Hard to Let Go

For the past 2-3 weeks, one of the patients in our intermediate care unit had been slowly circling the drain. I took care of her for four days last week, and by that time no one really remembered the initial reason she got admitted. Back then she was awake and oriented x3; by the time I "inherited" her from my partners she was unresponsive and could only moan to show she was uncomfortable. Her kidneys were slowly failing and she could no longer swallow, depending on TPN to fulfill her nutrition requirements. Essentially, she had become a vegetable, and everyone believed she was more suited for hospice care...except one particular daughter.

The patient had three daughters; one of them was the medical power of attorney. She did not trust the medical system because one of her former neighbors was a nurse who was apparently arrested for euthanizing patients, and in her love and devotion for her mother she refused to make her DNR. My previous partners spoke to her on a regular basis to try to get her to change the patient's code status to DNR, but she always refused. "My mother would have died six years ago if I made her DNR and didn't fight for her," she said. She insisted that we were "missing something" when the patient first became unresponsive; talking to her was like talking to a brick wall. The first day I assumed care for the patient, I must have spoken to her daughter for about twenty-five minutes about overall prognosis and what the daughter wanted for her mother. Her goal: keep Mom in the hospital for the next few weeks while her house finishes remodeling, and then bring her home. Stopping the TPN was not an option; "I'm not going to starve Mom to death." She thought her mother was not a candidate for a J-tube b/c of her hiatal hernia, and she said she read about massage techniques on the Internet that are supposed to help resolve a hiatal hernia. "Does the hospital offer massage services?" she asked. Yes, but not for free. She stated that she once counted 8 people in the same day who tried to tell her to change her mother's code status, and she didn't feel that the time was right yet. She also claimed that I was the first person to mention hospice to her, which I know is not true.

I could go on and on about how frustrating it was to speak to this woman, who was pleasant enough but just did not have the brain cells to listen to us. One of her sisters accused her of "torturing Mom," and she in turn accused her sister of being after their mother's will and money. Even the patient's oncologist, who is one of the most patient people I've ever met, became so frustrated with the MPOA daughter that he refused to speak to her anymore; that was bad. I could not see an endpoint with this woman, so I tried telling her that the hospital was no longer the best place for her mother, that she'd be better off at a nursing home (ideally with hospice services). "Wait a minute," she said. "All these weeks, people have been telling me that my mother could die any second, and now you're telling me she can leave the hospital?" Fortunately I was off that weekend so I didn't have to deal with her anymore, and she was assigned to another of our partners who's very good at talking to families about hospice and end of life care. He welcomed the challenge, but even he butted heads with her daughter because he wasn't afraid to say the things that we all tried to approach delicately with her. Since hospice wouldn't pay for TPN, he tried to find the cost of the TPN that the daughter would have to pay (which she had no plans to do as long as pt was in the hospital). Even still, he did one thing no one else could do for weeks: he convinced the daughter to make her DNR.

Two days after her code status changed, I heard an overhead Code Blue to her room. I wondered what had happened, but since I was in the ER I couldn't investigate. I later learned from nurse's notes and the partner who had her last that the daughter had apparently given her mother some mouth swabs, and when she tolerated that well, offered her sips of water (after the woman was NPO for over 2 weeks!) The patient promptly began coughing, likely aspirated, and suddenly became unresponsive. Fortunately she was already DNR and no CPR was done, allowing her to pass as peacefully as she could under the circumstances. Afterwards the daughter asked if she had caused this to happen, if her mother's death was her fault. I wonder how the nurses and MDs answered her. My partner stated that he thought it was fitting that the patient aspirated on water that her daughter gave her, but it wasn't funny at all. No one should have to live with the knowledge that his/her actions let to a loved one's death.

Even still, I think everyone felt a sense of relief that this woman's suffering had come to an end. "It was her time," one person said practically. It certainly was.