Friday, November 18, 2005

Just because you can doesn't mean you should, part II

He came to us four weeks ago with a tumor in his cervical spine. The surgeons resected as much as they could, placed hardware in his spine to keep his head erect, and arranged for him to start radiation therapy.

He came back last week, unable to hold his head up. An MRI showed that the tumor had returned, aggressively, covering and wrapping around the hardware we'd placed recently enough that his scars were still pink.

He's in his forties, with two kids. His wife had to make the decision to withdraw care, and had stayed with him since then. He was breathing near-pure oxygen last night through a mask, in short gasps, his ribs and intercostal muscles showing with every breath. The place in his skull where we'd taken out a bone flap after a brain biopsy was sunken. His wife curled against his chest and talked to him, telling him it was okay to relax, to go, to let go. For her, there was nobody else in the room.

I thought about that as I stood looking at the syringe of morphine I was holding. I'd just drawn it up; his wife had come to me saying that he looked as if he was about to go, and like it was hard work. Could he, she asked, have a little more morphine to ease his breathing?

He was already on a drip--not a lot, but enough to calm the demands his heart was making for oxygen.

You're taught early on that it's not unethical to give pain medication to people in palliative care, even if the amount of medication they receive might hasten their deaths. It's a decision about quality of life rather than quantity, and it's acceptable: no one wants to deny pain medication to a cancer patient in fear that they might either die sooner or become addicted. By the time you hear the word "palliative", it's too late to worry about addiction.

It's a different animal, though, when you're standing in the med room five minutes before shift change (a fact you note with only a part of your attention; at times like this, punching out doesn't matter) with a possibly-lethal dose of morphine in your hand.

If I give him this morphine and he stops breathing, how will I handle it?

He knew what he wanted; his wife knew what he wanted. There would be no problem for him. Not breathing for a few hours more would be no skin off his nose. Knowing the patient, he'd probably--if he were still aware--thank me for the favor.

But his mom and dad? His kids, standing at the bedside? His wife? Me?

There's a big difference between knowing something is ethically clean when you read it in a textbook and pondering the reprecussions when it's you that has to make that decision.

I gave him the full dose of morphine; he kept on breathing. The reprecussions were delayed for a bit in that case.

I wasn't comfortable with the morphine for a number of reasons, mostly because it seemed that I had the potential to cut short some sort of necessary process. Who knows what's happening to somebody else, what sort of transition they're undergoing, as they die? The old-fashioned pillow-on-the-face trick might leave them unprepared to do whatever the hell it is we do after we stop breathing. Either way, why is it my decision? Why is it my responsibility?

And there in black and white is the hardest thing about being a nurse: not accepting that a beloved, brilliant person has decided not to go on living, but realizing that at some point, you may have the task of helping them out, incidentally and unintentionally.


Jo said...

My thoughts are with you and your Aunt and family.
I know from very personal expeirience how hard it is to let go, and how "one more day" could mean a lot to a family member.
You have to start questioning yourself and ask not when to die but how.
I hope for your Aunt, it is peaceful.
Take care,

Jo said...

Jodi, I edited out the part that you're commenting on because, after I wrote it, I got an email from Mom that said that my aunt had died this morning.

It no longer seemed appropriate, if it ever was in the first place.

Thanks for your thoughts, though. Very much.

may said...

i know exactly how you feel. i had a couple of experiences of the same kind. ihad to ask the attending over and over, if he is sure i can give the morphine. the family members are almost begging for it. and for me, the minutes seemes forever. for sure, if i didn't give the morphine, they will still go, but why do i have to make that decision? IT IS HARD.

and condolences...

Michelle said...

I have watched patients suffer, silently begging them to die. I know it sounds horrible but it is the truth. What purpose will be served by having them gasping for the family to watch? I have bathed, turned, suctioned and medicated hoping to hasten the inevitable. It doesn't make me comfortable but neither does the suffering.

Mandy said...

I know we're almost 11 years past this entry....but I found your blog somehow, and I've went back to read from the start because I'm weird like that...and this resonates with me. So much so that I had to comment. See 5 years ago, in 2010 my husband was dying, in the neurology intermediate ICU at a fabulous hospital with FABULOUS nurses and an equally wonderful brain doctor. Basically both of his vertebral arteries were occluded and he had brain swelling, a lot of brain swelling and his brain stem was basically gone. I'm sure I don't need to describe to you what his symptoms were. My point of this comment is that when I gave the final end of life decisions for him I included the biggest dose of morphine they could give him. Why? The man had had two micro brain surgeries in less then 36 hours and NO freaking pain med. The danged morphine was for me. But it was also for him. I knew from a previous surgery of his that if he was on morphine his breathing slowed. Like slowed down so much it was scary. And so, I asked that they give him morphine for when his vent tube was pulled. thank you for letting me know that the that choice I made for him was ok. Thank you for doing what you do.