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Quality of Death

I watched someone die this morning.

Ever since I started working in the MICU I’ve been curious about what a death looks like but ashamed to admit to this curiosity. I remember reading some time ago about a serial killer and how he murdered because he was so fascinated by looking into his victims eyes and watching that moment when the light goes out. Because of this I find it difficult to admit to anyone that I am curious about watching a person die.

So on to this patient. He was in the room next to my patient’s room. He was 81 years old with sepsis. He had tons of comorbidities, and a declining state of health over the past year requiring multiple hospitalizations. Now he was in the MICU, not really waking up, getting progressively worse. A family meeting was held and they decided that it would be best not to prolong the inevitable and to let him die in comfort. They had made the difficult decision of changing his status from a full code to a DNR and they decided it would be best to withdraw care.

But not until tomorrow.

I do understand why people choose to delay this withdrawal of care. It’s a great amount of pressure. You are probably feeling guilt and denial. You may have this feeling that by turning off the ventilator you are killing your own family member. You’ve come to the decision that it’s best for your loved one to go in peace?but not just yet. So the healthcare team then feels obligated to keep this person alive until the family is ready to withdraw.

But usually no one thinks about the when the patient is ready.

So last night this patient was trying to die. All night long, little runs of V-tach, blood pressure waxing and waning, agonal breathing. His nurse would watch these goings on and get that momentary sense of urgency and then realize that there were really no measures that she could take. But she was so respectful of the family’s wishes, she was practically willing him to stay alive until the next day when the family would return.

Each little run of V-tach seemed to me like the patient was trying to take charge of his own death. The one thing the docs could do was make ventilator changes so they did that. It seemed to prolong the inevitable. Then right before change of shift, he lost his pressure. His heart rate started to fall. Even though his dopamine drip was increased his heartrate continued to fall.

He was determined. So his nurse was just kind of fussing over him. She kept cycling the pressure cuff and dopplered his pulse (for what?). I sat at the bedside computer and documented for her. I watched the monitor ? heart rate 90s, then 80s then 70s. A couple of other nurses gathered round. We had been expecting this all night.

The agonal breathing became more steady (even though he was still being mechanically ventilated). I watched his face and saw a momentary grimace pass through every thirty seconds or so. It was strange because he was so unreactive before and now his face was showing something…pain, anguish?

As he bradied down to the 40’s ?50’s, I was charting and the nurse next to me said, “Did anyone just feel a chill?” As she said it I realized that a chill had been vibrating through me for the last 10 seconds or so. As I became aware of this sensation, the chill was emanating, pulsating, prickling. Up until then I had been warm all night.

Then his heart stopped. We all entered the room and began cleaning it up, making it presentable for the family that was about to arrive. I checked myself. Did I still feel the chill? Nope. It was 100% gone. I felt kind of an empty feeling in my core, like something had vacated the space.

It was fascinating.

And as I read this I am amazed at my sense of detatchment. I just read Kim’s entry about her patient who died on Easter. (Damn Kim- You always beat me to the punch!) She had the luxury of sitting around with the family and hearing stories about what a great and wonderful life this person had. In the MICU on nightshift, we are often just alone with the dying or comatose patient, not knowing much about who they were or what they were like. We keep them clean, hold their hands, try to provide a peaceful atmosphere. We are just maintaining status quo until the family can make it there. This can go on for days.

Thankfully, we are starting a new committee in the MICU, the “Quality of Death” committee. This will hopefully help us to better educate families (and ourselves) on how to best prepare for a loved one’s imminent death. I can’t think of a better place to start a committee like this.