Night Shift
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A sense of sadness and doom struck me as I entered the room. 78-year-old female, chief complaint: sent in by home health nurse. “One of those,” I thought. Alone, elderly, contractures of both left extremities, vitals normal, no dyspnea, well dressed and groomed. No suitcase sign. Awake and in no distress, but hasn’t made eye contact yet.

“I’m Dr. DeLucia. How can I help you tonight?” I asked, somewhat reluctantly.
She turned slowly and then stared at me with deep brown eyes surrounded by wrinkled bags of skin.

“I just want to die at home,” she said. “There is nothing you can do for me. My home nurse didn’t want me to be alone. Called the ambulance when she left.” As she talked and moved she became slightly short of breath. Her pulse oximeter was 90, borderline for her age. More to gain rapport than to diagnose, I placed my hands and stethoscope on her and listened. Slight rhonchi echoed in the left lower lobe.

“Hear the cancer?” she asked. “My husband gave it to me. He didn’t leave me much, but he left me that. Second hand smoke. The bastard. I loved him so much. He would have lived forever if he didn’t smoke. Strong as an ox. I breathed his fumes for 48 years. We didn’t make it to 50.” The grief and loneliness was evident.

I suggested a chest X-ray and some blood work to see if she had pneumonia. I tried to question her more about symptoms.

“Are you listening?” she accused. “I have cancer. When I came in here for my stroke last year they saw spots on my brain. It came from my lung or should I say from my husband’s lungs. They’ve already done so much. Chemo, radiation, drugs, drugs, drugs! Cost me a fortune in co-pays! What are you trying to do; pay off your fancy, foreign car?”

With some chagrin, I told her I drove a Ford. I got closer and examined her more. She seemed to like the closeness and being touched. No fever. No other rhonchi or rales. There was maybe just a touch of edema in both lower extremities. No JVD. Mucous membranes were just slightly dry. Skin turgor and color good.

She could still have pneumonia, I tried to convince myself. She’s inactive with cancer. A good candidate for a DVT or PE. Worse yet, what if the cancer is advancing? She’s acting fatigued and tired. It could be an atypical presentation of a MI. I tried to be more assertive this time. In my best authoritative, doctor voice I informed her I was going to do blood work, CXR, EKG, and CT scans.

“For what?” she barked. “You’re going get me to walk again? You’re going to make me young again? We all gotta die sometime. Can’t you deal with it?”

It finally hit home. I often wondered if I was attracted to emergency medicine to cheat death, to beat the grim reaper at his own game, to play chess with God.

“I just don’t want to miss anything,” I explained. Emergency physicians always fear the comebacks with a missed diagnosis.

“We doing this for you or for me?” she snapped back. “If we’re doing this to maintain your batting average, you pay, I’ll do it.”

I had to excuse myself. I told her I was going to look over her records. She came in almost a year ago with sudden onset of left hemiplegia. Right middle cerebral artery CVA. CT found a few spots, underwent more CTs and PET scans. Lung biopsy confirmed non small cell cancer. MediPort insertion, multiple rounds of chemo then radiation. Multiple admissions for complications and side effects of same. This poor lady has been through hell. It gave her more time, I argued with myself, trying to justify not only the cost but also her discomfort this past year.

I returned to her room, bringing juice as a peace offering.

“What is it with you people and juice? What about a good strong cup of coffee?”

Finally a bargaining point: “If you tell me what I can do for you, I’ll get you a cup of coffee.”

“I just want to die in the home where I lived with my husband and children. I want something to leave my kids. I don’t want the government to take everything to pay for all these tests that don’t matter to me.”

I questioned her about her children, wondering if they were here and if they should be part of the decision process.

“I’m old, not stupid. I don’t need any one to tell me what to do. My kids are spread all over the country. You know the way it is today. Very successful kids. My husband and me, children of immigrants, worked till we got blisters our whole lives. All we wanted was for our kids to get educated. They did. My sons a doctor. Not like you. He’s a surgeon, built up a big practice. He can’t move or leave on the drop of a dime for me. Are you going to specialize?”

Ignoring her last question, I attempted to determine their involvement. “I’m sure they love you and want what’s best for you.”

“Of course they do, always sending me stuff, always visiting. It’s tiring. They offer to move me close to them, send me tickets. I don’t want to leave my home. Which kid would I move in with? We worked so they would be successful.” She hesitated, becoming more solemn. I leaned closer. “I wish I could die like my Grandmother,” she said feebly. Dumbfounded, not knowing my next move, I just listened. “I was just a kid. We were all sitting around after Sunday dinner. Back then we all lived together. Too poor to have our own place. Grandmom just slumps forward. Just like me, her whole left side becomes useless. We help her to the couch and call the doctor.”

“You mean the ambulance?” I said.

“Ambulance? What ambulance? We called the doctor! He comes to our house in less time then I had to wait for you. He examines Grandmom, tells us she had a stroke. No tests, no Cat scans. That’s a doctor. He helps make her comfortable. A few minutes later she dies. All of us holding her hands, telling her how much we love her.”

“But today we could have helped her,” I said, wanting to justify my existence. “We could have given her more time.”

“And take that away from her? She was happy to the end. This past year has not been happy for me. And Dr. Robin didn’t even want to charge us. We paid him his usual fee of $20. That included the shots.”

“Shots?” Home TPA? Did Dr. Robin euthanize Grandmom?

“Shots for my aunts and mother. They were hysterical. It calmed them down. Dr. Robin stayed there until he knew we were all going to be OK.”

As sharp as a tack. Her memory was so intact. She had so much more living to do. I was not ready for her to give up. Realistically, I knew her time was short. “Aren’t there things you want to do, people you want to see?”

“Yes of course. If I could, I would live forever. I know I’m getting worse. I know there has to be something from all this that is eventually going to kill me. I can’t do much. My life now is sitting in my home, reminiscing, looking at mementos from the past and waiting for someone to visit. If death takes that from me – or you do by putting me in the hospital – makes no difference to me. I’ve lived without regrets and know I am loved.”

I wondered if she knew how right she was. Some terminal event would come along and take her. If it was a pneumonia or PE, either way we would have to take her from her life to diagnose and treat her. Even with expensive, uncomfortable tests and treatment her time was limited.

Let me do just one X-ray, I pleaded. I would call social services to see if we could increase her home services and get her placed on hospice.

Feeling bad for me, she allowed me to do her chest X-ray. The X-ray showed her mass enlarging and causing obstructive pneumonia. She eventually admitted she was having some chills and sweats. She agreed to allow me to prescribe oral antibiotics for home and promised me she would take them.

Social services saw her. They were able to get her on hospice and increase her home services.

She called her daughter, who was more than willing to drive the 2 hours from out of town to take her mom home. I got to know her a little more that evening. As she left, she pointed to me, telling her family, “That’s my doctor.”

The shift went on, days and patients flew by. A week later, I was relieving my colleague who was in with a cardiac arrest. He was coding the old woman I had sent home to hospice. Apparently the home health nurse had gotten excited and called EMS. I immediately stopped the code. She had clearly stated she did not want this. I held her hand and whispered that she was loved.

My colleague could see the pain in my face. “What’s wrong, Joe,” he asked, “do you think you missed something?”

“No, I didn’t miss a thing,” I told him, “I listened to every word she said.”

Where is Dr. Robin when you need him?

Comments   

# Yvonne ED RN 2009-06-14 16:12
Thank you. I cried.We all should be able to die in the manner in which we want to live.With Dignity.
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# MDNancyJG 2009-06-19 07:18
Terrific story! I have spent a lot of time with families, letting them know what it meant to code their terminally ill family member; I probably got more 'no code' orders out of the ER than the oncologists. Warning though; after hours of ER observation, allowed another elderly lady to "go home to die," documented this in great detail and arranged for home health to visit less than 8 hours later. Her family sued me for elder abuse and abandonment; my only lawsuit in 26 years of Emergency Medicine; I prevailed, but not a fun experience.
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# Night shift ruminationsEllen Taliaferro MD 2009-07-03 01:02
I quite enjoyed this story and your ability to capture the nugget of truth from the patient as well as your coping with it all. Well written: brings smiles and tears. Thank you for taking the time to write this up and share it with us.

My Health After Trauma second quarter ezine came out yesterday and I featured your article in it. You can see it at http://www.healthaftertrauma.com/2Q2009-eZine.html

Ellen
Reply
# raluca micu rn 2009-07-08 05:47
I could barely contain my tears by the end, and as an ICU nurse, I think my patients' families and most of their doctors need to read and reread this article. Thank you.
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