A few days ago a 70ish-year-old patient arrived by EMS, end-stage liver cancer, sent in by her family because she was “not feeling well”. From home. No advance directives. She was frail and obviously unwell, jaundiced, her abdomen distended by ascites. EMS reported she was vomiting blood on the way in; her pulse was racing, her blood pressure was dropping. I asked her the paramedics to offload her into a Resus Room bed, and I followed in to help EMS lift the patient into the emerg stretcher and to help the primary nurse with the assessment.
The patient looked me in the eye, a look, I think, of astonishment, vomited once, and coded. We did the usual: called the code, started chest compressions (and fracturing ribs in the process), started IVs (the paramedic were unable to get a line), pushed drugs, until the family arrived and the physician went out to speak to them. There was a lot of blood. She was PEA; she had likely bled out from some complication of cancer. A pump needs fluid to work. A few minutes later the physician returned and pronounced death.
It was a bad death. I’ve seen several deaths like this in my years in the emergency department, concerned family sending in people at the verge of death or nursing homes calling EMS for residents at the end of life (at the behest of families or physicians responsible) who end by dying within minutes or hours of arrival. Some of them have elaborate direction for the end of life (but are ignored by well-meaning, or to be less charitable, indifferent family members); others, like this patient, seemed to have no sort of plan at all, despite being considered terminally ill.
I get that families sometimes cannot cope at home with desperately ill family members, or they live in a state of denial, or that they sometimes panic at the end of life; staffing issues in nursing homes make it difficult to carry out end-of-life directives, or institutional hospice care is often limited, or sometimes people near the end of life are unclear about the options available to them, that dying at home, comfortable in familiar surroundings is feasible and even desirable. But the alternative, dying on an emergency department stretcher with cracked ribs and all manner of other pointless physical indignities inflicted, seems grotesque, demeaning and otherwise an unworthy way to end a life.
Those Emergency Blues 
#1 by Jenn Jilks on Sunday 03 October 2010 - 1447
Truly, another bad death. It need not be so.
I understand, as a caregiver, that one is always afraid of NOT doing something. All it takes is a connection with some professionals who will be able to explain the end stages, what to expect, and how to make the person comfortable.
Fortunately, there are many who are ensuring that good deaths happen, too.
Thank you for sharing this tragic tale. It can be prevented with education, experience, and a guiding hand. All we caregivers need is truth from Primary Care Teams, and palliative care teams with information.
#2 by Caroline on Sunday 03 October 2010 - 1615
Not sure how I feel about publicly terming it a “bad death” where friends and family might be upset about it, and possibly feel guilty. As a nurse I constantly wanted to write public stories about this exact type (or at least uncannily similar) of thing, but restrained myself. Unfortunately there aren’t many other public avenues to vent and discuss these type of events, and this helps lead to amplified stress and burnout. However, there are other avenues…
#3 by torontoemerg on Monday 04 October 2010 - 1308
Hi Caroline — thanks for reading and commenting. I think you’re addressing a couple of different issues. First, confidentiality. Long time readers will know I take confidentiality very seriously, and please be assured there is no likelihood that any family members reading this blog will recognize the deceased I wrote about. Secondly, my intention is not so much to vent, but to get readers to consider their own death — and how they want to arrange it. Of course, no death is “good,” but you know, as an RN, that some are much better than others, especially those which respect the inherent dignity and autonomy of the patient.
#4 by Nicki on Monday 04 October 2010 - 1001
Newly following you and can’t wait to read your stuff. I am an EMT so I am looking forward to your blog entries!
#5 by Nicki on Monday 04 October 2010 - 1019
Ok, I got the chance to read this and I may sound cold to those who are not in the emergency field but I agree with you that there are better ways to die. Where I work, there are certain circumstances when we can “call it” onscene rather than transporting the patient to the hospital. Sometimes it is better to transport because the family will feel better knowing we did all we could but if I know the patient is going to die anyway, I feel it is sometimes better that we not transport. It gets messy for the patient and the family. The patient is in worse physical condition because of our rescue efforts (cracked ribs, bruising from IV’s or IV attempts) and I feel the patient and family members experience more pain in the long run. Add to that driving to the hospital during a crisis (not safe) and hospital bills to deal with when the patient could have died at home. I repeat, sometimes it is worth transporting but when we KNOW the patient is going to die and when the family knows that deep inside, sometimes we can allow the patient to die with more dignity.
#6 by torontoemerg on Monday 04 October 2010 - 1310
Thanks Nicki and welcome. And thanks for the link-love — I will reciprocate.