CHANGE OF SHIFT
I Know Where This Is Going Faber White, MD, FACEP* *Corresponding Author. E-mail: [email protected], Twitter: @FaberW3. 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.06.020
[Ann Emerg Med. 2014;64:676-677.] He arrives by EMS an hour before the end of my shift, already intubated. He is only 66 years old but has the appearance and diagnoses of someone 25 years older. He was found at his nursing home in respiratory distress. When paramedics arrived, they noted that he was breathing about 50 times a minute but, paradoxically, not moving much air, evidence of a functioning autonomic nervous system desperately trying to keep the rest of the body, which simply cannot cooperate, alive. No advance directive is in place, so the paramedics did what they are trained to do. By the time I assume his care in the ED, his oxygen saturation is over 90% and he is pink. However, he is tachycardic, hypotensive, and febrile—clearly septic. I know where this is going. It’s like a reflex: CBC, metabolic panel, UA, ABG, BNP, troponin, chest film. Call respiratory to manage the vent. Of course blood cultures, even though it won’t matter. Oh, lactic acid too, as if I don’t already know he’s sick. I ask for two more good IVs and whisper a prayer that I won’t have to put a central line in this gentleman. He’s clearly been through enough. The multiple pressure sores suggest that he hasn’t walked in months, and the nursing home staff said that he hasn’t spoken anything meaningful in weeks. Just as I’m falling into the trap of cynical indifference, questioning why this poor patient is a full code, his wife is brought to the bedside. She is likely about his age, but appears much younger than he does. She looks tired. As I explain to her what has happened to her husband in the preceding hours, she calmly listens, but I’m not sure she comprehends everything. As sympathetically as I can, I try to make her understand that he is gravely ill; he wasn’t breathing well on his own, so the paramedics had to put that plastic tube in his throat to keep him alive. I say this intending for her to understand his dire situation: that without the machine breathing for him, he would have already died. I fear that instead she hears that we’ve “saved” her husband, heroically snatching him from the jaws of death. Such unrealistic presumptions are so common. Delicately, I ask her if he has given any instructions regarding situations like this. She says no. It’s not that they didn’t have the conversation. As all the potential options were being discussed, he simply became overwhelmed. Eventually, he looked at her and said that he trusted her to make the right decisions on his behalf,
676 Annals of Emergency Medicine
whenever the time came. That was his advance directive: to trust his wife of 44 years to make these decisions for him. Despite completion of the second IV fluid bolus, his blood pressure is in the 70s, and his heart rate is 130. I know where this is going, but I also know that she isn’t ready to hear it as she sits quietly beside his bed, holding his hand. Behind her, a nurse is getting a central line setup ready. I pretend I don’t notice. I am certain that he didn’t consider the ramifications of placing decisions like these in his wife’s hands. To him, it was an expression of trust and wholehearted faith in their relationship, a declaration of his commitment to her above all else. I don’t ask, but I’m sure he accepted the same obligations for her. As I watch her eyes fill, it becomes clear that she doesn’t want this responsibility. Without instructions to the contrary, when the beating of his heart finally, inevitably, degenerates and ceases to drive the flow of blood, I will be obligated to at least try to restart it. A half dozen people will rush into the room, ruining the tranquility of the moment. Some well-meaning but misguided person will probably remove her from the area so the lifesavers can do their work. After several minutes of futile efforts to resuscitate a man who has stopped trying to live, I will pronounce him, and she will be brought back in the room to sit by her now lifeless husband, having missed his final moments. This predictable scene has played out many times. I know where this is going, so I self-deliberate over how best to make sure that doesn’t happen here. She must consent to the withholding of treatment, because no physician wants to be accused of simply standing by while a spouse clings to hope and wonders why the uncaring, cruel doctor won’t act to save her husband. Impossible hope, fear of loneliness, regret over lost opportunities, unfulfilled dreams, and many other concerns must be addressed, and all I have is minutes. She has to understand; this is futile. The monitor alarms every time a new blood pressure is taken. It is now 66/41, and his heart rate is 120. He has no urine output in the Foley. Antibiotics are already running, and a nurse is hanging norepinephrine in anticipation of the order. The central line kit sits on the table behind us. I kneel beside her chair so that my eye level is below hers. I calmly tell her that he isn’t responding to treatment so far, that he is becoming sicker. I sense that she understands, or is starting to. I feel some relief—hope, even—when she says, with tears streaming, “I don’t want him to go through this again.” Is that
Volume 64, no. 6 : December 2014
White
Change of Shift
perverse, the fact that I feel relieved that she seems to be increasingly inclined to let her husband die? I can feel the conflict rise within me as I discuss options with her. I sincerely believe that if he could speak, he would tell her to let him pass, peacefully. He has surely long since ceased to be the man she knew him to be. And yet.was that not also true of him yesterday, and last week, and the months before that? Did she love and care for him any less during these recent days than she did at any other time in their life together? Very likely not. Who am I to tell this woman what the “right” thing is? The truth is that I don’t know her, or their situation. Furthermore, I don’t know for certain that he can’t pull out of this tailspin. The reality is that I don’t know where this is going, and to think otherwise is arrogance. Given that uncertainty, how persuasively should I press this distraught lady to forgo life-sustaining measures for her husband? For the moment, it doesn’t matter. She breaks down, sobbing violently, and says, “I just can’t do it. I just..can’t. I’m sorry.” I can’t tell if she is apologizing to her husband, or to me. She knows what I was asking of her. It isn’t that she harbors fantastical notions of him waking up and conversing with her like days long ago. It isn’t even that she doesn’t want to take the steps she knows I request of her. It is simply that to her, giving me the authority to not prolong her husband’s life equates to giving up on him. And she isn’t able to bring herself to do that. Not sure what to say next, I promise her that I will keep him comfortable. I order a fentanyl drip. He is incontinent, and a
nurse comes over to clean him up. I call his primary care physician and order a bed in the ICU. I found out later that about 4 hours after leaving the ED, my patient died. According to the progress note, his status was made DNR after he got upstairs, and he quickly faded. I wasn’t surprised; I did wonder, though, what discussion was had with his wife. Did someone simply tell her he was dying and the best thing was to let him go? I wonder what I could have said or done differently in the ED. One of the most challenging, heart-wrenching, and ultimately fulfilling aspects of my job is helping families work through a loved one’s death. Few things provide as much satisfaction as being able to provide support and encouragement, and validate feelings of grief and concern. It is highly ironic: many of the most meaningful and touching expressions of gratitude I receive often come from families of loved ones who died with me attending them in the ED. My skills and knowledge have a way to go, but my ability and confidence grow with each shift. I can secure an airway, place a central line or chest tube, and make sure appropriate medications are administered promptly. And yet the farther along I progress in my career, the more I question what is really the right thing to do in moments like these. The more experienced I become, the less convinced I am that when I see a patient like this, I know where this is going. Author affiliations: Leading Edge Medical Associates, PLLC, Good Shepherd Medical Center, Longview, TX.
Did you know? You can track the impact of your article with citation alerts that let you know when your article (or any article you’d like to track) has been cited by another Elsevier-published journal.
Visit www.annemergmed.com today to see what else is new online!
Volume 64, no. 6 : December 2014
Annals of Emergency Medicine 677
I Know Where This Is Going Faber White, MD, FACEP* *Corresponding Author. E-mail: [email protected], Twitter: @FaberW3. 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.06.020
[Ann Emerg Med. 2014;64:676-677.] He arrives by EMS an hour before the end of my shift, already intubated. He is only 66 years old but has the appearance and diagnoses of someone 25 years older. He was found at his nursing home in respiratory distress. When paramedics arrived, they noted that he was breathing about 50 times a minute but, paradoxically, not moving much air, evidence of a functioning autonomic nervous system desperately trying to keep the rest of the body, which simply cannot cooperate, alive. No advance directive is in place, so the paramedics did what they are trained to do. By the time I assume his care in the ED, his oxygen saturation is over 90% and he is pink. However, he is tachycardic, hypotensive, and febrile—clearly septic. I know where this is going. It’s like a reflex: CBC, metabolic panel, UA, ABG, BNP, troponin, chest film. Call respiratory to manage the vent. Of course blood cultures, even though it won’t matter. Oh, lactic acid too, as if I don’t already know he’s sick. I ask for two more good IVs and whisper a prayer that I won’t have to put a central line in this gentleman. He’s clearly been through enough. The multiple pressure sores suggest that he hasn’t walked in months, and the nursing home staff said that he hasn’t spoken anything meaningful in weeks. Just as I’m falling into the trap of cynical indifference, questioning why this poor patient is a full code, his wife is brought to the bedside. She is likely about his age, but appears much younger than he does. She looks tired. As I explain to her what has happened to her husband in the preceding hours, she calmly listens, but I’m not sure she comprehends everything. As sympathetically as I can, I try to make her understand that he is gravely ill; he wasn’t breathing well on his own, so the paramedics had to put that plastic tube in his throat to keep him alive. I say this intending for her to understand his dire situation: that without the machine breathing for him, he would have already died. I fear that instead she hears that we’ve “saved” her husband, heroically snatching him from the jaws of death. Such unrealistic presumptions are so common. Delicately, I ask her if he has given any instructions regarding situations like this. She says no. It’s not that they didn’t have the conversation. As all the potential options were being discussed, he simply became overwhelmed. Eventually, he looked at her and said that he trusted her to make the right decisions on his behalf,
676 Annals of Emergency Medicine
whenever the time came. That was his advance directive: to trust his wife of 44 years to make these decisions for him. Despite completion of the second IV fluid bolus, his blood pressure is in the 70s, and his heart rate is 130. I know where this is going, but I also know that she isn’t ready to hear it as she sits quietly beside his bed, holding his hand. Behind her, a nurse is getting a central line setup ready. I pretend I don’t notice. I am certain that he didn’t consider the ramifications of placing decisions like these in his wife’s hands. To him, it was an expression of trust and wholehearted faith in their relationship, a declaration of his commitment to her above all else. I don’t ask, but I’m sure he accepted the same obligations for her. As I watch her eyes fill, it becomes clear that she doesn’t want this responsibility. Without instructions to the contrary, when the beating of his heart finally, inevitably, degenerates and ceases to drive the flow of blood, I will be obligated to at least try to restart it. A half dozen people will rush into the room, ruining the tranquility of the moment. Some well-meaning but misguided person will probably remove her from the area so the lifesavers can do their work. After several minutes of futile efforts to resuscitate a man who has stopped trying to live, I will pronounce him, and she will be brought back in the room to sit by her now lifeless husband, having missed his final moments. This predictable scene has played out many times. I know where this is going, so I self-deliberate over how best to make sure that doesn’t happen here. She must consent to the withholding of treatment, because no physician wants to be accused of simply standing by while a spouse clings to hope and wonders why the uncaring, cruel doctor won’t act to save her husband. Impossible hope, fear of loneliness, regret over lost opportunities, unfulfilled dreams, and many other concerns must be addressed, and all I have is minutes. She has to understand; this is futile. The monitor alarms every time a new blood pressure is taken. It is now 66/41, and his heart rate is 120. He has no urine output in the Foley. Antibiotics are already running, and a nurse is hanging norepinephrine in anticipation of the order. The central line kit sits on the table behind us. I kneel beside her chair so that my eye level is below hers. I calmly tell her that he isn’t responding to treatment so far, that he is becoming sicker. I sense that she understands, or is starting to. I feel some relief—hope, even—when she says, with tears streaming, “I don’t want him to go through this again.” Is that
Volume 64, no. 6 : December 2014
White
Change of Shift
perverse, the fact that I feel relieved that she seems to be increasingly inclined to let her husband die? I can feel the conflict rise within me as I discuss options with her. I sincerely believe that if he could speak, he would tell her to let him pass, peacefully. He has surely long since ceased to be the man she knew him to be. And yet.was that not also true of him yesterday, and last week, and the months before that? Did she love and care for him any less during these recent days than she did at any other time in their life together? Very likely not. Who am I to tell this woman what the “right” thing is? The truth is that I don’t know her, or their situation. Furthermore, I don’t know for certain that he can’t pull out of this tailspin. The reality is that I don’t know where this is going, and to think otherwise is arrogance. Given that uncertainty, how persuasively should I press this distraught lady to forgo life-sustaining measures for her husband? For the moment, it doesn’t matter. She breaks down, sobbing violently, and says, “I just can’t do it. I just..can’t. I’m sorry.” I can’t tell if she is apologizing to her husband, or to me. She knows what I was asking of her. It isn’t that she harbors fantastical notions of him waking up and conversing with her like days long ago. It isn’t even that she doesn’t want to take the steps she knows I request of her. It is simply that to her, giving me the authority to not prolong her husband’s life equates to giving up on him. And she isn’t able to bring herself to do that. Not sure what to say next, I promise her that I will keep him comfortable. I order a fentanyl drip. He is incontinent, and a
nurse comes over to clean him up. I call his primary care physician and order a bed in the ICU. I found out later that about 4 hours after leaving the ED, my patient died. According to the progress note, his status was made DNR after he got upstairs, and he quickly faded. I wasn’t surprised; I did wonder, though, what discussion was had with his wife. Did someone simply tell her he was dying and the best thing was to let him go? I wonder what I could have said or done differently in the ED. One of the most challenging, heart-wrenching, and ultimately fulfilling aspects of my job is helping families work through a loved one’s death. Few things provide as much satisfaction as being able to provide support and encouragement, and validate feelings of grief and concern. It is highly ironic: many of the most meaningful and touching expressions of gratitude I receive often come from families of loved ones who died with me attending them in the ED. My skills and knowledge have a way to go, but my ability and confidence grow with each shift. I can secure an airway, place a central line or chest tube, and make sure appropriate medications are administered promptly. And yet the farther along I progress in my career, the more I question what is really the right thing to do in moments like these. The more experienced I become, the less convinced I am that when I see a patient like this, I know where this is going. Author affiliations: Leading Edge Medical Associates, PLLC, Good Shepherd Medical Center, Longview, TX.
Did you know? You can track the impact of your article with citation alerts that let you know when your article (or any article you’d like to track) has been cited by another Elsevier-published journal.
Visit www.annemergmed.com today to see what else is new online!
Volume 64, no. 6 : December 2014
Annals of Emergency Medicine 677
