic for me on a personal level. Of course, as a nurse, I knew not to involve my personal history in my decision making. So, what could I do? I called the code. That was the husband's right whether or not I thought it was a good choice. Since several nurses were already in the room with me, fortunately, I at least didn't have to hit the alarm button at the bedside, which would have created a lot of drama with the sound of the alarm going off. Instead the charge nurse went and paged the doctor and called the code over the phone (which is the normal process after the code button has been pressed). Ironically, in the palliative care setting, the goal is somewhat of the opposite as it might be in a 911 call. Instead of doing EVERYTHING so that the family will feel like you've tried it all, we want to minimize invasiveness, so as to allow the death to be as peaceful as possible.

When the doctor and the code team arrived to the floor. The poor prognosis of the patient (she would die within a few days whether or not we resuscitated her that evening) and the change in code status were explained.

Fortunately, she still had a pulse. Her blood pressure was very low, however. And he oxygen level was in the 40's. An ambu-bag (manual device to inflate a person's lungs) was used to increase her respirations while the doctor pulled the husband out into the hallway to discuss what was happening.

The doctor explained to the husband that his wife was not getting enough oxygen and that she had probably already sustained quite a bit of brain damage as a result. The doctor reminded the husband of her poor prognosis. She suggested that we discontinue the code and allow his wife peaceful time alone with her family to say her goodbyes. The husband agreed.

The daughters didn't handle their father's decision perfectly well, but within a few minutes, they adjusted their own agendas and began telling their mother how nice it would be for her to see their other relatives who'd died before her. Her husband asked me to stay at the bedside with some morphine in hand just in case she appeared uncomfortable at any point. I did as he requested. He told his wife, "Remember how we said it would be? You will be so much more comfortable and at peace. It will be okay." His calm reassurances and the love and warmth he expressed were incredibly touching.

The family said their goodbyes as she took her final breath. The sight of this woman dying, surrounded by her loving daughters and husband as they spoke so many loving words to her was infinitely more powerful than any defibrillator or vasopressor could be for this family in that moment.