Saturday I accept a patient from the ER; stage 4 breast cancer with mets to bone and lymph, needs an emergent pericardial window, but her platelets are too low for surgery. Somewhat confused, anxious, in enormous amounts of pain and on a moderate amount of O2. We talk about options. She doesn’t want to think about end of life, doesn’t want to talk about it. Doesn’t want a procedure done today, wants to wait until the morning. CT surgery says now or never. We need to intubate her and bring her to the OR or she will die within the next few days. He husband wants to know, if we put her on the vent, what are the odds of her coming off? Not good, we tell him. On the other hand, should they choose to forgo the procedure, she’s gonna die.
I spend a while with both of them. The odds of coming off the vent aren’t good, I tell them. But if the procedure isn’t done, at some point her heart will stop and we will have to do CPR and it isn’t going to bring her back. So you should choose either to withdraw and stop or to go all out. Don’t leave us hanging, forced to break her ribs for nothing. She is pretty lucid while we talked about this, and the husband started bawling and asking her if she wanted to just go home. Should I just bring you home, he keeps asking her. Michelle, should I just bring you home?
I give them some time, and meanwhile wait to correct the platelets and all the other urgent things that need to be done. These things take time. The poor woman is up the wall anxious, and I finally have to take her catheter out because she keeps trying to climb out of bed to go to the bathroom. I’m pretty sure we are going with comfort care at that point, so I take the initiative and oops, it comes out.
One way or another, I tell them, we are looking at the end. It isn’t easy for me to talk about this stuff and I’m always worried that I’m going beyond my scope of practice and that a doctor’s going to contradict me, but I tell them anyway. Whether we stop care, I say, continue without the procedure or do the procedure, it is probably going to end. Many people don’t get a chance to decide how they want their last days to go, but you do. It is in your hands now.
We’ve never talked about this before, the husband tells me, because we didn’t want to admit that the end could come. I just thought we’d have more time. I didn’t expect it to happen so soon.
There is a lot of discussion, time passes, and finally they choose to stop. I witness the DNR, put up a pain drip (continuous of 10, morphine!), dope her up with ativan and leave her alone. She sleeps, at last, and her husband is so thankful. I could have reversed her clotting time, replaced her iv’s, done a hundred heoric nursing things and he would not have been half so impressed as he was that I was able to make her sleep. It’s the little things.
I leave that evening and feel as though I’ve done something worthwhile. I listened. I got two people to talk about things they never would have. I helped a woman sleep.
When I come back on Monday, the patient has come back to MICU from the floor. The oncologist convinced them to pursue full care. He’s told them that it isn’t the cancer that is killing her right now, it is her heart and she needs the procedure.
I’d like to strangle the oncologist, but that is outside my scope of practice.
I think the family may be a little perturbed to see me, who had so advocated for comfort care, at the bedside, but if a family has made a decision, I try to support them with all I have. I know that some decisions are agonizing, and families have enough trouble convincing themselves they’ve made the right choice, let alone standing up to a nurse who doesn’t agree with them.
She is again anxious and in pain and confused. She goes to the OR, has the drain placed without complication, and then begins to decompensate when she’s back with me. I up her oxygen and it helps a little. An hour later she is moaning and anxious again, oxygen levels dropping. We give her as much oxygen as we can and I send a blood gas. It isn’t good. I bring it to the doctors. I’ve done my bit, and now they need to decide what to do. The problem isn’t that we can’t do more; we can, it just that she’s going to die no matter what.
At 1800, with the patient getting worse, I demand an answer of Wasim. What are we going to do, stop care or intubate her? If we wait any longer, I’m going to break her ribs with chest compressions. Family doesn’t know which way is up, they keep trying to understand what she was saying even though it doesn’t make sense. (At this point, I start to feel like I’m the only one who actually understands what’s going on; the family thinks she’s lucid, the surgeons are asking questions and not waiting for answers, my doctors are trying to look the other way and pretend the patient doesn’t exist.) So Wasim talks to the husband, gets an answer and we do what we do best. Intervention. A tube is placed and she is on the ventilator, easy breezy beautiful. And then it all goes to hell.
I could relate in technical terms what happens after that, but it doesn’t matter. What matters is that she slides very quickly towards death and despite our best efforts, we cannot stabilize her once she begins her quick decline. We’ve got three doctors and five nurses in the room. The monitor won’t shut up. Meds are everywhere, xray is at the bedside, we’ve got a code cart out. And the husband pushes his way in and says stop. Just stop.
I wish I would have hugged him.
So what I told him the beginning comes true. She does go on the vent, and she can’t come off. And this is how he has to remember her last day; tumultuous and awful. Full of clinging to hope and finding only despair. The resident keeps running through possible diagnosis; he is torn up that we couldn’t figure it out. I am torn up that we had a bad death. We told them in the beginning (well, I did) she is going to die no matter what we do. And she does die. And it is a bad death and no one is happy.