But is it what she would want?
In the Emergency Department, we think of ourselves as life savers. But sometimes, "saving a life" means letting it end.You know the ninety year old Little Old Lady or Little Old Man with advanced dementia, has an advance directive stating DNR & comfort measures only, sent in from the facility by ambulance because they're "just not themselves". If you work in an Emergency Department, you know the one I'm talking about.
You carefully place the advance directive on the very top of the stack of papers sent with them from the facility so the doctor can't miss it, place the chart in the rack, 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, for reasons you cannot fathom, the doctor orders bloodwork, fluids, and a cath UA. Who here hasn't had to pry apart the contractured legs of a demented Little Old Lady that doesn't understand what you're doing down there, or have someone hold down the hands of the demented Little Old Man 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 only 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 Little Old Lady 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 Little Old Lady.
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.
About Anna Flaxis, ASN
Anna Flaxis has '12' year(s) of experience and specializes in 'Emergency'. From 'U.S.'; Joined Oct '10; Posts: 2,886; Likes: 8,691.Sep 29, '11What a beautiful and fitting story, and what a gift you gave to your patient. Bless you. :heartbeatSep 30, '11Thank you for allowing 'your Little Old Lady' to die with dignity and respect. You and the hospitalist are to be commended for advocating for your patient.Oct 2, '11Working in Long Term Care I encounter this scenario quite often! Regardless of what the patient wants, the family members can not let go. I have had the "hard conversation" many times and apologize for the bluntness while as delicately as possible explain exactly what is going to happen if they insist I send their loved one to the hospital. The tests, pokes, machines, all in a sea of confusion because they barely know what is happening in the familiar facility let alone a scary strange hospital. I paint a picture of the comfort we can provide ensuring they are as pain free as possible and cared for an loved in thier familiar surroundings allowing nature to take its course. Usually I succeed in getting them to come to grips with the reality of the situation and make good on my promise to do whatever it takes to ensure the end is as comfortable and loving as possible but once in a while the family member just can't let go and for that I am sorry for all parties involved! The hospital who puts resources towards a futile attempt of maybe buying a little more time for the family member's sake, the agony the family will go through as this will occur again and again until they are convinced to let go or the patient hopefully goes in their sleep before any "interventions" are possible and most of all to the patient who is put through useless transport, tests, restless nights, and agony. Nobody likes to have that conversation but it is for the good of the patient! I always ask are we keeping them going for them or for you, what is the quality of life we are hoping for? Unfortunately as much as we are our patients advocates we do not have the final say....Oct 6, '11Stargazer, Thank You for writing this article. I see this situation every week on my neuro/tele and step down unit. I get so very sad when my little old people come in with strokes, advanced infection or failure to thrive, and the family wants "Everything Done" to get their loved one better. If the family would just talk to their love ones and open their eyes, they could see that their elderly parent is trying to die with dignity. Not eating at an advanced age is common, and occurs right before someone passes. It is a peaceful and painless way to die. But what I see over and over again is the patients that have a DNR, are frail and at the end of the road, their families decided to put a feeding tube in their abdomen and tube feed them , and continue with the endless lab draws and painful tests. I also see that most of the doctors in my facility leave the heart to heart about end of life issues, to the nurses. This is a subject that the doctors need to be discussing with famiies, and they need to emphasize that their loved one is at the end of their life and encourage families to let their love ones die without pain or suffering. This subject saddens me the most as a nurse. People want their loved ones with them at any cost. It doesn't matter that they are confined to a bed in a nursing home, incontinent of bowel and bladder, have alzheimers, or are aphasic and paralyzed from a CVA, can't tolerate food by mouth and have a feeding tube. They want their mom and dad to be in that bed waiting for them alive each time they come to visit. How as a society have we got to this point that we allow our elderly to suffer like this?Jan 21, '12I wondered this the one Christmas day I had to run a full code on a 101 year old man with end stage Alzheimer's. His ribs were like twigs and broke. He was covered in feces and urine. We worked on him for an hour because the family couldn't let go. They were screaming in the halls when we had to call it quits.
I still have nightmares about that. It's awful.
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