It was my turn for an admission. A patient was coming from the ER. Shortness of breath, change in mental status, intubated for airway protection. His heart rate had dropped down to the thirties but recovered with a tiny bit of atropine. He had been discharged from the hospital a couple weeks ago after having two of his heart valves replaced. Apparently he had taken a long time to recover from the surgery, but had finally made it home and was being cared for by his daughter.

So we got him settled in and an echocardiogram was done at the bedside. Later, the resident came with the results.

“So what’s going on?” I asked.

The echo showed that he had a dehisced valve.

Yikes, just the sound of it…Dehisced valve. I am wishing I knew more about post-cardiac surgery complications but I am a MICU nurse – if it’s not about lungs, livers, or kidneys, I’m lost. I try to visualize it. I know that a dehisced wound refers to one that is coming apart. So I am picturing his artificial valve, breaking away from the rest of his heart and just kind of flapping around. And I am starting to get scared for him. The resident is also conveying a sense of urgency to me. However, there’s not much we can do except observe him, and keep him stable.

Then the cardiac surgeon comes around to take a look at him.

I asked him what will happen.

“Oh, this is bad,” he said. “This is really pretty bad.” He went on to explain to me that his valve replacement hadn’t gone so well. His anatomy was strange and when it came time to attach the valves it didn’t look like it was going to work very well. So he wasn’t very surprised to see this patient again. He also estimated that with further surgery this patient would have a 5-10% chance of survivability. I asked what his chances are without further surgery. He didn’t even hesitate. “Zero” he said. The family was called in to discuss the plan.

So now my adrenaline rush starts to kick in. Anything could happen. He could code (imagine what the chest compressions would do to the flapping valve). Or he could rushed off to the OR at any minute.

The family is confronted with the news. They decide to go ahead with the operation. I start to fill out the OR checklist. The resident comes back.

“So the operation is scheduled for Saturday.” (It was a Tuesday).

Excuse me but WHAT???? I just listened to the surgeon saying oh shit, this is bad, he could go at any minute, etc. etc. But now it can wait until Saturday?

I was confused. I looked up the echocardiogram report. Maybe it wasn’t as bad as I thought. Maybe the valve was just a teeny bit dehisced. But, no they actually used the word “flapping” in the report.

I tried to make sense of it all. The surgeon gave him some pretty grim odds – with or without the surgery. The patient also had many co-morbididties that would work against him. The surgeon most likely had no interest in even doing the operation. He had been in there, in his chest. He knew what he had to work with. And maybe he was thinking, no way am I going back in there. So maybe they scheduled it for Saturday with the hopes that he wouldn’t last that long?

Kind of disturbing, but there it is. So now the palliative care nurse in me takes over. What can be done now? So what about the patient? His family wants him to have the surgery but what would he want? How do we find out? He’s intubated but does he need to be? He’s on the lowest 02 settings. We now know that his main problem isn’t directly related to his lungs. Why not treat him like any other patient and start weaning him of the ventilator? The doctors want to keep him intubated until the surgery.

So I come back to work on day two and now I have a goal in mind for my patient: If there is any possibility to get this man extubated, let’s do it. That way we can ask him what he wants. I bring this up during rounds. The doctors seem skeptical but agree that we should try to move in that direction.

Step one, I had to lighten up his sedation. This turned out to be a major problem. He was waking up fast and he looked like he was in pain. I was faced with the decision – give him more narcotics and run the risk of him not waking up enough to be extubated? Or withhold sedation and watch him suffer all afternoon? I chose the former.

Meanwhile his daughter had called to check up on him. “He’s much more awake,” I said. “He’s awake enough that he can hear you.” I though the daughter would be happy with this news.

“Well don’t tell him about the operation. He wouldn’t want to go through with it.”

I feel anger surge through me. If he wouldn’t want to go through with it then why are you consenting to it? I want to say.

But of course I do not say that. These things need to be handled in the proper way, through the proper channels.

I let the attending know what the daughter has said, and that there may be a conflict of interest here. We set up another family meeting for later that day.

So now he’s really awake and he’s looking at me with panic and fear. I realize that he’s now awake and no one has given him an update, no one’s told him what’s wrong or how he got here. I tell the doctor. He says he will go in and talk to him, but only when the family gets here.

So now I’m stuck with him all afternoon. I’ve always kind of felt this conflict about giving news to a patient. I know it’s the doctor’s responsibility but what about when the doctor won’t do it? Or puts it off? It’s just me and my patient. I decide to tell him just some basics. “It’s your valve,” I said. “They may have to operate again.” He rolls his eyes and looks defeated. Then he starts trying to get up out of the bed. I gave him some more sedation.

After several more hours, the family finally arrived and the doctor went into the patient’s room with them. He performed some basic mental status assessments on him and guess what? The patient failed. He failed miserably. The doctor was not convinced that he was able to decide for himself.

I was confused. Did I sedate him too much? Did I only imagine that he understood what I was saying?

Or did he tune out because the he didn’t want to hear the news?

I tend to think it was a combination of all three.

So in the end the family still wanted him to have the surgery. I came in a couple days later (Friday) and to my amazement he was still there but he had deteriorated rapidly overnight. The family was called in and they had decided against the surgery. By that time I had spoken with the daughter some more and I could really see her starting to come around. I began to understand that her previous comments were merely the beginning of the process of her coming to terms with her father’s impending death. Hours later everyone had arrived. Everyone began saying their goodbyes. He was barely hanging on. The family wasn’t sure what to do next. I knew it was time but I felt like I was forgetting something. What was the next step? I was trying to review it all in my head. What was I missing? What was I forgetting?

Someone came up to me and said, “Have you called the chaplain yet?”

Duh. How could I forget the chaplain? Our chaplains are excellent. They have a way of swooping down and taking charge of an end of life situation – they pick up where the caregiver leaves off. They know just what to do, just what to say. So the chaplain arrived and everyone gathered around the patient for a final prayer. And then the patient’s heart gradually stopped. No chest compressions, no messy surgery. The family was able to share their loved one’s last moments of life. As far as deaths go, it was a pretty good one.

So my week was unique in that it had a beginning, a middle and an end. It was a week that encompassed almost every aspect of my job: The adrenaline. The frustration. The responsibility. The conflicts. The power and the helplessness. And above all the profound experience of sharing the end of life with a patient and his family.