Sunday, March 23, 2014

ICU

I had an experience I have never had and that is generally the criteria I use to justify the effort of posting. I held a patient's hand while she died. I've been in a thirty-bed ICU for the last month and I've seen a wide variety of patients. Most of the people transferred to our ICU have actually been IMCU patients which is a designation for lesser acuity or more stable patients. Occasionally, however, we have taken care of very sick patients: multiple gunshot wounds, necrotizing fascitis, Streptococcus pyogenes pneumonia, status epilepticus, acute blood loss anemia, and the run-of-the-mill end organ damage (kidney, heart, liver, etc).

Despite all this, this week was the first time I was actually present to witness a patient passing. She was brought into the hospital unconscious with multi organ failure. She had no family members listed in her chart, but did have a boyfriend who happened to be a few hours away. The chart indicated that on a previous hospitalization she was listed as DNR/DNI, but did not have a POLST (physician order for life-sustaining treatment). The POLST is the important part of the DNR - the part that actually gives the order to make things happen or not. The DNR is used to guide decisions that go into the POLST.

By the time I saw her, she was struggling for breath, grunting with each expiration. I could hear the crackles in her lungs from across the room. While we waited for a final order from the doctor, she was being given fluid but no medicine to maintain her blood pressure, but it went straight to her lungs. Her heart rate was fast trying and failing to sustain her falling blood pressure. She did not respond to questions or painful stimuli. Except for the nurse and I at her bedside and the occasional inspection from the doctor, she was all alone. As her blood pressure fell to more critical levels, we finally got the order to make her comfortable and to not call a code.

She was given fentanyl every 10 minutes. Her breathing slowed first and the grunting stopped. From that point, it took about two hours for her heart rate to begin to decline. I didn't know what to expect which is partly why I stayed well past my shift. The other reason, the biggest reason, was because I felt that no one should die alone. I held her hand for the last hour. I don't know at what point exactly she passed. Was it once her heart stopped or her breathing? Was it while we were waiting for the next breath, or was it shortly after she became unconscious earlier in the day? Had she left the empty, failing shell hours before? Or was she officially dead once we disconnected the monitors and no longer cared about her heart rate, respiratory rate, pulse, and blood pressure?

Her grip started to tighten on my hand during the last hour. Was it rigor mortis? If that was the case then technically she had passed, according to textbooks, three to four hours earlier despite her still-present heart rate?

More importantly, why was she alone? Where were her friends, her husband, her kids, the people whose life hers had touched? Why was she spending her last moments in the care of strangers grasping the hand of someone who was there only by chance who cared for her as a patient, but not as the person she had been? Would it have mattered if her loved ones had been present? Did she have the presence of mind to comprehend the identity of those at her bedside?

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