Enlightenment

Chapter 1 - Denial
I have been taking care of a sweet, very sick 65 yo man admitted for lung CA with mets. His prognosis is for only weeks of life, and he was desperate to hold onto hope of survival. He said that he wanted to remain full code, "do anything you can". He was subsequently intubated (put on a ventilator) one early morning for respiratory failure, and I came in that day to start my four day week (44 hours).
He was sedated initially, but I was able to ease off the second day or so. Soon he was intubated without sedation, just a little fentanyl. He was animated, able to communicate easily, making eye contact, completely intact. He was not able to speak of course, but he made his needs known. He said again that he wanted everything done, chest compressions, paddles, you name it. Even if he were in a coma forever, he wanted to be kept alive. Jeez, now that is hardcore.

Chapter 2 - The Prologue
Ready to extubate today, day 4.
I came in, sats were 86% (you and I are 99%). He was on a breathing trial, the vent started alarming, his tidal volumes had dropped to 18 from 500, he started turning color, sats dropping to 70s, I call for assistance, he was taken off the vent and bagged, tons of secretions. Back on vent, doing better. He was coughing a lot, copious secretions through the am. Not going to extubate right now anyway...
Later the floors were being waxed with industrial waxing chemicals-- in the ICU -Nice. My room was one of the last, so I had to move my guy to the next room, uneventful, RT (Respiratory Therapist) (Frank) bagged him over. Shortly after, his daughter calls, I go to put the phone to his ear and he starts coughing out a lung (literally), he coughs out his ETT (breathing tube). ("Can you call us back in just a little bit?") It isn't as dramatic as it sounds because this sucker is strapped on like like a helmet on his face. It just tweaked enough that it was not under his vocal chords anymore and he was losing air from the system. We tried to push it in position to no avail. We called his medical team and decided to extubate and see how he fared. His sats were ok, but he wasn't coughing much out junk, we called anesthesia for possible reintubation, but decided to hold off and see how he did through the afternoon.

Chapter 3 - The Meeting
I had to go to this kiss-ass administrative meeting in the afternoon for 1 hour. I had 2 nurses watching my sweet little don't-let-me-die patient. When I came back, I found my guy on his side, mask on, sats 72, completely unresponsive- you have got to be kidding me -- "Call Anesthesia!" I rolled him over, started to bag him, my other nurses ran in. The noise from the f-ing waxing fans were so loud they couldn't hear the alarms, we got his sats back up, he is not withdrawing to pain, totally obtunded. Anesthesia intubates, my guy starts to come around.

Chapter 4 - Enlightenment
It is now 1700, my patient is totally alert. He loves me. I am the light of his world right now. I have talked with his whole family, I have led him through the last 3 days and kept him alive - barely. The Docs and I are talking in his room and he writes "I want to dirzz"(can't make out the last one). One dr writes "die" on the paper, "yeah right" I scoff. My patient looks at me and nods his head. He then writes legibly "I want to die". He motions for the tube to come out. After and hour of discussion, questions, him writing, "I don't want pain", "will it be easy?" - we allow his choice to be made after he repeats over and over that he does not want to wait till tomorrow. He has realized that he can't be saved, and he would rather go in peace.

Chapter 5 - Transition
It is now 1850, RT is called, morphine is hung, the drs ask me if I would be willing to call some family members as I am close with them. I do, then we extubate him, titrate up the morphine, and Sandy and I sit with him on the bed, holding his hands.

(Sandy and I are alike in many ways when it comes to patient devotion. We are both exceptionally loyal, not afraid to stick it to the drs, and we treat all patients as if they are our own. We have sung patients through death together, where we are the only support they have - and they are hardly ever our assigned patients. We gravitate toward families, loss, and death. We are also the loudest, funniest people on our unit. Also, we both like to drink a lot, go figure.)

1945- end of shift. I give report on my other patient (did I mention I have another guy on a vent?) I go back and sit with my little guy. He is quiet, breathing with raspy deep breaths, I give him another 5 of morphine, he is asleep and doesn't move as I spot check his sats - they are of course an ironic, laughable 97%. I said good-bye and went home.

I'll probably see him on Monday.

Hilarious