Saturday, May 31, 2008

Let me go

Mrs. Hardy is quite clearly doomed. She had a gastric bypass operation (she weighs more than 400 pounds). If anyone knows whether the hernias she developed afterwards had anything to do with the surgery, they are not saying. We have our suspicions. In any case, the hernia repairs left her with infected, perforated bowels which did not get better. When I first took care of her, all but 30 cm of her small intestines had been removed. For a couple of weeks she had been opening her eyes and looking around the room, but had been unable to respond to her name or connect with anyone. The 3’X 4’cavern where her guts once were was now filled with black vacuum sponges and covered with an airtight dressing. Two suction tubes hooked into this dressing pulled about a liter of pinkish yellow fluid off every hour and it was the nurse’s responsibility to measure this and infuse an equivalent amount of IV fluid every hour of so to prevent her from becoming dehydrated.

Any nurse knew within 5 minutes of starting to take care of Mrs. Hardy that she did not have a prayer of getting better. We see it all the time. This is going to be nothing but a long, drawn out, agonizing death. A nurse of some experience once explained to me, without any malice, that morbidly obese patients are like whales and the bed is the beach. The longer they are trapped in bed, the harder it is for them to get back up. In bed they develop sores, their muscles waste away, infections set in and they end up “circling the drain.” So when I heard in report that Mrs. Hardy had been listed for a small intestine transplant, I was disgusted. This would be nothing short of a science experiment. She was already too far gone to get better even if her intestines were intact. There is something very evil about the whole transplant industry, but I will write about that another day. I decided to make it a priority to get the palliative care team involved in managing her end of life care

Mrs. Hardy’s pain medications had been stopped more than a week ago when it was noticed that she was not responding. Still no change. I got into a difficult spot with the attending physician when, upon being asked, I mentioned the possibility of brain damage to the family. I expected that, after more than a week, I would not have been the first to do so, but Mrs. Hardy’s daughter had become alarmed. “Brain damage! No one has said anything about brain damage!” I went with some urgency to try to get the attending to speak with them and was chastised. All of her brain scans were negative for damage. Her condition was related to her blood infections and although it might well be permanent, I should not have said “brain damage.” He was annoyed at this extra task I had now forced on him. I thought about how I could have said it differently, but could not come up with anything.

The palliative care nurse, Susan, came by in the morning to see another patient (palliative care is often busy in the surgical ICU) and I caught her in the hall. I gave her a quick summary and my conclusion that Mrs. Hardy should not be used as a guinea pig. She agreed and asked me to page her so that she could be present for rounds. I did so, and when the physicians were discussing Mrs. Hardy’s case, Susan asked directly if they felt it was appropriate for her to be involved. The attending physician replied very much in the affirmative. Even if everything went perfectly, Mrs. Hardy would still have no quality of life.

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