ICU By Default? A Parish Nurse Asks the Question

jeastridge, BSN, RN

"If any of you lacks wisdom, he should ask God, who gives generously to all without finding fault, and it will be given to him." James 1:5

The music was loud and surrounded me as I sat in the football stadium turned music venue for a community-wide concert. I felt my phone vibrate in the seat of my canvas arm chair and I glanced down to note a text message from an unfamiliar number, asking me to call. I found a quieter spot and listened as the emergency room nurse told me of a very sick patient, adding, "The sister asked for you by name." Knowing the person involved and his long term health issues, I asked, "Is he dying?" The nurse hesitated a second before answering, "I think so."

I gathered up by things, said quick good byes to friends and family and began the walk to my car. Fifteen minutes later, I pulled back the curtain of the ER treatment room, holding a fresh package of tissue and my pocket Bible in the other hand.

Mr. R laid on the gurney with a neck immobilizer in place. Dried blood was matted in his white hair and seeping onto the sheet below. His face also showed evidence of trauma and a endotracheal tube protruded from his mouth, snaking over to the respirator two feet from the bed. I briefly took this in before reaching over to hug his sister and hold her while her shoulders shook with both sadness and shock. She took one of the tissues I offered and told me the story of how they had gone out to lunch together and then he simply tripped on the curb at his house when they came back. At the time, he appeared dazed but unhurt, having bounced his head hard on the cement. He was able to get up and make his way inside where she brought him an ice pack, got him settled, and left to go to her home, just a few blocks away. She later found out that he made some lucid phone calls to his children and told them how he had hit his head. But two hours later, when she called to check in, he didn't answer the phone. She hurried on over and when she arrived, found that he had somehow fallen again and this time, opened a gash on his head, possibly by hitting the granite counter top in the kitchen. He was on the kitchen floor in a pool of blood, drawn up into a fetal position, arms twisted in the awkward posture indicative of brain damage.

As she dried her tears, we stood around the gurney and prayed. We read a Psalm together and said the Lord's Prayer. After she had a few minutes to gather herself, I asked what the doctor had told her.

"They said he cannot recover from this," she answered. "He has a big bleed in his head." We talked more about what his wishes were and she told me unequivocally that "He would not want anything done to extend his life." Mr. R had been suffering from progressively worsening chronic obstructive pulmonary disease (COPD) and found each day a chore with breathing treatments, oxygen, difficulty sleeping, anxiety. His sister knew he was tired of fighting.

I had also spoken with him about his wishes. Two months before this event, when his sister was gone on an extended vacation, I called to check in and see how he was getting along in her absence. In the course of the conversation, we talked about what he would want if there ever came a time when he couldn't speak for himself. "Nothing. Absolutely nothing," was his firm response.

The ER nurse came in and said, "We have a bed for him in the ICU. He will go up there and you all can stay in the waiting area while they get him settled." I looked over at Mr. R whose choreoathetosis caused almost rhythmic leg movements. I touched his limp, cool hand and then, looking at his sister asked, "Do you think he would want to go to the ICU? Did you get a chance to talk with the doctor about his wishes?" His sister shook her head from side to side and said, "He was very clear about not wanting anything done to extend his life. And I have just talked with both of his children who confirm that we are not to do anything to make this go on."

The nurse looked surprised but said, "Let me get the doctor so you all can have a discussion about this."

While the nurse was gone, I explained what would happen if they extubated her brother. I explained the sedation that would be given and the possibility that he would continue to breathe for a period of time and need to be transferred to a palliative care unit for care until he died, reassuring her that through it all, the doctors and nurses would work hard to make sure that he had the best care possible to minimize suffering.

When the doctor came in, she talked quietly with the patient's sister, ascertaining that his wishes were well known and that the family was also on board. She clarified that no recovery could be expected from such a massive blow to the head and explained that his brain was slowly herniating through the natural opening at the base of the skull. Once the decision was made, she asked that we go into the family waiting area while respiratory therapy came to help take him off the vent.

As we were preparing to leave the area the minister of visitation arrived. We held hands in a circle surrounding Mr. R as he read from a book of prayers, a "Prayer of Release." We stayed together in the waiting area, sharing memories and talking about what had happened until the nurse came back to summon us to the bedside. Mr. R continued to breathe at intervals with prolonged spells of apnea until he finally took his last breath, free to move on from there to begin another life in eternity.

The experience left me with questions and some concerns. I wondered about those times when the parish nurse was not able to be there. Would someone else be able to ask the question about the patient's wishes or would he have simply gone on to the ICU?

Joy Eastridge, RN, BSN, CHPN

ICU By Default? A Parish Nurse Asks the Question

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