Monday, July 31, 2006

Back to Life

The paradox of palliative care is that sometimes, when you quit poking somebody, they improve.

She had come to us after a fall in the mall parking lot that resulted in a subdural hematoma. She also had a subarachnoid hemorrhage--probably what caused the fall--and had had a glioblastoma resected three years earlier. It was the nasty sort of glio, multiforme, that has a life expectancy (untreated) of three weeks. After conventional chemo and radiation, she'd gone to a clinic in Texas that, while it's mentioned on QuackWatch, has had some success in treating patients with brain and other cancers.

She was also septic. MRSA sepsis, which means it's tricky to treat. We'd had her on vancomycin and rifampin and she wasn't getting better. When I took over her care on Monday, she was globally aphasic (couldn't speak or understand speech or communicate at all). By Tuesday, she was tachycardic and moaning. On Thursday, her sodium had dropped to an eyebrow-raising 124 (135 is the bottom end of normal) and she was minimally responsive to pain. She was producing almost no urine and was swollen and blotchy all over.

The doctors ordered a nasogastric tube. I'd spoken to her family at length about what she and they wanted, and I was pretty sure an NG tube wasn't part of the plan, so I stalled until her family arrived that morning. They decided, with the doctor, to stop all interventions, put her on palliative care, and let things happen as they'd happen.

I didn't expect she would live through the weekend.

Imagine my surprise, then, when I walked in Monday morning and she sat up in bed, waved, and smiled at me.


The wave was a little messy, as she had a spoonful of mashed potatoes in the waving hand, but I was glad to see it anyhow.

We'd repleted her electrolytes and rehydrated her and dumped dozens of grams of various antibiotics into her. We'd put in a central line, taken it out, put in a different central line, pumped her full of drugs to keep her comfortable, sat her up in a cardiac chair, and generally been as unpleasant as caregivers can be to a patient who just wants to rest.

So, finally, she got a chance to rest.

I explained to her family that, since her sepsis was only about halfway treated, she could go rapidly downhill at any point, and would probably die from that sooner rather than later. Still, as the week progressed, she continued to improve. By the time she left later that week, her edema was gone, her urine output had normalized, and she was talking and (mostly) making sense.

Regardless of what happened in the end--and I'm not sure, even with no tumor regrowth, that she would've survived long--she got a week or two of mostly-compos-mentis-ness to spend with her family. That's enough.

Rule Number Seven Gazillion of Nursing: Sometimes just sitting down and shutting the hell up is enough.

1 comment:

Janet said...