It’s a regular day in the emergency room.
I’m covering the resuscitation room again.
In comes a frail 91 year old lady, brought in by ambulance.
She is out of breath. She looks bad.
Her oxygen saturation is in the low 80’s.
That is usually an omnious sign.
Impending death unless treated.
In 15 years of practice in the emergency room,
i have seen this kind of patient over and over.
COPD on home oxygen. Frail and tired.
It’s her third admission in that many months.
I quickly assess her. I’m waiting for the family to arrive.
I don’t see the need to discuss resuscitation issues acutely with this patient, we can wait for now
I can save her this time, I’m pretty confident.
Our recipe is tried and tested: a lot of salbutamol and ipratropium, a bolus of solumedrol, a bit of oxygen, some antibiotics if febrile and a trial of bi-pap.
Usually, it does the trick.
We start her on nebulizers.
I order her medical chart, maybe i’ll get my answer there.
The big question is : code or no code.
Intubate or not if she does not respond to initial treatment.
Most of the time, this kind of patient has already given advanced directive about this.
The family arrives. I tell them about her condition.
They have heard the story again and again.
Three admission in three months.
Many more in the previous years.
I estimate her odds of surviving one full year close to zero.
I estimate her quality of life index to be in the lowest value possible.
She barely survives every day, connected to her oxygen tank. There is no pleasure in this kind of life, just survival.
I talk with her daughters. They tell me she is a no code.
They also tell me that they buried her husband last week.
What a sad story. She lives alone now.
She was living with her beloved husband until the end.
Now he’s dead. She barely survives every day…
I ask the daughter: “Did any doctor offer you a no treatment, palliative care option?”
Tears in their eyes:”No… But she is constantly talking about being with her husband in paradise”.
“Ok, let’s go together, talk with her”.
“Madam? Yes. I’ve been told your husband died recently. Yes. I’ve been told you are also very sick most of the time. Yes. Now we can treat this and you might get better… until next time. But we can also decide to not treat and that means that you might be with your husband sooner than you think… What do you say? Ohhh yyyeesss, thank you, please no treatment, let me go, i want to be with my husband…. “
With that, she start crying.
Not tears of sadness but tears of joy.
I take her in my arms and give her a big hug.
“It’s all going to be OK, i promise”.
We stop everything. Cancel the blood work. Cancel the x-ray. Cancel the oxygen and heart monitor. Cancel all treatment.
We give her a small dose of morphine and scopolamine to dry her secretions, for comfort.
We transfer her in a more private room and i leave her with her daughters.
Two hours later, i visit on them again.
She has Cheynes-stokes breathing pattern.
She is peaceful and comfortable.
Her daughters at her bedside, holding her hands.
I tell the family that death might be imminent.
One hour later, i visit them to confirm the time of death…
It was a beautiful death, peaceful and calm,
She was surrounded with love when she left.
I feel it is a privilege for me to be a witness and a guide in one of the most important life event of this old soul.
This time, love was stronger than sadness.
She wanted to be with her husband and her daughter loved her enough to let her go, to accompany her until the end.
The family thanks me and, as i always do…
I go see another patient.
But, for the rest of the day, i feel blessed by this idea:
Love can be stronger than sadness.
Thank you.
Martin Pham Dinh 