The first week of rotation I was rounding with the team and one of the patient’s presented was preparing to have her vent and IV fluids removed and tube feed stopped. She had had a massive MI and never regained function. She was anoxic for 30min but was resuscitated. I asked my attending why. Why do you keep trying to resuscitate someone after they have been without oxygen for 30min? What is left? When do you make the decision to stop pumping, or pushing, or pulling? When/What is enough? For his part, he was also unsure. To me, I would’ve thought this would cause so much less pain on the part of the patient’s family. They wouldn’t be the ones to decide, they wouldn’t be the ones to give up, they wouldn’t be the ones to blame. We can take that burden. That is our responsibility, it seemed, to me.
The patient’s children and mother decided to remove the vent, assuming (along with the medical team) that she would be unable to breathe on her own. She was to be given morphine to decrease the labor of breathing and to ease her comfort. This was a bit of a solemn time on rounds. Everyone had cantankerous patients or patients you rolled your eyes at because of non-compliance issues, or drug use landing them in the hospital. Everyone had confusing patients that really made you think about possible diagnoses and management and call in consult services and research. And there was just nothing to present for this patient: nothing really to say. Ms. F remains unresponsive. That Sunday we removed the vent, and she breathed on her own.
We also had the patient moved down to an observation floor and had given her morphine for comfort, as was discussed with the family. We stopped the tube feeds, as per our understanding of comfort and palliative care. Family traveled in to say their goodbyes. And we were told we set this woman aside and left her to die.
They were so incredibly angry with us. They didn’t understand why she was moved. They didn’t understand why tube feeds were stopped, why monitoring vitals was stopped. They thought we were rushing her out, rushing them out, with the morphine push. And so overnight, feeding was reinstated, vitals were being monitored, morphine was discontinued and this hope that Ms. F would miraculously recover, in days, months, years, began. This hope began in the family. On rounds Ms. F was still presented as- Pt remains unresponsive. The tone of the team became almost rebellious. Presentations got longer. Pt remains unresponsive to painful stimuli. Pt is breathing but it was explained to the family that this is nothing more than brainstem functionality and represents no significant change. Pt is posturing consistent with the decrease in cerebral swelling. It was like we were yelling “Nothing is going to change! Give up!” when we didn’t- perhaps when we should’ve, weeks ago. Ms. F and her family slowly transitioned into the group of patients you present with rolled eyes.
I went to a meeting with the neurology consult, the head of the ethics committee, the attending on my team, the palliative care attending, pastoral care, the nursing team, social work, and Ms. F’s daughter and mother. The biggest feeling of relief I think I’ve heard so far in the hospital so collectively was when the family stated that they still did not want IV fluids or medications or a ventilator placed. I found out later that due to the patient’s inability to protect her airway she would probably then die of pneumonia and we would not be able to cure her with only PO medications. I guess to the medical staff, that concession signaled when the end would come, at least to us. We were then given the chance to prepare. Her temperatures are spiking and not controlled by aspirin or PO antibiotics. We are ready.
My attending told the family today to get ready. Unfortunately, due to the patient’s relatively young age and good health before this event, the pneumonia may be protracted. Her skin breakdown is increasing. My intern hates running painful stimuli exams. This case is hurting all of us. No one is rolling their eyes at Ms. F anymore. It was easier to roll my eyes when I saw the family so angry. It was easier to be defensive against people striking at you. Today however, was the first day, since the initial decision to pull the plug, that the patient’s siblings seem prepared. Today the son cried. And I wish that we could’ve just done nothing sooner. And they could’ve been angry with us. The anger, I prefer, to the tears.
I was going to write about the healthcare that this patient doesn’t have, the bills that will begin to be sent to her family upon her death. But I won’t see that part. This part I saw, and felt, and will not forget.