Sunday, June 14, 2009
Sometimes I have the autonomy to override a doctor's orders. Sometimes I do not. This weekend was an example of a time when I did not. It was also an example of the concept that just because we can do something to prolong a life doesn't always translate to we should. A lesson in medical futility and ethics. I have been assigned to the MICU for the past 6 days. The sickest patients in the hospital were once again in my care, as is happening even more frequently now.
A patient was admitted on Wednesday night, and by Thursday, it was well-known that there was nothing we could do for him. The name was familiar to all of us, but none of us could place his face. Disease had ravaged his body until there was little with which to work. I am not going into detail about the disease process or any other fact that can be used to identify this patient because I want to protect him as I am legally obligated to. But he was very, very ill. I watched as a parade of specialists for just about every body system in a human organism came and went from his room, speaking with his family.
I'm sorry. There is nothing more we can do.
We will provide him with comfort while he makes this final journey.
We will allow him to die with dignity.
I made sure he had enough oxygen, then went on to other patients of mine. Patients who were not breathing on their own, hooked to my ventilators. Not much time passed before another specialist came to see the patient. The patient, on top of everything else, had a raging infection. Sepsis. He wanted me to suction the patient, something we don't usually do for the dying patient because it is so uncomfortable for them. I asked him to explain why. His follow-up was that we were going to suction him, and then intubate. Within 15 minutes, the family wants to do everything. Put him through the medical gauntlet. The doctor seeing the patient for his infection bypassed the cardiologists, nephrologist, pulmonologists, neurologist, and oncologist. Told the family we could fix him.
My experiences with family members facing the loss of a loved one have taught me something. You must be very careful when you walk into the room of a dying patient. Because any tiny word you utter can be misconstrued as hope. Hope where there is none. And they grab onto to that like a life preserver, and hang on to it. To the layperson, this would seem like a gift to them. Instead it makes it worse. The patient passes away anyhow, after they have thought it was not going to happen. From the minute we know that death is looming, our care shifts from the patient to the ones left to live. Every action becomes about them. Making it easier for them. Never more difficult. The have enough difficulty to face.
We failed that family. We didn't do what we should have done for the patient.
We intubated. I hooked him up to the machine that would breathe for him. I stood at the bedside and cleared mucus from his chin and smoothed down his hair while the ventilator hissed and puffed behind me. In that instant, I realized who he was. One of our regulars, I would always save his breathing treatment for last because we would always end up talking about his military service and kids. Through all of his admissions, he never forgot that my son's name is Evan. He would always light up and ask me if my Evan was still driving me crazy. He always called me his "Breathing Angel" because he said I always seemed to show up in the same instant he was thinking about calling for a PRN treatment. I tried on several occasions to explain to him that it was probably due to the fact that he was due for his medication and less about me. "In fact," I would tell him, "I'm actually really mean in real life." He would always giggle and shake his head, telling me he couldn't believe it.
I almost didn't recognize him through all of the tubes and lines.
Within 5 minutes of intubating him, he tried to go into cardiac arrest. We brought him back. I heard his ribs crack during CPR.
By the time I had reported for the next day, he was on continuous dialysis. We had given him the maximum amout of medication allowed to maintain his blood pressure. Dopamine. Levophed. Vasopressin. I was no longer able to maintain any sort of oxygen saturation on him. We had to insert an arterial line in his femoral artery, in his groin. His body temperatre was 88 degrees. We had him wrapped in heated blankets and a warming system so that only his face was visible. He had a rectal tube inserted that was draining blood. 10 IV pumps going. About the only drug category we didn't have covered was sedation. Through all of it, he didn't need any.
The family still was clinging to the hope that we could fix him. Despite the fact that we told them repeatedly that it was gettting worse. They held fast to that life preserver. I left my shift praying for his death.
By the time I reported for my shift the next day, he had died on his own. It took 6 nurses and me to remove all of the lines and tubes. His body released every fluid in it. There was a piece of tissue that I assumed to be a part of his trachea that came out when I removed the endotracheal tube.
I didn't cry. Instead I hated my job. I was upset that I didn't put my foot down for him and advocate for him. I realize that even if I had, and refused to participate, they would have just called another of the therapists. This was one of those that I could not override.
I still feel like I failed my patient. I wasn't his Breathing Angel anymore.