Monday, December 15, 2008

Confession

I wish I could always claim altruism when taking care of dying patients. But the truth is, there are times other priorities in my life try to stake a claim in my work.

This happened last week at work. I had met with a lovely family to discuss our plan for their loved one who was on a ventilator, not responding, and likely permanently stuck like this.  He'd had the most aggressive care possible, but it seemed brain damage was irreversible. In the family meeting they told stories of his great accomplishments and were very clear that living a life on a vent with artificial nutrition through a feeding tube in his stomach, in a nursing home somewhere, was not something he would have wanted.

The decision was made then to withdraw the aggressive measures in place. We'd remove the ventilator and antibiotics and support him as his body transitioned to a dying process. We always warn families the process is unpredictable in terms of time frame. He may live minutes or days, something I wouldn't really know until he was off machines.

It was a very peaceful process. The family was all in the room. We removed the breathing tube. Took off all the other tubes and wires, beeps and buzzes, and let them just be with him.  It was evident he'd been very sick, because he really made no effort to breath on his own. I prepared the family it would be more in the minutes range and left them to be with him.

Sometimes the monitors out in the nurses station still record the electrical telemetry from the heat. I'm not as used to this, as usually everything is turned off, but in this case I could look at a little computer monitor to see his heart still beating.

Here's the confession. With my husband out of town this month, I'm the one to pick up our daughter from daycare. I'd already stayed in the hospital longer than I usually do, and was keenly aware as I watched the blip of this mans heart, that each blip was time getting later and later. As it began to get slower and slower, I found myself mentally coaxing the heart to stop. "'c'mon, let that be the last beat. I've got to go!"

I know, how callous! When I realized what I was doing I was immediately disappointed in myself. This bleep on the screen signified a person's life...by hoping it would stop soon, I was essentially wishing this man dead.  Not for some noble reason, like to end his suffering, but so that I could pick up my daughter on time from day care. 

That's my confession. And my apology to this man's soul, who's heart did stop. And to his family, who weeped at his bedside and hugged me in gratitude for helping him die peacefully, not realizing my hidden selfishness. 


Monday, December 8, 2008

Toddlers at work

I lead a lot of family meetings for my job. This week, I felt like I was mediating a bunch of toddlers at one such meeting. The sad thing is the fighting had little to do with the actual health of my patient.

The background: Mr Jones, 60's, came into the hospital with bad emphysema. The woman with him identified herself as his wife. She then became the primary contact for decisions as he got sicker. "Shall we do this surgery Mrs Jones?" and she directed the doctors on what he'd want. It got to a point that he was on the ventilator and required neurosurgery for extra fluid on his brain. At this time, she decided to call the rest of the family who lives out of town to tell them their loved one was in the ICU and critical.

Chaos ensued. A son flew into town. Two sisters drove in. All entering the ICU with steam whistling through their ears. The family was angry. There was no "Mrs. Jones", they said. This woman had been married to the patient 20 years before for only 4 months. After a restraining order and a loss of a great deal of money they divorced. She arrived at his door a few months ago, needing a place to live, with a certificate showing she was a licensed caregiver, which the patient needed. So she moved in with him.

It was in the fireworks of these two parties meeting that we were asked to intervene. The good news was that the patient was doing better, and able to get off the vent, so I could speak directly to him about his medical decisions. He could also designate who he wanted to be his decision maker in case he got ill again.

The family and ex wife still needed some help and as I met with them, I realized that true issue was not the patient and his wishes but the house he was living in. He was renting it from his out of town sisters. When they arrived in town they found the ex-wife had changed the locks and barred them ,with police force, from entering.  I guess because the patient was renting it, he had to give permission for the "landlords" (his family) to enter, and being on the vent his "wife" had that power.

Sadly for this fake wife, as the patient awoke, he was able to give that permission to his family, and her scheming began to crumble. As she began to realize the situation she emotionally started to unravel, pleading with the patient, newly off the vent and still in the ICU, to change his mind. She hysterically begged me to convince him otherwise as she'd soon be homeless. The family, not helping the situation, antagonized the woman, with threats of calling the police.

I tried, in vain, to help them talk as adults, but as they bickered and threw insults and waved different legal documents in front of each other, I began to see them as two-year-olds struggling to both play with the same toy.  My reasoning doesn't help with my own two-year-old, so why would it help now.  Like with toddlers I finally said, "Enough! Time for both parties to leave. Your fighting is hindering our care of the patient."  They did need a bit more coaxing from the hospital security before they finally left.

It's interesting what brings out the worst in people. In this case it was a house. Never mind our sweet patient who almost died, who will need good care at home once he leaves the hospital, and who emotionally is sickened to find that someone he really loved was trying once again to swindle him