"What's the story?"

"She's 87, with a history of Parkinson's, Alzheimer's dementia and seizures. Her son said she's usually perky, but today she's quiet, won't respond, won't eat.. She looks prettty out of it."

I bent down next to her, the blood pressure cuff already in place, I pump it up and begin to listen for the small, crunching sounds in my ear that indicate a pulse. Nothing. She is breathing, her skin pale and dry; she makes no sound. Occasionally she moves her arms as if to brush us away like pesky flies in summer.

"Nothing here. Better get the doc. Anyone talk to the family?"

Yeah, they want everything done."

"Everything? They sure?"

"That's what the son says. Everything."

We always try to respect the choices people make, especially the incredibly difficult choices that come up at the end of a loved one's life. It's hard, though, when you know what "everything" means to someone who is very old and has debillitating mental and medical problems.

Here's "everything", at least on our end. We start an IV, a means to draw blood and administer medications. We draw a blood gas. This is a blood sample from an artery that tells us if her blood is too acidic and if her blood is getting enough oxygen. We do an EKG, the least invasive thing possible. The blood gas shows that she is retaining a lot of carbon dioxide and not getting much oxygen. The doctor decides she needs to be intubated. That means her mouth is held open by a metal blade while the physician looks into her throat for the opening to the trachea, the wind-pipe. After much suctioning, a plastic tube is inserted into the trachea and into the large tube that supplies air to both lungs. When we're sure that tube is in the right place, a balloon at the tube's end is inflated so that it can't easily come out.That tube is attached to a ventilator which will breathe for her. After that, it's time for a nasogastric tube which goes through a nostril and into the stomach. Its purpose is to decompress the stomach of swallowed air. Then a catheter into her bladder to drain her urine. Except there is no urine because her kidneys have apparently shut down.

So let's review - she has had a minimum of two needle sticks (since she very old, probably with bad veins, it's likely she'll have many more than that), a tube in the mouth, nose and urethra. She's attached to a heart monitor, a ventilator to assist her breathing, a blood pressure machine, a pulse oximetry cable. Oh, and she needs a chest x-ray.

What's the alternative? Comfort care. Make the person's last hours or days as comfortable as possible. This is not what's always comfortable for the family, but for the patient. That only happens when spouses or parents and children talk to each other and communicate what they want. Want to be an organ donor? Or not? Want to have every last-ditch treatment tried before giving up the ghost? Want to be buried or cremated? Talk about it. Tell somebody. Otherwise, nobody knows and Grandma racks up $20,000 in new hospital charges,

Our patient? She's in Medical Intensive Care. The combined services of a university nursing and medical staff will work to keep her alive as long as possible. They can never cure her Alzheimer's or make her a young mother again, or allow her to walk along the river. But they can keep her breathing for a few hours or days longer.

It's tough to face. I know, twice over. But the latest studies show that we're all going to die. Someone once described the practice of medicine as "buying time". That's alright. Sometimes buying time is what is most needed. No one is in a rush to see the other side. But sometimes people just get tired. It's an act of love to allow someone to die as comfortably, as warmly, as easily as possible. My daughters already know that I don't want heroics, I want morphine and plenty of it.
8:04:08 AM    Comments?()