Saturday, July 19, 2008

Final post on Mrs. Hardy

I was off for five days and returned expecting to hear the story of Mrs. Hardy’s passing, but she was still hanging on. There had been another family meeting and she now had “do not resuscitate” (DNR) orders in place. She also had orders for no further escalation of care. Even though her systolic blood pressures were now in the mid to low eighties and her heart rate had dropped to the 50’s, her Levo drip would be left at the same dose it was at when the do not escalate orders were put in place (4 mics). I asked her nurse, Mark, for the stories from the last few days and he was glad to tell them.

Mrs. Hardy had had three dialysis treatments over the last five days to correct her critical metabolic acidosis. This had brought her back from the brink, but she continued to decline slowly and would have required continuous dialysis. “How aggressive do we want to be, considering her condition?,” someone from the renal team had asked.

Susan had gone on vacation and Debbie, a bolder, more experienced palliative care nurse, had taken over the case. She had decided to put an end to the farce. There had been a family meeting the day before. Lori was Mrs. Hardy’s nurse that day, and she made Mrs. Hardy’s children stay in the room with her for the dressing change - just before the meeting. They were shocked apparently. “This is never going to heal. Do you understand that?” Lori told them. Debbie caught the attending before the family meeting and explained things to him (she told me the story herself). She told him that the family needed to be told what care the doctor felt was appropriate, not asked what they thought was best. In the meeting, she told the family that this meeting was not going to be about their needs, like the last two had been, but was going to be about Mrs. Hardy’s needs. The son would just have to figure out where he was going to live, and what to do without that check he was getting (Debbie confirmed this as being part of the problem). The family agreed to make Mrs. Hardy a DNR without escalation. Lori had wanted to withdraw care right away, but Debbie was concerned that pushing too hard might have undone the progress they had just made. Mrs. Hardy had already had to wait three months. Another day would not be the worst outcome.

As the day passed Mrs. Hardy’s systolic pressures dropped into the seventies and her heart rate slowed to the forties. Everyone kept asking about the children. The oldest son and the daughter had said they would return, but they did not show. The younger son was going to stay away. Mrs. Hardy was dieing very slowly, all alone. I left at 7:30, expecting her to pass during the night.

The next morning, Mrs. Hardy’s systolic pressures were in the sixties and her heart rate was in the 30’s. Most people’s hearts would have given out by now. The night nurse related that Mrs. Hardy had opened her mouth to allow her oral care upon being requested to do so. Her eyes were half open with almost no movement. It was hard to tell if she could see or not. Her children had decided not to come. As I stood at the entrance to her room, pausing to watch her and the monitor, Laura came up behind me. “Did you hear what the daughter said? ‘Go ahead and pull the plug!’ If I could shoot someone right now…, but I do not have the time.” Laura was taking the charge nurse role for the first time this week. She checked on us every two hours.

Mark was taking care of Mrs. Hardy again today. The children had told him they were ready for care to be withdrawn, but they had not spoken with the physicians. The new residents were not sure if the attending needed to speak with the family, and had put it off for rounds. On rounds the attending instructed the resident to call the family for confirmation, but this was put off until after rounds. Even after rounds, the resident could not be bothered. There were a few sick patients on the unit that needed attention, and it was clearly a low priority for them. Mark had taken care of Mrs. Hardy more than any other nurse on the unit and his frustration was evident. He kept asking the doctors to call. They kept putting him off.

Debbie arrived in the afternoon. She had had other engagements in the morning. She got on the phone to call the children right away, fielding two calls at a time from the siblings. She caught the attending as he was walking by and put him on the phone with them. We would turn off the Levo and take Mrs. Hardy off of the vent. Mark thanked Debbie for her help. Debbie joked about killing patients off, showing awareness of possible other perspectives on what she was doing. “This should have been done a long time ago,” I said, not that she needed to hear it from me.

Mark started an ativan drip. Debbie grabbed Joe (the extern) and a brand new nurse who had just started orientation on the SICU to be present in the room. Even with everything off, it still took a couple of hours. About three quarters of the way through, I came around the closed curtain into the room. Mrs. Hardy, now off the vent, was taking agonal breaths. She did not seem to be in pain. The room was dark and the new nurse was standing close to her face. “Has it always been that color?” she asked. Debbie replied that she was getting a little cyanotic at this point. I did not disapprove, but thought about how different it would be if family was present. Her lifeless body was still in the room at the end of the shift. The night shift did the tagging and bagging. By morning there was another patient in the room. And do you know what? His story is not too much different from hers.

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