Death with dignity in the emergency department

The ambulance crew rolled him into my ER breathless in his pajamas, O2 mask on his face, gasping for air, his short cropped hair a mess, standing straight up. Eugene was what the staff called a “frequent flyer.” As the nurse injected some IV Lasix I reviewed his chart to find a classic downward spiral.

It was a busy evening. The bays were full of the usual cuts, broken bones and chest pains, the waiting room with snotty noses and chronic pain patients hoping for a refill from the new kid in town. I was a freshly minted family practice doctor taking a year after residency in this rural California emergency room to take a break, get some experience and make a little money.

I came to call this “a MASH Unit in reverse.” We had no on-site surgery. It was my job to keep the life threatening cases alive until the helicopter arrived to take them to the trauma center a 40 minute flight to the south. In MASH they flew the wounded in.  Here my job was to keep them alive until we could fly them out.

I had vowed that no one would die in my Emergency Room if I could help it.  Until I met Eugene and Mary Ann.

She was a stark contrast to Eugene. Looked like she had just finished dressing to go to church on Sunday morning: immaculately pressed with perfect hair and her knitting in hand. She had obviously been here before. It was clear from the first second I laid eyes on her that she adored her husband of 56 years. Despite the mask and the respiratory distress, I could see the same love for her in the old man’s eyes.

This was his 6th visit to the ER in the last 18 months. He had a bad heart and it didn’t take much to throw him into pulmonary edema despite 14 pills and over $200/month in medication. On a good visit he spent 4 days in the hospital getting his meds adjusted. On a bad visit he was on the ventilator for 3 days and in the hospital for 10. Each time he emerged weaker. Lately he was wheelchair bound and Mary Ann had learned to deal with adult diapers and getting him around the house. This would be one of the good visits.

I sat down with them once his breathing was easier and asked, “How are you feeling about the quality of your life lately?” Mary Ann wiped some tears as Eugene told me how miserable he was, how much he hated being a burden and what a good life he and his wife had in days past.

None of us said anything for a while. Mary Ann set her knitting aside and sat as close as she could to the bed. They held hands – as the nurses said they always did.

“We can keep giving you medicine and even putting you on the breathing machine if you want, and here is what I am afraid of. It is only a matter of time before you won’t be able to get off that machine. When that happens Mary Ann will be faced with the decision of whether or not she tells the doctors to turn the machine off. I am pretty sure none of us want to put her in that position if it can be avoided. It sounds like you have been pretty miserable lately and you are getting weaker as time goes by.

I want you to know that each time you come in on the Ambulance is potentially the natural end of your life. We are stopping that with our medicines. If the two of you want, we don’t have to do that. If you two have a discussion and decide you would like the next time you come in to be the natural end of your life, and I am in the ER when you come in, I can help that happen for you.”

He was breathing easier. We switched him to the nasal cannula and his sats held. I left the room and let them talk about this new option for a few minutes.

When I returned she was standing by the bed. Eugene spoke. “We want you to help us do that doctor.” I looked them in the eyes and nodded. Both of them were crying in a way that I knew the foundation for their emotions was love – the love everyone sensed when in their presence.

I had them fill out his Living Will and No Code paperwork. Everyone wished them well as they were wheeled to the medical ward. Before the end of the shift I huddled with the staff and told them the plan, secretly hoping – and dreading – I would be on staff the next time.

6 weeks later, at 10PM on a Saturday shift, the call came in. Eugene was on his way. Severe respiratory distress. Rales to the apices. O2 mask in place.

We wheeled him into the room with Mary Ann holding his hand. Eugene was barely able to maintain his consciousness, panting with blue lips. They immediately recognized me. I looked at each in turn. They both nodded and quickly looked away. I gathered the staff and told them what we were not going to do, pulled the curtains around the bed, and held Mary Ann’s free hand.

The noises of the ER receded to a background hum. Mary Ann stroked his forehead as his breathing worsened. She gripped my hand, looking up to me from time to time.

It only took 10 minutes for Eugene to die. At the point of his last breath — we witnessed his passing — that span of seconds when we could sense his spirit leaving, almost see it happening. Joy, memories, love, grief, pain, longing for more time, relief that it was finally over, the last goodbye, filled the room.

Mary Ann was so happy, so sad, so intensely remembering all they had shared. We hugged. She thanked me and everyone on the staff.

Bittersweet doesn’t come close to the taste of that evening. Holy, sacred, the end of a life well lived and a relationship we all aspire to.

I stepped out into the full blast of the sights, smells and sounds of my next patient and the remaining 10 hours of my shift.

Eugene was the only patient I lost in the ER that year.

Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.

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  • lesliemaor

    Dear Dr.Drummond, God bless you for having the discussion with the pt and his wife, thus allowing them to decide on a DNR. I also  hope that you afforded “Eugene” judicious and liberal ativan and morphine.
    Sincerely,
    L. Cummings RN CHPN
    Solamor Hospice

    • drseno

       My thoughts exactly. I also wondered, and will post this above, whether hospice was consulted for home care in those last 6 weeks. Could have prevented that last ride to the hospital and perhaps eased the shortness of breath among other things that don’t seem quite right about dying in an er…if you can help it.

  • http://twitter.com/Hootsbudy John Ballard

    This is as good as it gets. Thanks for sharing. 

  • http://www.facebook.com/profile.php?id=1378952878 Lorette Lavine

    This is truly a death with dignity…thank you for sharing with us and with “Eugene” and his wife.

  • mia_mccabe

    I appreciate the intention of this ED doc but what about hospice? This man could have died at home peacefully without the anxiousness of being short of breath and the stress of a ambulance ride.

    • http://www.thehappymd.com/ Dike Drummond MD

       Great point Mia … and I would certainly do just that if this situation ever arises again and especially if I was his primary care doctor. I am not sure if hospice existed in that community in 1987 when this event actually occurred.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    OK, this is good and moving and definitely preferable to torturing people until the very last moment to rack up the charges. However, what is this novel obsession with death? You can’t go through one day of reading without some poignant story about the benefits of dying, quickly, peacefully, with dignity, painlessly, surrounded by loved ones, etc…… It’s getting to be a bit eerie…..

    • http://www.thehappymd.com/ Dike Drummond MD

       Margalit … no obsession. Often times the end comes after an emotionally exhausting and enormously costly prolongation of a very poor quality life. Our medical procedures can keep nearly anyone alive … which puts us in a position of having to ask the questions that I did to Eugene. He can choose his method of exit … and typically that will only occur if someone asks him how he wants to go.

      This “end of life” discussion is often avoided on both sides for obvious reasons. It is important to ask, listen and honor the person and their desires. They need solid medical advice more than ever in these final days.

      My two cents,

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

    • NEIL WHITELEY-ROSS

      No one has invented the eternity pill, yet everyone acts like we have. So, It’s about time we as a culture start talking about death and dying in “best practice” patterns so that we can wisely choose the path we want when our own time comes. So, I say bring on more of these types of stories, even the “gushy” ones…

  • eijeanMD

    The advances and limits of today’s medical technologies have put all of us in these difficult situations of choosing how we want to die and how we want our loved ones to die. Perhaps we talk about it so much because the decision is so final and it is always hard to discuss – for the doctors who’ve done it hundreds of times before to the mother whose only son understood his own prognosis and trusted her to let him go at the “right” time…but she can’t. The family dynamics and politics doctors get drawn into can sometimes be ugly and sometimes inspiring. I have seen families bite the bullet and turn off the machines, and the patient wakes up. I’ve seen families standing there trying to decide and end up witnessing a tiny portion of the resuscitation and can’t forgive themselves for not having decided sooner. Hope, uncertainty, not being ready to let go – it’s a tough balance. 

    Thanks for sharing this experience.

    • http://www.thehappymd.com/ Dike Drummond MD

      Thanks for your comment eijean. I don’t think there is such a thing as too much communication on how you want to exit this world. A friend just died unexpectedly and my girlfriend and I ended our remembering of him over dinner with a detailed discussion of how we each wanted to die and be laid to rest. Talk now. Be clear with your loved ones now. Tell your kids your desires … ask all your patients now. I feel it is an area where we really do get to choose something very, very important and you don’t want to wait until the decision point on intubation to communicate your desires.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Dr. D, it’s not you alone. It’s the confluence of similar stories all over the place that makes it a bit creepy. It wasn’t so long ago when media outlets were full of different types of stories: new medical inventions, people “battling” whatever disease and “winning against all odds”, people that should have been dead running Marathons etc.

    It seems that along with a depressed economy and spreading hardships and disparities, the national psyche is taking a turn towards an attitude that frankly, I don’t think is conducive to success.
    Sure, everybody will sooner or later die, and everybody knows that. People clinging on to their lives or to that of a loved one, are not really expecting eternal life. Just a small miracle, and medicine used to take pride in the small miracles in its arsenal, and was diligently working on creating new ones. There is a subtle change to that attitude now.

    We are all animals, and animals sometimes will chew their own limbs to
    escape from a trap, and certain death, only so they can die days later
    from blood loss or starvation. I am not doubting the importance of being prepared and having end-of-life conversations. Planning though, is not a term I would use in this context, until the end is very real and near. People in excellent health tend to think one way, and when disaster strikes, tend to accept levels of discomfort and disability that they could not imagine while healthy. Dr. Jerome Groopman writes a lot about this. And I do agree 100% that physicians should keep communication lines open and support folks in these final decisions, whatever they may be and however they make change. I’m just a bit concerned about the “serenity” aspect…. I don’t know, maybe it’s just me….. Sorry for the rant.

    • drseno

       It’s just you.

  • drseno

    Beautiful story, the kind of which we need more. These stories teach and eventually we’ll tip (hopefully) into improved end-of-life communication and experiences wherein patient and families get their needs for information and comfort met.

    Did you consider consulting hospice for Eugene’s last 6 weeks of life? Few ER docs are going to have your abilities. Just wish you all would think of making referrals to hospice.

    The description of Eugene’s last part of an hour did not sound fully managed. Virtually all shortness of breath, pain and other symptoms can be managed. Hope that your next opportunity affords awareness of that. Thank you, v

    • http://www.thehappymd.com/ Dike Drummond MD

      Hey drseno,

      Thanks for your comment. This event happened in 1987 in a small rural hospital. I am not sure if they had hospice. I understand the situation could have been “managed” in different ways. By the time we had confirmed they wanted this to be the “natural end of his life” – remember that those are the words I used to describe what would happen – Eugene was unconscious and I saw no reason to do anything other than let nature take its course.

      I have not worked as an ER doc since that year. This situation never came up in my family practice … mostly because it was avoided by having these end of life discussions early and often. No matter how uncomfortable it may be for the doctor to ask “How do you want to die” … ask anyhow. The patient is always ready for the question … in my experience.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

      • drseno

         Thank you, awesome. I also find that they’re always ready. Probably because they ‘know’ already what most everyone is unwilling to allow. If you were doing that in 87, wow. Not doing that remains an unsolved problem in health care today. But I think we’re getting to, at least, the top of the mountain. Thanks, again.

  • Bishan25

    Dear Dike,
     
    Thanks for sharing this post and your experiences – it was a beautifully written piece that has generated some good discussion in this thread. 

    I believe “Death with dignity” is a very important subject. I agree with some of the comments below and your own responses in that a good primary care physician plan may have been of benefit here, or the involvement of the hospice at an earlier stage could have been ideal. Nevertheless I think the hospital health system is now looking after an increasingly elderly population, and the Emergency Room Physician is going to be faced with “end of life care” in an increasingly frequent manner. 

    As an ER resident who has been working in Australasia for some years, I note that similar situations are not infrequently encountered in our practice. I found the description of your encounter comforting as I myself recently had a similar conversation with a 94 year old lady who was transferred from a nursing home to the resuscitation bay of our ER acutely short of breath. She was managing reasonably well for her age and quite independent, but it was clear that she was at the end of her life as she also had some worsening co-morbidities. It was fortunate for me that her two daughter guardians quickly turned up on the scene and they firmly advocated for her to be allowed to die naturally, which i confirmed was her wish, and found out later that it was something that had be discussed previously. Nevertheless I spent some time talking to her and explaining options and what I also thought was best in a similar way to the way that you described in your article, and in the end we managed to talk to the staff at the nursing home and arranged for her transfer back to her room for further end of life and purely palliative care. 

    In her case there was already an advanced directive that stated she was not be resuscitated, but still the ambulance was called. In my experience this is not an infrequent occurrence and whilst I agree that this situation be corrected at a system level, I also think we should be equipped to deal with this in a patient focussed way. I saw my patient at the end of a 10 hour nightshift, and these can be emotionally intensive and challenging encounters even though they don’t don’t pose much of a medical treatment challenge. I looked at your website and think that physican health and well being is an interesting and important topic. I personally believe there is not enough debriefing about these emotionally challenging situations because it is assumed that such situations are expected to be handled at the bat of an eyelid. I believe the opposite, such encounters are potentially some of the most worthwhile work we do (if they are done well), and deserve as much education, attention and training as managing some of the more “life saving” scenarios that we encounter in Emergency Medicine – food for thought perhaps?Thanks again for posting your story and bringing this important and educational discussion to the forefront. Best wishesBishan :)

    • http://www.thehappymd.com/ Dike Drummond MD

       Thank you for this lovely post Bishan … Namaste

  • http://www.facebook.com/NEPetHospice Heather At Neph

    Incredible story, Dike.  It takes so much courage and so much compassion to have that conversation.  I have done that also.  But it is the kindest and most altruistic gift you can give anyone – honesty, compassion, dignity and choice. 

    Heather Merrill
    Founder and Director
    Certified in Thanatology: Death, Dying and Bereavement
    New England Pet Hopsice, Inc.
    http://www.NewEnglandPetHospice.com

  • betsymurphychpn

    The Medicare Hospice Benefit was enacted in 1982. There were very limited numbers of hospice providers in 1987 compared with the numbers that we have today. At that time, hospice was also viewed largely by the general public as being for end stage cancer patients and Eugene may not have been identified as an appropriate referral.  Dr. Drummond was ahead of his time. Although working in an environment that focuses on cure, he took the time to have a difficult conversation with a patient who he did not know well.  Today, hospice benefits many patients with end stage heart disease by providing them and their families with a plan. Part of that plan is to receive medications to ease pain and respiratory distress which are started at home.  As  patients decline they are kept comfortable and rehospitalization is often avoided.  Thank you for sharing this lovely memory.