His name was Al. He was 84 years old. He had several different careers in his time, but he retired years ago. He had a minor bout with cancer during middle age, and beat it.
He liked to talk shop about e-books and his new Kindle. He used
Facebook to keep in contact with his kids, and grandkids, and
great-grandkids. He spent a lot time walking, and fishing, and keeping up his lawn. He didn't eat very much but he usually felt pretty good.
Last week he came to the hospital because he was a little short of breath. The ER did an ultrasound, an X-ray, and a CT. These scans showed fluid on his lung, and possible other issues. Our surgeons did a thoracotomy and placed a chest tube.
When he got to my floor, he was very weak but in good spirits. His respirations sounded awful, but he was breathing okay with just a little bit of supplemental oxygen. The chest tube was draining fluid and his lung was reexpanding. He couldn't move much without assistance, but he put in as much effort as he could manage. He told jokes about all the wires and lines we had him hooked up to. He had no appetite but drank the nutrient shakes we gave him for supplements.
This weekend, the pathology results from his surgery came back. The physicians explained that his cancer had come back, aggressively. This time it had spread to his lungs. Chemotherapy might work, as it did last time, but the chances were poor. Radiation was not an option. Surgery was impossible.
Al took this better than anyone could expect. He was a bit withdrawn, afterward, but he still told jokes. He forced a laugh and said that he beat cancer once before, and dammit, he'd do it again. He seemed to need more company. He found lots of reasons to call me into the room, and keep me there for a while. I didn't mind. I often had some free time during my shift. I spent a lot of it there, just talking with him.
A few nights ago, while we were chatting in the very wee hours, Al suddenly sat up on the side of his bed. He pulled off his oxygen cannula, tossed it on the floor, and started disconnecting his cardiac monitor leads. It was the most movement I'd ever seen him do without help. He said, "Get this shit off me. I know I'm a dead man. I might as well be comfortable."
I explained that we would not do anything he didn't want us to do. If he wanted us to withdraw care, and make him as comfortable as possible, then I would call the physicians and get those orders. But didn't he want to talk to his family first? Would he please, just for now, let me put his oxygen and his monitor back on, so he could be comfortable while we made the arrangements?
He agreed. I got him back in bed and wired back up to the monitor. Then I excused myself and started making phone calls.
The arrangements weren't complete by the time my shift ended. I made sure the next nurse was aware of Al's wishes, and was on top of what needed to be done. Before I left for the day, I went back in to his room, and promised him that we were doing what he wanted.
That day, while I slept, the orders went in. The whole team of physicians spoke with him, in person, in pairs and small groups, going over the exact details of his prognosis and his options. He chose to be placed on comfort care only. His whole family came in to visit. Some of those tried to change his mind. Others just came to say goodbye. There was a large family conference about where Al would live now, for hospice care, once he was discharged from the hospital.
His youngest great-granddaughter brought in a poster she had made from a blown up photograph, of the two of them together, carrying fishing rods over their shoulders. Surrounding the photo were stick drawings of fish and boats and waves. Across the top, in fat blue crayon, childish handwriting said "Get Well Soon."
By the time I came back in the evening, Al didn't look at all well. He had refused to take any breathing treatments all day, or most other medications either. He was pale, and gasping. His oxygen was turned up as high as it could go, without using a cumbersome mask that he didn't want. He didn't respond to questions. His daughter, the only family member still at the hospital, thought he seemed to be pain.
I gave morphine to relieve air hunger. I gave lorazepam to relieve anxiety. I turned on a fan in the room to provide a sensation of easier air movement. I turned off the cardiac monitor and removed the electrodes. I disconnected the IV. I washed his face, and remade his bed, and turned down the lights. He appeared at last calm, and comfortable.
His daughter kissed him goodbye, and left, to take care of the rest of her family.
Once he was alone I checked on him every ten minutes. Only a few rounds later-- less than an hour-- I came in and noted that his breathing was agonal, in a distinctive pattern of sudden gasps. As I watched, he took one more breath, and then no more.
I checked for a pulse on the radial artery, in his wrist. Then the carotid, in his neck. No blood stirred under my fingertips.
I put my stethoscope on his chest and heard faint sounds. Not the two part lub-dub, lub-dub of a functional heart, but a soft single tick, tick, tick, just electrical twitching, too weak to flex the heart or open the valves. As I listened, the tick slowed like a clock winding down, and finally it ceased.
I found another nurse to listen and confirm my assessment.
I pronounced a man dead.