Wednesday, December 16, 2009

Please Make Her Comfortable

During a recent shift, I was witness to a family's struggle and courage in facing their mother's illness.

Their mother, age 96, had broken her hip a week prior. Because of significant health and social issues, the family and patient concurred with the orthopedic team that it wouldn't be wise to operate.

The patient was sent to a local rehabilitation facility. Prior to the transfer, the patient and her family had discussed at length a living will and to what degree heroics were to be performed in the event of a medical emergency. They opted for no intervention whatsoever--no CPR, no medical testing, no antibiotics, no intubation, no resuscitation efforts. Basically, they wanted only comfort measures for pain and anxiety relief.

A very difficult decision, of course.

Within a week of being transferred to the rehabilitation facility, unfortunately, the patient started to have a cough. Soon after, she began to have a harder time breathing.

The facility, despite their best efforts, eventually sent the patient to our ER when it was discovered that she had very low oxygenation levels. They were not equipped for this.

I walked into this patient's room and after introducing myself to her and meeting her family, consisting of two sons, a daughter, and a daughter-in-law, I began to sort out what I could do to help this patient and her family.

On exam, this patient was obviously struggling and appeared to have pneumonia. She had a fever and very low oxygen levels. When I listened to her lungs with my stethoscope, she had classic findings for infection. She was starting to get very fatigued and was not as mentally alert as her family knew her to be.

Normally, with a patient in this situation, we are very aggressive. She would have been intubated and received three, sometimes four, antibiotics intravenously. She would have gotten a very thorough workup that would have included x-rays, blood work, and possibly a CT scan of her chest to make sure she didn't have a blood clot in her lungs, a possible consequence of her hip fracture.

However, upon review of the patient's paperwork sent from the rehab facility and the family's personal request at her bedside, we did none of this. We respected their wishes and this patient's living will.

I did order this patient some low doses of morphine and valium which made her more comfortable. The family was quite appreciative. Although the patient was critically ill, she was not yet near her end. After another discussion with the family, we came to a mutual decision to admit their mother to the hospital and continue her comfort care. The family was uncomfortable taking the patient home with her hip fracture. I called their family doctor and he graciously came in and handled the admission.

During the admission, I was stopped by the daughter in the hallway. She was very tearful, as any of us would be, and second-guessing their family decision of no heroics.

"Mom lead an amazing life. I know it's time...but this is so hard to watch. I feel like we should be doing something more."

I put my arm around her. "God Bless your family," I said.

"Well," she sighed, "this is how Mom wanted it, so I guess we have to respect her decision."

I nodded at her words. I have several times witnessed these decisions reversed, but it seemed that this family was not going to follow that route.

The daughter, though, still needed to reconcile the decision with her anguish.

"What would you do?" she asked me suddenly.

Her question caught me off-guard. It was a question that I couldn't possibly answer for her. Her family's decision was made after weighing many specific circumstances, circumstances that I knew nothing about. So no, I couldn't give her a direct answer.

I explained this to her. "But," I continued, "does the rest of your family still support this decision?"

"Yes," she said, "and I think I do, too."

I decided to open up to her. I shared with her how several years ago, my beautiful mother, after courageously fighting and beating back leukemia for several years, decided that it was time to stop. It had been an extremely difficult decision, fully supported by my father, my six siblings, and myself. Because Mom knew. And despite all the setbacks, her faith had never wavered and her spirit had remained unconquerable. She had fought the fight and had benefited from that fight. But, unfortunately, her disease had come back with a vengeance. After several failed attempts to reenter remission, she chose to stop all further treatments and go home to spend her remaining days enveloped in our love.

"So, yes," I said, "it was very hard to watch. But it was the right thing for Mom and our family."

Now, the daughter nodded at my words. After a moment or two, she spoke. "Mom did have an amazing life, but yes, it is time."

I squeezed her hand in support and she leaned in and gave me a hug.

"Thank you," she said as we parted.

No, I thought to myself as I walked away remembering my mother's beautiful spirit, thank you.


jimbo26 said...

Thank you .Jim ( UK )

Rositta said...

Reading this made me cry this morning. I went through the same decision with my mom just over two years ago and being an only child it rested just with me. I'm still second guessing myself to this day. I respected her wishes but I know that it didn't have to happen. The hospital made too many mistakes from the get go and she became irreversibly ill. Here elderly are not respected in hospital, they are treated as a burden to our already stressed "free" medical system. I too asked the doctor the question "if it were your mother" and he told he he'd let her go. I did...ciao

rlbates said...

Beautifully written.

Bianca Castafiore? said...

I don't want you to be overcome by too much praise... but do feel free to clone yourself!

It's the willingness to be ordinary in an extraordinary situation that makes the difference.

Thanks so much.

Leslie said...

Beautiful story! Your blog title was chosen well, you are a great story teller.

Like Bianca, I love the fact that you were "real" and honest with your patients daughter.

DrJohnM said...

Very nice.

Us docs have personal lives too, and often, sharing our vignettes with patients helps, I think.

These sorts of uplifting interactions make me glad I checked the "MD" box on career day.


terri c said...

Beautifully done. I am a hospice chaplain; Sunday a home hospice patient was transferred to inpatient for a broken hip on top of his several other bad things including two kinds of cancer. A delightful gentleman, he looked forward to meeting all the staff--who were looking forward to him as well. He wasn't going to be able to go home again if he got better, because it just wasn't safe. The attending couldn't bear to tell him a nursing home was in his future. He knew anyway. He died this evening, having declined suddenly and very rapidly. I'm glad I got to meet him Sunday and spend time with him. I loved him.

J-Quell'n said...

My uncle developed blood clots in his lungs following surgery for colon cancer. He was rushed to the ER and all efforts were made to save him (intubation, medications, etc.), but in the end, his blood pressure never recovered. We had to make the decision to withdraw life support and let him go then or to wait it out for a few days, weeks until he ultimately passed while on life support. We decided to withdraw life support. All the time, I struggle with this decision. I know it was right, but it feels like we gave up on him or something.

Thank-you. Your story makes me understand better.

Smalltown RN said...

One of your readers wrote "Us doc's have personal lives too" How true is that. All healthcare professionals have personal lives.

Your story reminds me of many situations I experienced as a Palliative care nurse...but it brought back many memories of the loss of my mom, dad, and sister. All of them opted for no heroics.

It was my sister at the age of 49 that I found the most distressing. Being the nurse in the family a lot of responsibility landed on my shoulders. My sister wanted to die at which she did...but it took a lot of work to make that happen for was only myself and her in her room when she took her last breaths...I recognized the signs....I knew what to siblings and her husband had little understanding of the process of dying. They were couragious and even though they didn't understand it all they knew that was her wishes.

My GP who treats a large population of seniors has a wonderful book and stuffed inside it is a DNR....he talks to all his patients about's better to make you wishes known up front than to wait for a time when the loved one is doing poorly.

In the not to distant past before antibiotics they use to say pneumonia was an old persons friends....I don't know if I would call it a friend...but rather nature taking it's course...

Thanks for a great post...

Anonymous said...

I'm not sure I grok the "no antibiotics" thing just because the inevitable infection sounded like it would surely be miserable. But I guess side effects from them are also terrible.

But, yeah, if someone says no drastic measures, that's what they should get. As an only child, I hope I have the balls to agree to that.

Cal said...

It was brave of you to share not only at that moment, but to recount your experience here, tapping into your personal history. I am amazed at how people like you are able to go through this emotionally-challenging work, it cannot be easy.
On another note, I think you are gifted in the way you are able to narrate both lighthearted funny stories, and then, at the next post, convey such delicate feelings, pulling at our heartstrings and making us cry.

Christian Sinclair said...

Thanks for sharing this story. ER docs have the opportunity to do a lot of palliative care work. I am a doctor at a hospice inpatient facility and occasionally we have accepted transfers directly from the ER (instead of being admitted to the hospital). If this is available in your community I would encourage you to look into it as it gives you another disposition option that may provide better whole person/family care then you may get at home, nursing home or in a hospital for this special time of life.

green ink said...

Beautiful. A very brave story, both yours and your patient's.

Palliative Care Nurse said...

Great post! What I find concerning is that she was transferred originally to a rehab facility and not as well referred to Hospice or Palliative care if available. This family/patient would have been more prepared for the potential complications we all know come after a fall in an advanced age person.
One other thing is when you felt a sting when the daughter asked you what you would do?...I am a Palliative care nurse in a community hospital, and often encourage my families to ask this question of the MD's. It seems that our medical staff speak of what "we need, or what we will" do next for this patient. They offer many clinical treatments, and I watch families and listen to families explain..."This is what the Doctor recommended" After many years of witnessing this situation, knowing the MD didn't "recommend" the Peg tube....what was the problem here...Well..the MD is speaking to what is next .... patient has a Duotube, and not progressing on oral intake, know the picture. So there goes the GI consult for Peg. So ... families think MDs are offering their 'opinion, or recommendation" just because they are offering choices they have to...per se to "CYA"...when you encourage the family to listen to the MD, and then when he is done, thank them, and ask, What is their 'opinion', if the patient was a one of their family members, what would they do?" in their Opinion. When this happens, the MD's shoulders almost seem to relax, as though they get to be truly honest vs. worring about not offering something the don't want to..but also have to worry about that coming back to bite them in the often does the opinion differ or 'lean' towards a more dignified approach.
Families don't realize that when MD's offer or say this is what is next, that this may not be what you think is best, in your medical opinion.I have had so many families thank me for giving this question to ask, as they felt it made a difference is what they felt the MD's really were thinking in regards to patients prognosis.

Christine Okon said...

Yes, you are a gifted writer. Thank you.

Will's Dad said...

I would assume that "what would you do?" is a question you would hear more often. Perhaps it is the ER setting but I know that amidst all the decisions we have to make I always like to end our chats with the doctors with that one. After all the discussion I find you can cut through the jargon and some of "what the hospital requires I say" BS and get to the heart of the matter.