Before You Go

When I do nursey stuff, I work in a ventilator unit. I say "when" because I used to do it full time. Now I do it part time and every time I work, I remember why I can't work there full time. When the house is full, I am responsible for up to 13 patients. On any given day, half of those patients are in a persistent, vegetative state, one fourth are "awake" and one fourth have an actual hope of going home. Of those folks who are "not awake" some are DNR/DNH (do not recussitate/do not hospitalize) and those who are not, should be. DNR means that if I find you unresponsive, I will not initiate any life saving measures such as CPR and I will not send you to the hospital. Do not hospitalize means that if you have something wrong with you like lethally abnormal electrolytes, we will try to manage the situation in-house, but we won't send you to the hospital. It is one of the steps the road to hospice or comfort care.

This weekend, I cared for a woman who was actively trying to die. It is a privilege to care for people in this state. Sometimes you're the last touch they feel, the last voice they hear. If you are the last bridge between this world and the next, you always hope you made the "here" better for them. This woman was in agonizing pain when the morphine wore off. It hurt when I wiped her mouth or repositioned her hand. So my job for the day was to make sure the morphine didn't wear off.

By now, we all know that hearing is one of the last senses to leave when someone is dying. In my practice, I recommend the patient be surrounded by family talking about the positive things that are happening. If the TV is the patient's only company, I make sure it's tuned to music. What a patient should not be hearing is "I don't want to send my mom to the hospital for a blood transfusion, I already told that stupid doctor that!" What we have here is an ambivalent son. He doesn't want his mom to suffer, but he doesn't want to let her go.

At this point, I suggest we step into the nursing office. I explain that the Responsible Party (the person who has legal authority to make health care decisions on a patient's behalf) canceled the "Do Not Hospitalize" order on Thursday and with blood work as abnormal as this patient has, I have to follow the orders of the on-call doc unless the on-call speaks to the Responsible Party directly.

(It should be noted the the on-call doc has NEVER seen this patient and practices medicine in such a manner as to keep the patient safe and not get sued. I leave it as an exercise to the reader to decide the order in which these occur.)

At this point, the son is actively trying not to wring my neck. He is frustrated because he knows he argued his step-dad into canceling the DNH order earlier in the week. Step-dad knows the score and understands that his beloved is not going to recover and is suffering. Son is not ready to let go of his mother. Who is? I tell the son that I will not send his mom to the hospital if he will help me get the step-dad in touch with the on-call. It's the only way. Son gets on the cell phone - it goes to voice mail. Step-dad is on his way home, somewhere between Philadelphia and the Poconos.

Finally we are able to get the step-dad connected with the on-call and a new DNH order is obtained. End of shift, I go home.

But I'm still thinking about work. What happened here is mostly avoidable. Mom is probably in this situation because she did not have a living will. Without the living will, this family had to go to court to decide that the spouse and not the son would would make decisions on behalf of this lady. This case is not isolated. Many of my patients are not married to their companions. But without any document indicating who should make decisions or who should execute the decisions you have already made, you will be kept "alive" until your heart gives out (not a good death), some other party will choose for you, or your companion will have to go to court to "prove" that you are a family.

You don't have to be married and you don't need a lawyer. For a few dollars, organizations like Five Wishes provide living wills in simple language. All you have to to is fill it out, get it notarized, then give it to your doctor or make sure your companion has it. The red tape in a nursing home is ten-fold. Your family has enough to worry about with you in a coma. Before you go, do them a favor and execute a living will.