Tuesday, January 5, 2010


She was 92, desperately ill, and screaming at the top of her lungs. I was rounding in the hospital when I got the call from the residents in ICU -- could I come right away? Of course I could. It's hard enough dealing with critical problems when you've got some physician miles under your belt. But it's truly terrifying for a young doctor, just months out of medical school, to face a problem that doesn't easily reduce itself to lab tests and x-rays. I've long felt a responsibility to not leave physicians in training alone to stumble in the darkness.

She lived in a nursing home, which shipped her to the emergency department because she was "altered." In other words, she was acting crazy. The ED did its job. The staff quickly determined that she probably had a serious infection, that her kidneys had stopped working, that her lungs and heart were perilously close to failure, that her blood would no longer clot. She was bleeding from her rectum and possibly into her head. Her odds were slim to none. Family members quickly gathered before she was sent upstairs to ICU, yelling and thrashing on the gurney. The nurses responded by tying her wrists to the bedrails.

Blessedly, the family's first question was, "Do you have a palliative medicine doctor available?"

The residents and I quickly confirmed the ED's findings. Even before I briefed the family, I talked the residents through some basic moves -- small amounts of a powerful pain medicine called fentanyl, safe when the kidneys shut down, to treat the obvious pain; an antipsychotic drug, haloperidol, to calm her and hopefully allow us to remove the restraints; and a drug to reduce the gurgling noise she made with every breath, chosen carefully since some medications of that type can worsen delirious behavior. We decided to keep the family in a separate room until their loved one was less uncomfortable. Why should their last visual memories be of a person so obviously not at peace? But it took too much time for things to happen. No one was moving at an acceptable speed. Dying patients who are not getting life-sustaining treatments sometimes fall lower on the ICU priority list. I finally spoke to the nurse in charge: "This is an authentic palliative care emergency, just as surely as a cardiac arrest is an emergency. We need these meds to be given, and we need that to happen now." My voice was under control and I stayed calm, but there was no doubt about what I expected would happen next. Drugs appeared and were given quickly. After a few minutes we could already see that our patient was calmer, still awake but not nearly so agitated.

Ten family members and I talked in a conference room smaller than most walk-in closets. I reviewed the test results and the prognosis. Unlike so many families I deal with, this family closed ranks quickly around a unanimous opinion -- treat for comfort, and allow a natural death. I returned to the unit, worked through some dosage adjustments with the residents, and asked the nurses to untie the dying woman. About 45 minutes after she arrived in the ICU, our patient was ready to receive visitors. The family crowded around the bed, saying their good-byes. A little later, our 92-year-old mother, wife, and grandmother closed her eyes, and three hours after she came through the doors of the ICU she was gone.

If we have nothing else to offer, it seems to me we can at least offer the possibility of a smooth transition from this life to whatever may or may not follow. In medicine, an emergency means a situation that just can't wait. A delirious elder at the end of her life, obviously suffering with a life expectancy of minutes to hours -- if that isn't an emergency, what is?

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