Two Perspectives

WhiteCoat Rants has a great post up called The Difference Between Life and Living, which addresses the futility of keeping some patients alive using artificial means. Check it out--and read the comments. Some were very thought provoking, and inspired me to write this post.

As a student, I had a patient who was covered in bedsores, vented, and who would code once a day. Like clockwork. After about 15 minutes of chest compressions (crunch crunch crunch), defib, and drugs, we'd get her weak, tiny heart to start beating again. Until the next time. Then she got a pneumothorax. Chest tubes were inserted. This went on for the week that I was at her bedside.

I asked the doctors and nurses taking care of this patient if she had any relatives, or if we were coding her every day because we had no advance directives at all.

She had a son who refused to address any DNR issues regarding his mother. He snuck in and out for a few minutes each day during shift change so as to decrease his chances of being collared to discuss her. He was a doctor.

Eventually her case was brought up to the ethics committee and the son was forced to acknowledge that his mom was not coming back in any significant way. The next time she coded, she was let go.

Another case was one we had recently in the ER. A middle-aged woman with three young-adult sons was brought in for heart failure. It was clear that she was at the end of this disease and would not live very long. She was awake and struggling to breathe, and requested that she be vented so that all of her sons could be at her bedside. (Two were there and one was coming from a few hours away.)

For the next few hours, she was vented and on pressors, but was fully awake for most of the time with two of her sons holding her hands. I offered her sedation once an hour, but she would shake her head and refuse. Finally, her third son got there, and we got a bed upstairs for her (I'd been fighting to find a spot for her because I didn't want this family to have to experience this death in the ER with all of its lack of privacy). I asked again if she wanted to rest for a while, until we got her settled upstairs, and that it was relatively short-acting sedation, that she could be awake again in an hour or so. She nodded. Three hours later, she died quietly with her family at her bedside.