How does one determine the end of another’s life? How does one know when the best option is really to let nature run its course and allow the body to naturally shut down? When do fervent prayers for a miracle need to be shifted into prayers for hope, strength, and healing in the years to come?
Questions like these are frequent in the hospital setting. Many patients come in for a slight pain or elective procedure and are diagnosed with terminal illnesses. Some never leave the hospital and others are readmitted shortly after discharge. Many patients do not fill out advanced directives before terminal events, making family decisions challenging and burdensome for the appointed surrogate who must make the above decisions.
Imagine a middle-aged woman being diagnosed with metastatic, stage IV cancer. She is a “frequent flyer” back and forth from the hospital to the nursing home. She is “call-light heavy” and asks for minor things every thirty minutes such as her pillow fluffed, right leg moved in the bed, or to be pulled up a couple more inches to the top of the bed. Then, imagine family issues as she has no advance directives, is borderline confused, and the family disagrees on the plan of care. It is a disaster.
Now, the patient has returned, each time getting progressively weaker and lethargic. She doesn’t call as much and staff is concerned because we know she is far from her baseline. Her prognosis, originally at one year, now at only a few weeks.
Discussions about hospice and comfort measures were repeatedly getting declined by family. The patient remained a full code as she was actively dying with her respirations becoming slower and labored, blood pressure in the 70s systolic, level of consciousness decreasing, and PO intake next to nothing for several days.
Nurses would sit outside of her room with a crash cart just watching her breathe and observing the fluctuating O2 sats. We realized at the end, that her family did not want to be the one to make the decisions about neglecting CPR and opting for comfort measures. Eventually, the doctor strongly encouraged and at roughly 14 days inpatient, actively dying, the patient was transitioned to comfort care.
This is not a story of simply ordering a DNR/DNI because staff didn’t want to participate in a code; it was a matter of the patient being under serious trauma and probably wouldn’t survive CPR alone, let alone intubation for the prolonged future. Media often portrays a false sense of CPR effectiveness and does not consider the trauma that comes along with compressions, defibrillation, and subsequent ventilation. In-hospital CPR survival- discharge rates on average are roughly 25% according to the NIH. The patient was dying, but her prognosis was originally set for several more months and the family kept repeating that “she had more time.” They held on to this hope in the midst of the patient’s rapid decline.
Speaking to patients about advanced directives before they are in these situations is so important. It was heartbreaking following this case for weeks with no progress and false hopes.
Until next shift,
Shania