It was a typical shift. Critical patients streaming in to the ED back to back. Each one was handled by some great team work as we labored to resuscitate the septic, treat the acute strokes, and deal with the intermittent trauma. Uncharacteristically, EMS arrived without calling in a radio report in advance. The patient was having his respiration assisted with a bag-valve mask. Two paramedics were sweating, anxious, and speaking very quickly. They had responded to a call for shortness of breath. When they arrived they were confronted with a gentleman who was alone, in distress because he couldn’t breath, and trapped in the back of a small trailer. As they struggled to get him out of his home, he worsened. He was not able to move himself or walk, and his breathing was becoming critical. They gave thought to intubating him on scene, but realized it would be impossible in the small corner of his trailer. After a few minutes of struggling, the two men had managed to physically extract the patient into the the ambulance and begin administering emergency care. By now his breathing was critical and his pulse was barely palpable. His blood pressure would not measure, and his skin was so wet with sweat that they could not apply any monitor stickers to measure his heart rate or obtain an EKG. Relying solely on a pulse they could feel in his neck, they could tell it was very slow. They began assisting his breathing with a mask and managed to dry his skin long enough to apply the pacer/defibrillator pads. As one drove, the other was pacing the patient, measuring his pulse, and assisting his breathing. They did all they could to get him to the hospital, which was thankfully not far away. Each of them apologized for not doing more and for not alerting us to their impending arrival.
As I assured them their care was excellent and we completely understood their predicament, the team descended on the patient. We spent the next 30 minutes intubating the patient, obtaining IV access, intermittently performing CPR, running through advanced cardiac life support protocols, and giving boluses of epinephrine (push dose epi) while mixing an infusion. His EKG showed a large inferior MI and the cath lab was alerted. In the midst of it all, a document was located with the patient’s emergency contact information. We had a brief window of stability as I called the patient’s adult child. The patient was in his 80’s and the children did not live in town. As I spoke to a son, he explained that his mother, the patient’s wife, had recently passed and the patient had not taken it well. He was withdrawing and refusing medical care. He shared that the patient had recently been hospitalized for an MI and underwent a heart catheterization not more than 2 months ago. He went on to tell me that the patient had voiced his fatigue with his health problems, his loneliness after the death of his wife, and his refusal of any more interventions. It was at this point I asked about the patient’s directives. He had not completed a “Do Not Resuscitate” order, but he had spoken about his health and already refused some intervention. We were actively resuscitating him and it appeared as though there would be more invasive procedures coming. Would this be something he wanted?
Over the course of the next hour, I spoke with multiple family members while we continued full support of the patient and the cath lab staff stood by waiting. The cardiologist and I spoke with each family member and heard the same story… the patient had refused care before, but hadn’t taken it any further. He was recently hospitalized but had not been back to see his physician yet, and he was distracted and suffering from the recent death of his wife. After numerous conversations, it was decided that heart catheterization, balloon pump placement, and continued mechanical ventilation would not be what the patient would have chosen. We all agreed with the decision.
As I walked back to the room, I felt sorrow. We have seen many similar cases, and progressed through similar conversations with family in the past. But something was different about this case. The patient responded to our efforts. His vital signs had improved. We had him in that window where the body responds to therapy and appears to have returned to normalcy. As I informed the nursing staff of the decision to withdraw care, I could see the same emotion on their face. “So we just stop?” … “Yes.” No more medication for his blood pressure. No more CPR if he becomes bradycardic, and supportive care only from this moment. “But he will die” one of the nurses said. “I know. And so does the family. This is not something he wanted” was the only comfort I could provide.
We carry our patient stories with us. From the paramedics to the nurses, the intensity of the resuscitation experience is severe. It is difficult to reach that level of focus on a goal only to be told to stop. We feel a sense of loss. Our instinct is to resist, to defend our patient, to advocate for them as we do all the time. It is difficult to understand that the person who’s very life we are struggling to maintain, would have wanted something else. This is the reason that end of life or palliative care seems so foreign in the ED. We constantly battle death, resuscitate, and strive to stabilize long enough for a definitive intervention. In that setting, it takes a significant re-orientation to allow the natural course of a disease to take place without intervention from us.
There is no doubt in my mind that the decision made that day was the right one. I pray that the patient’s family has the same peace. It was a difficult decision for them, and one that could have been eased by a deliberate conversation with the patient before that day. All too commonly I hear that family was intending to have the conversation at the right time. Don’t wait. There isn’t going to be a time when it feels comfortable to do it. Often it is relegated to the primary care physician to discuss these issues, but all of us should be discussing it. We think of it as a difficult conversation for the patient, but if we wait it will be worse for the survivors being asked to make decisions. Take some time and start the conversation today. Few things in life are more important.