You know the 90yo LOL/LOM, advanced dementia, has an advance directive stating DNR & comfort measures only, sent in from the facility by ambulance because they're "just not themselves". You know the one I'm talking about.
You carefully place the advance directive on the top of the stack of papers sent with them from the facility, place the chart in the rack for the doctor, and don't begin any interventions because it's clear that the person has end stage disease, and it's clear from the advance directive that the person doesn't want any aggressive intervention.
But of course, the doctor orders bloodwork, fluids, and a cath UA. Who here hasn't had to pry apart the contractured legs of a demented LOL that doesn't understand what you're doing down there, or have someone hold down the hands of the demented LOM so he can't hit you when you stick the tube in his urethra? Who here hasn't felt like dirt poking those birdlike little arms a half dozen times, trying to cannulate spiderweb thin veins to have them blow, one after the other, all while knowing this was not what the person wanted?
Family members stand by, wringing their hands helplessly, wanting you to do something to "fix" Momma, to make her better so she can go back to "living" at the facility. There is no fixing here! This needs to STOP, you want to tell them. And yet, you understand their reluctance to "give up" on their loved one; their grief.
Today, my LOL was admitted to the hospital. The hospitalist who came to see her had a heart to heart with the family, explaining to them that even though we could fix this particular problem, we could not fix the bigger problem; that she was at the end of the road, and that here was an opportunity for her to die peacefully, in comfort, surrounded by family, rather than prolonging the inevitable with needles and drugs and tests and procedures. She explained why antibiotics and IV fluids are not comfort measures, and what kinds of things could be done to keep a person comfortable during the dying process.
I went into the room and removed all of the cords and cables, discontinuing cardiac monitoring and vital signs. I stopped the antibiotics and IV fluids ordered by the ED doctor mid-infusion.
"Thank you" said the LOL.
I bundled her up in warm blankets, and draped her with one of those quilts sewn by the volunteers that we're supposed to give to the sick children who come through. She didn't know I gave her a special quilt, because she couldn't see, but her daughter at the bedside saw and knew. I packed up her belongings into a plastic bag and sent her upstairs to the inpatient unit, to die.