A few weeks ago I had a patient named Helen who died. I’m not talking about a dramatic code or trauma, with people running around shouting for IV access, but rather an elderly woman who was at the end of her natural life. Dying in the Emergency Department is not ideal by any stretch of the imagination, but very frequently does happen — and will happen so long as hospitals treat EDs as medical/surgery/ICU overflow units. EDs are noisy, the stretchers are narrow and hard, there is no privacy, the lights are on all the time, and ED nurses, frankly, have limited knowledge of providing end-of-life care and don’t have the time to provide the thorough care dying patients deserve. To my way of thinking, the ED is one of the awfullest places to spend your last hours.
Worse still is dying alone in the ED. My patient had a single child, a daughter, who seemed dedicated but clearly was exhausted by the exigencies looking after someone who was dying by inches from a Grade IV left ventricle. The day I cared for this patient, it was pretty evident she wasn’t going to last the day. She had the death-is-near-me look all experienced nurses recognize. Her blood pressure was failing, she was more-or-less comatose, are her breathing was becoming irregular. Helen’s daughter needed to leave to rest. She was well prepared for the inevitability of her mother’s death: there was no drama or bedside hysterics, and she recognized her mother might die in her absence.
A little while after her daughter left I noticed her pulse had dropped into the 30s; by the time I got to her bedside a minute later, her respirations were agonal. “Oh Helen,” I whispered, “go gently.” As I held her hands she drew her last breath and died peacefully. In my experience, this is how most people die, without fuss or bother. I felt honoured and privileged to be present. I won’t pretend my presence was anything but accidental. If I had been busy with another patient, she would have died alone, with a dimmed light over her head, and the pulse oximetry mindlessly recording the fall in her blood oxygen level. I know very often patients die alone, not only in the ED but all over the hospital, where there deaths unmarked and unwitnessed by anyone. It’s said death is the loneliest journey, and the pathos of dying alone is nearly overwhelming.
I get that sometimes it’s not possible for nurses in the ED (or elsewhere) to provide the end-of-life care in a way that honours, comforts and respects the dying, nor can families always step up and provide emotional support at the time of death. But even so, I think despite our rhetoric about dying with dignity, we actually don’t as a profession or as society at large care much about it. Witness Helen or a thousand other patients.