During my last night on call, I had the privilege of being involved in the care of a lovely lady who, sadly, was going to die.
Years ago, when I started working as a porter in the hospital, I was quite disturbed by the part of my job description that involved moving bodies to the morgue. I remember the first time I was dispatched a morgue call, I instinctively slammed the phone down and rejected the job. Over time, the job got easier, but I always felt uneasy with the idea of touching or moving dead bodies.
My attitude is different now. I don’t know if it was a year in anatomy class dissecting corpses and inspecting real human specimens, or if it has been the numerous deaths that I’ve been privy to over the past few years. Maybe it is a combination of both. Regardless, I now see death as a normal and natural part of life. While it is a sad and difficult time for everyone involved in the death of a patient (including that patient’s family), I have quickly come to discover that it can be an affirming and rewarding experience for the health care providers involved in the care of the patient.
When I was first asked to see this lady, whom I’ll call June, she was in emergency and was brought in by a transfer crew who was bringing her to her new long term care facility. They thought she looked unwell and when they took her vital signs, she had an extremely low blood pressure. As the surgery resident, I was asked to see her because her abdominal x-ray showed some air in her abdomen (which is never a good sign). Before seeing June, I learned that she had bowel surgery for cancer 2 months previous, and was brought into the emergency room twice in the past week for “feeling unwell.”
I came around the curtain of June’s bed and found her fairly alert in bed, surrounded by her concerned and doting family. I introduced myself and allowed the family to express their frustrations on why it has taken so many visits to the emergency room for their mother (and grandmother) to be investigated properly. I didn’t know why she was not investigated differently on her last visits, but I knew by taking one look at her now that she was being investigated seriously because she was obviously in shock: low blood pressure, poor urine output, mental status changes, and some kind of probable internal infection. The family was obviously upset and they wanted us to do everything we could to save their mother.
A few test later, we learned that June’s abdomen was completely full of infection, her lungs full of fluid, and her heart was having a difficult time keeping up. She was becoming less responsive, and she was so sick that she wasn’t even a candidate for admission to ICU. The best we could do was move her into an observation unit. Shortly after arriving there, June’s blood pressure began to drop more. I was riding a difficult line between supporting her blood pressure without filling her lungs with fluid. We were doing everything we possibly could to treat her infection, including giving her the most powerful antibiotics and draining the infection with a tube. But she was still getting worse. June’s family could see we were doing everything we could do, and they could see that their beloved mother was likely going to die.
At this point, it was clear to me that I had a difficult conversation to face with June’s family. As we stood around the beside of this ailing lady, I explained to her children what would happen if her heart were to stop of she were to stop breathing:
“Your mother’s current code status would require us to call a code blue, which means that about 20 people would come running into this room, you would be sent out into the hallway, and we would start doing CPR and put a tube down her throat. Unfortunately, given her current condition and her rapid deterioration, our efforts would likely be unsuccessful.”
“Alternatively, we could make a decision to change her goals of care to focus on optimizing her medical management and try to get her through this. However, if her heart were to stop or she were to stop breathing, we would take that as a sign that she is not strong enough to fight this battle and we would let her go. In this instance, you all could remain with her during those moments and we would ensure that she is comfortable through this whole process.”
“There is no right choice, either option is acceptable, and we will do whatever you would like. Any decision you make is not permanent and if she does start to improve, we can revisit this decision again.”
June’s family members, who were so angry only a few hours earlier, looked at me with tears streaked down their faces. I knew I didn’t need to give them much time to think about this decision.
“Doc, do you think she is going to die tonight?” Her son asked me?
“I can’t say for sure, but she has declined very rapidly over the last few hours and we are currently doing everything we possibly can. It is very likely that she will continue to deteriorate. I’m sorry.”
I didn’t even have a chance to leave the bedside before they all looked at me, nodded their head, and in solidarity agreed that they would want her to go peacefully and with them by her side, if that’s what was going to happen. Before I went to fill out the necessary documentation for her code status change, I stepped into the hallway to invite the rest of her many family members to come into the room. I knew it wouldn’t be much longer.
Only about ten minutes had passed before I heard a monitor alarm begin to sound and a nurse frantically calling my name. I looked over to the corner of the room where June’s bed was and noticed the commotion of her family members withdrawing from her bedside. I ran over to see June lying with her eyes wide open and gasping for air. I rushed to her bedside to grab her hand: “June? June? You are okay… you are doing okay…”
After a few seconds, the monitor stopped beeping and she relaxed back into bed, closing her eyes as she did. We all thought that was the moment, but the poor little lady fought. Her heart rate was strong and her blood pressure was higher than it had been all night. I encouraged June’s family to stay with her and asked the nursing manager to make some changes to get June and her family into a private room…
“I’m sorry… I don’t care if it is 2:30 in the morning,” I told her.
June was still fighting a few hours later when we did our morning rounds. As the rest of my team moved on to the next patient, I held back.
“I am going to be going home soon, but I just wanted to know if there was anything else that I could do for you all before I leave.”
The family all looked at me and most of them shook their heads.
“No, Doc, really, you have done everything you could. Thank-you so much for everything – we really appreciate it,” June’s son said to me as he reached out his hand to shake mine.
His sisters looked up to me with sorrowful smiles on their faces and nodded along with their brother’s words. I walked away from June’s bedside with the knowledge that I would likely not see her when I returned to work the next morning.
I felt oddly calm and at peace, despite having been awake all night with a dying woman and all of her family, whom I had only met hours earlier. My experiences of the night were more rewarding than I could have ever imagined. I could not believe that I was now that person who rushes to grab the hand of someone who is about to take their last breath in this world. Death was no longer something that I feared.
When I came to work today, I was sad to learn that June passed away early this morning. Of course, I was hoping that we were all wrong and that she would continue to fight until our treatments took hold. I was happy to learn, though, that June did get her private room, she was surrounded by her family during her struggle, and despite losing her battle, she gave it the best effort that she could. I was honoured that, despite the failure of our medical treatment, I was involled in the care of June’s family at one of the most difficult moments in their lives.