Nine months ago he was diagnosed with idiopathic pulmonary fibrosis, a disease where the elastic tissue of your lungs slowly is taken over by scarring, effectively building a wall between the oxygen in the air and your bloodstream, as well as making it very, very difficult to take a breath. Since scar tissue does not stretch, when IPF patients inhale, instead of their lungs expanding easily like yours and mine do, they have to fight with their respiratory muscles (in their ribs and their diaphragm) to stretch the scar tissue to get air into their lungs.
He came in to our emergency department two days ago, profoundly low on oxygen and extremely difficult to oxygenate. The scar tissue had gotten so bad that we had to put him on the BiPAP machine, to use pressure to physically force the oxygen molecules across the wall of scar tissue into his blood stream. We tried what we normally try with the BiPAP -- give them breaks to let them recover from respiratory muscle fatigue, and then take them off and let them fly on their own for a while. The idea is that we use it to limp them over whatever acute (ha) problem they have with their breathing so that we can get the antibiotics and the steroids and diuretics and the like into them in the mean time.
Sometimes they tucker out again and have to go back on the BiPAP for breaks. Most people hate the machine, since it involves a mask that covers your face and fits very tightly. It makes it impossible to eat or drink (without removing the mask) and good luck trying to get someone to understand you while you talk. This man flew on his own off the BiPAP yesterday for several hours, though it took a complicated contraption and about 20 liters a minute of oxygen to keep his oxygen saturations above 85%.
He ended up getting put back on, after taking a turn for the worse that was very sudden. Even on the BiPAP with 100% oxygen and high pressures, his saturations were drifting downwards, 90, 87, 83, 81, 78, 75... the intensive care physician had written in his chart that there was no more medical intervention that could be done and that comfort measures was the way to go at this point.
As per comfort measures, we were giving him morphine every 20 minutes or so, whenever he looked like he was gasping for air or struggling to breathe. The morphine relaxed him and took away his shortness of breath, took away his pain. Slowly his respiratory rate began to drift down too, from in the high-50s (yes, I'm serious) to the 30s, to 24 a minute, which is damn near normal comfortable breathing.
His family was all there with him, sitting in geri-chairs and on desk chairs and stools, covered in hospital-issue blankets, calling relatives with a phone the nurse (Andrea) had provided for them, to tell them that they had bad news, that their father, grandfather, was dying. And I, as the asshole responsible for the mask strapped to their dad's face, was the one who got the questions about how it is he's going to die.
I explained that he was actively dying while we spoke, pointing out that his oxygen was drifting down, and from closely watching his breathing I could tell that he wasn't fighting back anymore, the morphine was doing its job and keeping him comfortable and free of dyspnea. They listened quietly and nodded slowly, some daubing at their eyes with kleenex, while I explained that dying is a process, and that everybody dies of low oxygen at the end of the day -- whether it be low oxygen in their heart from a heart attack, or low oxygen in their brain from a stroke, or any other number of things. I pointed out that his oxygen was low as it is, and that it was really only a matter of time, at this point.
My colleague had told me she'd had a little mini-chat with them along the same lines while she was on evening shift, and they'd told her that they weren't really ready for it to happen yet. When I spoke to them, they seemed much more at peace, and told me that they were going to make some international phone calls (to tell relatives the bad news) and that after they'd spoken to all their family, we'd talk about what to do. I'd implied that leaving him on the BiPAP machine was making the process of his death take longer, since instead of letting him stop breathing on his own, I'm forcing air into his lungs; instead of letting his oxygen drop and his heart stop, I'm forcing oxygen into his bloodstream. I explained that basically, we were waiting for the moment when even the BiPAP wasn't enough and he would pass away anyway.
They were very concerned about his level of suffering, and so I spent quite a significant amount of time explaining how morphine helps with people who are dying, by taking away their pain, by relaxing them so they are not afraid, and by taking away the feeling that he is struggling for breath. I explained that when I put him on the machine [yesterday], it was because he'd asked for a break, it was because it made him more comfortable at that time. I told them I was not going to tell them what to do, and that my only concern was that he was comfortable.
They asked if he would struggle for breath when I took the mask off: I explained that the morphine might make him sleep so comfortably he actually forgot to breathe. I said if he was struggling that we would give him more, to make him more comfortable, even if we "accidentally" gave him too much and made him forget to breathe. They seemed to understand that this death, the death where we help you drift softly away into dreamland, so you pass peacefully in your sleep, is preferable to us (who have to watch them suffer) than doing everything we can to prolong his life.
I explained that since we know he is dying, it is a matter of how long the process will take. I explained that the BiPAP and similar things can make this process take longer, and that the only reason I would suggest taking away the BiPAP is to take away the uncomfortable tight mask, and to make it so that the suffering of death did not last hours and days, if taking the mask off means we could make it last only minutes.
I told them they did not need to make a decision at this time, that things are looking as if he's on his way as it is, and that even if they choose to let him sleep on the BiPAP (since he did seem to sleep more comfortably on it) that they need not feel as if they've made him suffer unnecessarily by "prolonging his death" since, as I said, I believed (based on the evidence above) that death was near, no matter what actions we took.
They thanked me, and I backed softly out of the room. An hour or two later, I got a page from Emergency, saying that the family was ready to let him go.
Andrea and I slipped into the trauma bay, which we'd darkened and pulled the curtains. He was in Trauma 2; we'd deliberately tried to avoid admitting anybody to Trauma 1, so that they could have the whole of the trauma bay to grieve. Ordinarily we would have given them the isolation room, because it's private and has doors instead of curtains, but that room was presently plugged with someone on isolation for MRSA, so we couldn't.
Andrea gave him some extra morphine, while I suspended all the alarms on the monitor. A grieving family doesn't need to hear DINGDINGDING DINGDING DINGDINGDING DINGDING when their loved one passes away. I silenced the BiPAP alarms, and started getting an oxygen mask ready. Andrea stopped me and whispered, why not just put him on room air? I thought about it for approximately 0.5 seconds, and said, "He'd go so much faster that way, in minutes." She nodded. I understood. Make his suffering as short as possible. The morphine was making him snore; he wasn't aware of his breathing anyway.
So I did just that. I took the mask off his face, shut the BiPAP machine off, and began to quietly unplug it so I could maneuver it out of the trauma bay. I didn't have a chance to get it unplugged before he passed. I held a cloth to his nose and mouth to absorb the pink, frothy pulmonary edema that spilled from his lungs as he died.
His widow hugged me, and with her cheek pressed tightly against mine, she thanked me. I hugged her, and told her I'd lost my younger brother, and that I found the hardest time was after everything was all over, and I was by myself. I squeezed her shoulder, and told her to please, make sure she took care of herself during that time.
Andrea lent them her ID badge, so they could move their vehicles to the staff lot overnight, so that they wouldn't get a ticket. The reason they were leaving their vehicles was because I asked them to make sure that nobody who was particularly distraught do any driving. I said I'd hate to see an accident, thinking in the back of my mind, how my brother was distracted with anger when he turned left in front of a van, which ended his life. They looked at each other, as if they hadn't thought of it, and agreed to carpool with one of our patients' son-in-laws, who appeared to be the pillar for the family at the time.
I returned to the department walking slowly, each step feeling weighty and full of meaning. This too, has changed me, I think. I've never killed someone before.
My co-worker who'd been taking care of him the previous morning came in at 6:45, asking cheerfully if Mr. So-and-so was still on the BiPAP. I told her he'd passed away, and how it'd happened, and she was sad with me. We hugged, and exchanged words of compassion for his family. I just remembered him dying, peaceful, his breathing free and easy, despite the bloody froth leaking from his nose and mouth.
The media likes to put such a spin on "pulling the plug" and when I talk about it in public I sometimes get lambasted for daring to say that sometimes, people should be allowed to die. I feel like I have two faces, the one the public sees, where I'm judged as unfeeling and kill-happy and seeing patients as pieces of meat to harvest organs from, and the other, the one where my only thoughts at the end of someone's life are about how to make their suffering as short and discomfort-free as possible. I bet you the workers who worked with Terry Schiavo grieved when she died, but CNN will never tell you that. Similarly, they'll tell you all about how I killed a man, but not about how I hugged his widow and offered words of encouragement afterwards.
I wish people could understand, or would understand. This is one of the things that makes me who I am. And nobody understands, except those who've stood where I'm standing right now.