Originally published on KevinMD
He had cardiomyopathy and CHF for over 20 years. At the time, doctors told him he could die at any time. That was 20 years ago. His EF was 10 percent — barely livable.
Two decades later, this admit kept him on a see-saw with respiratory distress, a bad heart, bad lungs, atrial fibrillation with RVR and heart rate in the 140s all day long. He progressed from nasal cannula to Optiflow to 100-percent BiPAP. A Cardizem drip was added to no avail. His next step would be intubation.
I pulled his wife outside of her husband’s room. And I told her that he wasn’t doing well and we may have to progress to a ventilator, and not to let him drink anymore — aspiration and aspiration pneumonia.
I could see the years of suffering on their faces. The dedication and love they had for each other.
His wife agreed. But 20-minutes later, she came to talk to me.
“We don’t want a ventilator. We’ve dealt with this for over 20 years. He doesn’t want a ventilator,” she said.
I grabbed our intensivist and gave her the heads up. She talked with the wife and the patient who both requested a DNI.
The patient stated he would go through one round of CPR … just one round. A strange request, I thought.
The MD added DNI to the patient’s chart.
An hour later, his wife came to talk to me again, “This doesn’t make any sense to not put him on a ventilator but to do CPR and crush his ribs and hurt him when we know he has a bad heart and lungs. I think it would be cruel! He’s ready to die. He told me so. We don’t want to see him suffer anymore. He just wants to be pain-free. No more pain and suffering.”
I could see the years of suffering on their faces. The dedication and love they had for each other.
Back in the day, we had a universal policy: All or nothing. Either a full code with CPR, intubation or nothing at all. Now patients and families can choose. There are different variables: no intubation but do CPR. Or give ACLS meds but no CPR. Many of these variables/ protocols make no sense to me, but the families and patients get to choose.
I agreed with Mrs. Smith and explained to her as we were surrounded by three respiratory therapists that by not intubating but doing CPR one time was like giving him a car but telling him he couldn’t have any gas.
The respiratory therapists agreed.
I introduced the thought of morphine in small amounts. A 2 mg IV push helps with breathing and anxiety and air hunger.
She agreed. And Mr. Smith was made a DNR/DNI.
The man’s family came from near and far. His sons, daughters, sisters, brothers, his buddy from elementary school, his favorite chaplain and his wife. They all sat by his side and kept vigil. They shared stories of Mr. Smith as they laughed and cried.
As Mr. Smith nodded in and out of consciousness, they held hands and hugged one another as a tear rolled down Mr. Smith’s cheeks.
We made Mr. Smith “comfort care.” And that’s what it means: providing comfort at end stage lung, kidney, heart, liver diseases, terminal cancers and multi-system organ failure.
Morphine was given as needed for comfort.
And we watched Mr. Smith drift away from our universe — the inevitable.
I cry as I write this. But I rejoice in knowing that we did not torment this man with CPR, cracked ribs, ventilator, wrist restraints, central lines and dialysis.
I remember something my husband once said to me,”Who is alive: man or machine?”
Do Not Resuscitate 