Posts Tagged death

Favourite Poems LVII: Death

The first two lines — “Because I could not stop for Death,/He kindly stopped for me” — must be among the greatest opening lines of any poem.


Because I could not stop for Death,
He kindly stopped for me;
The carriage held but just ourselves
And Immortality.

We slowly drove, he knew no haste,
And I had put away
My labor, and my leisure too,
For his civility.

We passed the school, where children strove
At recess, in the ring;
We passed the fields of gazing grain,
We passed the setting sun.

Or rather, he passed us;
The dews grew quivering and chill,
For only gossamer my gown,
My tippet only tulle.

We paused before a house that seemed
A swelling of the ground;
The roof was scarcely visible,
The cornice but a mound.

Since then ’tis centuries, and yet each
Feels shorter than the day
I first surmised the horses’ heads
Were toward eternity.

— Emily Dickenson

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Dying Alone

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.

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How Mr. Jones Died

Mr. Jones was 83-years-old when he died. He came to us by ambulance from with shortness of breath beginning a little after lunch. He was from a nursing home; he had the alphabet soup of morbidities: CHF, CVA, NIDDM, CAD, COPD  — topped off by dementia related Parkinson’s.

He had pancreatic cancer, and plainly, he was dying. His advanced directives, outlining the plan for end-of-life care stated no heroic measures, but if he became seriously ill, he was to be transported to the emergency department for evaluation.

The nursing home where he lived did just that. He went through the usual emergency department process — seen, treatment started and referred to the internist for admission — all the while obtunded and gasping for air, despite the high flow oxygen. He  was a tall man, broad-shouldered; he lay restless in the narrow emergency department stretcher, his gnarled feet hanging over the end.

A flood of patients had deluged the hospital. There were no beds upstairs. I talked with Bed Flow and we made Mr. Jones a priority for a bed. But somehow his criteria never met bed availability, and when I came back two days later, he was still in the Observation room — and still no room on the floors. I had Housekeeping look for a regular hospital bed for him. There were already three being used in the department, and the overflow of  admitted patients meant there were none to spare. The Obs room nurses provided comfort measures, did mouth care, applied barrier cream over bony prominences, repositioned every two hours. They did what they could, but in truth, they were not palliative care nurses, a unique speciality unto itself. He never opened his eyes and he died by inches. Mr. Jones finally went three days after admission. His feet were still hanging over the end as we packed him away in the body bag and sent him to the morgue.

For the nurses, who knew what care Mr. Jones deserved, the experience was distressing. For the family, it was devastating, a layer of suffering over grief. For the patient himself, we can only hope he knew little and felt less.

There is absolutely no space in the system for patients like Mr. Jones — elderly, debilitated and often requiring complex amounts of care — to die with dignity. Nursing homes, despite their demographics, are very poorly equipped and frankly don’t have the resources to deal with dying patients. They dislike having dying patients; they will send them to the emergency department even when the advanced directives explicitly state the patient is not to be transported. Emergency departments are similarly not geared for end-of-life care, even though death is something we deal with frequently. We have neither equipment nor expertise; we don’t even have ready access to expertise.

And yet the case of Mr. Jones is not exceptional. How can we ensure people can die comfortably and with dignity? It’s a problem, I think, without at quick fix, but is by no means intractable or even complicated. It means explicitly recognizing that for the majority of cases, the best place to die is not in hospital, but at home or under nursing care in the community, and providing the resources to make it possible. And if such patients must come to ED, giving us the tools to do our jobs properly, so we can provide safe, competent and ethical care. That would be a good start, and a necessary one.

Because all I can think, that might be me one day. Or you.

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Thoughts on Death on a Sunny Morning

A little while ago, a woman who deeply influenced me and whom I respected greatly died. She was 89 years old. Her death was hardly unexpected: she had been in fragile health for the past couple of years, burdened principally by a failing heart. About a year ago, in a matter-of-fact way, she told me she was “ready to go home.” She missed her husband, she said, and she thought she’d had quite enough of this life.

When she did go, her death saddened me but I wasn’t distraught or overwhelmed with grief. I didn’t cry at her funeral, but smiled instead of the memories of her.  She’d had a very long and full life; she had a large and (as far as families go) loving family, she was a prominent member of the little community in which she lived; she had done many good things; she bore the discomforts of her last years with grace and good cheer. What more could you want?

I used to believe if death desensitized me, I would quit nursing and —  I don’t know, become a Gurkha and guide people up Everest. Now I think I’m just more phlegmatic about dying and death than I was as a young nurse. Perhaps I’m hardened a bit. I have seen a lot of people die, after all, and the Great Mystery is maybe not so mysterious. Most people go very gently. Deathbed drama, at least among they dying, is vanishingly rare.  If there is one gift (among many) we can receive from our patients, it’s learning how to face our own mortality — and learning how to die.

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If you’re here for the first time via Change of Shift (or have just sailed in), welcome, and feel free to put up your feet on the furniture, and look around.

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Dead Alive Dead [Updated]

Emergency Medical Services — the paramedics, in other words — use a radio system called the patch telephone (which I am sure is not the correct technical name for it) to advise us of patients who are coming to the Emergency Department. Usually these are the critically ill, need-immediate-intervention-and-treatment patients, but sometimes not. The other day we got a patch about a patient that was definitely in the Not category. The patient had died in the ambulance, and EMS was requesting permission to proceed directly to the morgue.

This happens more often than you might think. The frequent scenario is that a patient already dying is sent to the Emergency because — let’s put the best spin on it — the nursing home staff has convinced the responsible physician the patient cannot be cared for appropriately in the nursing home setting (thus rendering superfluous, of course, any strictly delineated “No Transfer to Hospital” directives from the family), or else the patient is dying at home, and the family suddenly decides they can’t cope. In any case, it must be an ugly, unpleasant way to die, bouncing along in the back of an ambulance on, say, the 401.

Imagine our immense surprise, then, when the EMS crew arrived with the patient at Triage, the monitor faintly beeping. (What, she got better?) The nursing home had in fact decided the patient — who was a DNR and a “No Transfer” — had been “poor” for the last few days, and needed “a little IV fluid to perk her up.” EMS found her unconscious with agonal respirations, and on the way to the Emerg, she died. Literally. I saw the rhythm strips myself. Asystole. For a very lengthy period of time, long enough, anyway, for the paramedics to call to ask for the morgue key.

And then, claimed the paramedic, the ambulance hit a bump on the highway — and presto! she had a heartbeat again.* When she arrived, she was in an idioventricular rhythm. Not a great rhythm, but a rhythm and a thready pulse. But more importantly, she was not breathing spontaneously. Her pupils were already fixed.

She really was dead, but her heart hadn’t gotten the message yet. So we quickly off-loaded her into a Resus Room bed, and her heart stopped a few minutes later.

Again, it needs to be reiterated: this is a very crappy way to die. It astonishes me that nursing homes, which are supposedly equipped to deal with the frail and elderly, can’t cope well with the inevitable outcome of frailty and age.


*[UPDATE] Okay, on reflection, the medics may have been pulling my leg a little on the bump. Maybe.

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Full Code

Far nearer to death than life, yet her eyes, pale blue like a set of china cups my mother once had, were suffused with light, and her eyes showed life and that was all that remained. They were mostly drowsy now and half-opened: her body was a discarded husk, wracked by strokes,  and further insulted by dementia. She recognized no one and spoke not at all. She had decubitus ulcers over each hip, deep and foul, eating into the underlying tissue; she could not lay on her back: the contractures from her strokes had pushed her frail legs up to her chest. She lay in a fetal position, at the end of life, but she had no cushion of amniotic fluid, only a thin emergency department mattress and a few pillows. She was incontinent of stool and urine, and when the ambulance off-loaded her onto the emergency stretcher, her adult brief was heavy and soaked.  The stench of piss, strong and rank with (I suspected) white cells and bacteria, was overwhelming.

She could not swallow, and this, perhaps, was the ultimate source of her problems. She had a feeding tube inserted directly into her stomach, through which she was nourished by a sophisticated version of Ensure. Patients with feeding tubes are supposed to be propped upright after feeding to avoid any regurgitation of the feed up the esophagus and into the lungs. At some point or place, this was not done; maybe her contractures made it difficult to position her, or maybe she vomited anyway. At any rate, she aspirated, and a good deal of her stomach contents passed into her lungs, in turn prompting a pneumonia.

In short: she was demented, stroked, hopelessly contracted, ulcerated (and along with any number of nontrivial comorbidities, like coronary artery disease and diabetes) — a patient with objectively no quality of life from a nursing home notorious for providing poor patient care. She was febrile, hypotensive, dehydrated and probably septic. And after 89 years, 6 months, and twelve days and maybe 3 1/2 billion heart beats, she was dying at last.

According to the nursing home notes sent with her, she was a full code.

Full code means, if a patient has a cardiac or respiratory arrest, we are ethically and legally obliged to perform life-saving measures. We go full tilt. Rib cracking compressions, intubation, defibrillation, various push medications and infusions to prolong life, in this case, for a few hours or days.

We cleaned her up and assessed her, started an IV and the antibiotics, and after a while, her daughter arrived looking older, I thought, than the date that would show on her birth certificate. She sat by her mother, and even so, she looked lonely, worried, unhappy. She stroked her mother’s hair, all the time looking for those eyes, now closed.

I asked her about her mothers wishes, and what would she would want if she knew she was dying. I asked her about what she understood about resuscitation, and discussed with her all the treatment options. Finally, I asked what she wanted us to do in case her mother’s heart stopped.

She seemed puzzled by the question. She considered, and then said with unintentional humour, “Maybe a little shock or two to help her.”

I suppressed a smile, tried another tack. I asked her about her mother’s life. Silence for a moment, then she told me about her mother, who did “nothing important” but carried the burden of a drunken, abusive husband for forty-five years, until he mercifully died in 1988; after which her mother seemed to bloom for a season of five or six years, until the first stroke, and then a second left her nearly completely debilitated.

Was there conciousness at all behind those blue eyes? I wondered. What would she want?

I went through all the treatment options again, while she held her mother’s hand. I talked about quality of life, and futility and dignity.

“She wasn’t important,” the daughter repeated. “She never did anything exciting. I’m all that’s left of her.”  She peered anxiously at her mother’s face. She would not make eye contact with me. “She has me and I have her.”

I got it, at last: she wasn’t ready to have the conversation.

I thanked her for her time and assured her her wishes would be respected.

I thought: full code granted her mother importance, as if we  in attending to her death we would give life significance. Full code meant her life had value and meaning, after a life of seeming meaninglessness. And at the end, all they both had left was each other.

I flipped through the chart to the nursing notes, and set pen to paper. I started to write: “Full code. . .”

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On Death and Dying

A couple of articles of note, both longish, but definitely worth reading. For nurses, in any setting, providing care around death and dying is probably the most profound and meaningful thing we can do — and I have seen nurses do it exceedingly well, with sensitivity and empathy. Excerpts:

The Last Hours of Living: Practical Advice for Clinicians

Clinical competence, willingness to educate and calm, and empathic reassurance are critical to helping patients and families in the last hours of living. For most dying patients, predictable physiologic changes occur. Management principles are the same at home or in a healthcare institution. However, death in an institution requires accommodations that include ensuring privacy, cultural observances, and communication that may not be customary.

In anticipation of the event, it helps to inform the family and other professionals about what to do and what to expect, including matters such as when rigor mortis sets in, and how to call the funeral home, say goodbye, and move the body. Care does not end until the clinician has helped the family with their grief reactions and helped those with complicated grief to get care. Care at the end of life is an important responsibility for every health professional, and there is a body of knowledge to guide care.

Life Review in Critical Care: Possibilities at the End of Life

When any form of life review is undertaken, a life is examined, and questions such as the following are asked: Who am I? How did I do? How did I live my life? Thus, an important difference between reminiscence and review must be addressed. Life review is “not a random sharing of pleasurable past events, but rather a structured process containing a component of self-evaluation.”  Life review can be used with both patients and patients’ families; the outcomes include increased life satisfaction and accomplishment, promotion of peaceful feelings, and a state of integrity. Furthermore, Garland and Garland contend that life review has a distinct purpose in end-of-life care by upholding the unique value of each person’s life. These themes are consistent with Erikson’s theories of development: the final task is ego integrity versus ego despair. Ego integrity involves acceptance of the course of one’s life, acceptance of one’s place in history, absence of death-anxiety, and satisfaction with life. In contrast, ego despair echoes in the words of the poet Robert Frost: “. . . nothing to look backward to with pride, and nothing to look forward to with hope, so now and never any different.”

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The Anti-Angst

The antidote to the Walmart-inducing existential angst I had a couple of days ago:

Think continually how many physicians are dead after often contracting their eyebrows over the sick; and how many astrologers after predicting with great pretensions the deaths of others; and how many philosophers after endless discourses on death or immortality; how many heroes after killing thousands; and how many tyrants who have used their power over men’s lives with terrible insolence as if they were immortal; and how many cities are entirely dead, so to speak, Helice and Pompeii and Herculaneum, and others innumerable. Add to the reckoning all whom thou hast known, one after another. One man after burying another has been laid out dead, and another buries him: and all this in a short time. To conclude, always observe how ephemeral and worthless human things are, and what was yesterday a little mucus to-morrow will be a mummy or ashes. Pass then through this little space of time conformably to nature, and end thy journey in content, just as an olive falls off when it is ripe, blessing nature who produced it, and thanking the tree on which it grew.

— Marcus Aurelius, Meditations IV.48

Might just be me, but I think this is particularly fitting for nurses, no?

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