A peaceful death–side by side

The author's decision to stray from the care plan brought comfort to an entire family.

By Steven L. Thomason, MD
Family Physician/Austin, TX

Doctors on call for their partners typically stick to the established care plan. The principle is simple: "Continue present care, and address new problems as they arise." But there are times when sticking to the care plan isn't enough.

I'd just settled in for Friday evening dinner with my family when my pager sounded. Glancing down, I recognized the number of the ICU nurse's station. Only five minutes before, my partner had reported to me on his patients. The fact that my pager had gone off so soon afterward wasn't a good sign.

A nurse told me that Mr. Smith—a 96-year-old nursing home resident admitted to the hospital with pneumonia—had been moved to the ICU. Mr. Smith's condition was deteriorating rapidly, so I needed to come quickly. There was something else, the nurse said. Mr. Smith's wife had also been admitted to the hospital with pneumonia.

A brief examination confirmed what I'd already anticipated: If Mr. Smith had any responsible family members present, I needed to speak to them immediately. We needed to talk about whether extraordinary measures should be taken to keep him alive. That question couldn't wait for my partner to return on Monday, and, frankly, I was somewhat frustrated that he hadn't resolved it with the family before now.

Mr. Smith's daughter was present and clearly anxious. Apparently, the nurses had already talked to her about the seriousness of her father's condition.

I went over the current plan of care in greater detail, and then asked whether her father had written any advanced directives. "No," she replied, "but I'm sure that, in a situation like this, he wouldn't have wanted any aggressive action to be taken."

I wrote "DNR" in the chart, confident in my authority to change the care plan and equally confident that I was doing right by my new patient and his family. But I wanted to do more—especially for Mr. Smith's daughter, who seemed so distraught.

Mr. Smith's wife was also my patient. Pulling a few strings, I arranged to have him moved from the ICU to her room on the seventh floor. Neither was conscious, but seeing them together was enormously comforting to their daughter. She touched their faces, held their hands, and whispered hushed words of comfort to each of them.

Neither father nor mother responded, but they may have understood more than we knew. Indeed, two days later, after I pronounced Mr. Smith dead, his daughter turned to her mother and whispered, "Daddy's gone, and it's okay." She never opened her eyes or responded in any way. But less than a half hour later, with her daughter at her side and her husband's body still in the room, Mrs. Smith quit breathing.

Their daughter was grateful for the arrangements I'd made. Being with her parents during their final time on earth was very comforting to her. I knew I'd done the right thing for the entire Smith family.

 

Steven Thomason. A peaceful death--side by side. Medical Economics Dec. 19, 2003;80:39.