Today I watched a man die. A few of us stood around as his heart stopped beating, and did nothing about it. It was kind of surreal, but the mood in the room was quite calm – there was no frenzy of activity with buzzers going off and people running: instead there were three professionals standing up at the top of his bed, discussing the ins and outs of his situation. In his final minute or two our talk was mostly academic, about the physiological responses to hypoxia and such other exciting things. But I’m getting ahead of myself a little, let me explain:
A man who looked to be around his mid to late seventies presented to emergency after collapsing at a care facility. He had a GCS of 3, and the only known history was that of recent renal problems which landed him a stint in ICU.
On arrival: his pupils were non-reactive to light, and he was making no spontaneous respiratory effort. He was being manually bagged with an LMA mask, and was quickly intubated after arrival. He was hypertensive, and had an erratic heart rate with frequent arrhythmias (ventricular runs with rate 90-100, runs of bradycardia at 30-40/min with ectopics, then runs of tachycardia ~110-130).
The usual lines, bloods, fluid, ECG, and neurological checks preceded the obvious CT scan, which subsequently revealed a large intracerebral haemorrhage . Consultation with neurosurgery based on his scans and myriad of other co-morbidities resulted in a prognosis of basically zero, which left him intubated with pupils now completely fixed and dilated, an erratic heart rate, and no spontaneous breaths at all.
We reversed some of his prior drugs such as vecuronium with neostigmine and atropine, to ensure he was not under the effects of earlier drugs, then used the old watch and wait treatment.
Which brings us to watching him die. Gradually he was weaned down off the ventilator, with frequency of breaths lowered from 16 to 14…. 10…. 8…. 4…. and percentage of delivered oxygen lowered from 100% to around the 50% mark. There was no neurological response at all, and no spontaneous breathing: even hypoxic encouragement failed to induce any kind of respiratory effort.
And so we stood around, waiting to see if he would take a breath, all other avenues exhausted at this stage.
Everyone was in agreement with the treatment of this man, yet it remains a kind of surreal moment: our aim is to fix, to heal, to help, to treat…. and also at times to watch the inevitable. And so we made him as comfortable as possible, this disheveled 66 year old man, and contacted the only member of his family we knew of, who did not want to come in.
Part of being able to work well in emergency departments largely depends on the aftermath of this kind of situation: how you deal with bodies, putting them in a bag, removing all the tubes… writing up your notes, making sure your times are accurate, double checking the drugs you gave… liasing with other staff, making sure you were spot on legally. Finalising the paperwork, making sure correct forms are done, talking to the mortuary, arranging to remove the body…. And coming to terms with death yourself.
I’ve been in the game long enough to cope very well with such situations, but everyone handles things differently. Personally I find the only way is to completely remove myself from the situation emotionally, and if anything we tend to keep the mood as upbeat and productive as possible, despite the dire situation. And the reason? There’s a new trauma arriving in 3 minutes – the bay needs to be ready by then……
As a 14 year veteran Firefighter/EMT with much experience in the field as well as in the clinical atmosphere, I can say that you are right on target with your description of seeing and dealing with death. I think it is something that more people should experience in their lives. Death is not always of the violent nature that television shows us. Many times it can be calm and peaceful. I will never forget transporting a very elderly woman who knew she was dying and was probably not going to make it to the hospital. To this day I can’t recall her medical condition, however she was coherent and aware of all that was going on around her. She looked up at me and asked me to hold her hand. As I took her frail hand in mine she said “I just don’t want to die all alone”. She closed her eyes and passed away within minutes.
People ask me when I tell them that story, why I would hold her hand instead of work to save her life, and I reply that I could have spent those last minutes caring FOR the patient just to have her suffer a little longer, however, at that time I chose to care ABOUT the patient.
Hi Rattle09, thanks for your comments.. It’s interesting when you say more people should experience this kind of thing in their lives – I’ve often thought that the public perception of death and dying can be quite skewed, hospitals and closed doors let people’s imaginations run wild I think! And you’re dead on the money (no pun intended) when you mention delaying the inevitable – to what end? This kind of decision comes up very frequently – is there any point to extending treatment etc for the sake of buying a few extra weeks/days/hours etc. in some cases…
i work in a chronic dialysis clinic. It started as a normal day… We brought back one of our patients who haunt done well with dialysis. a lot of anxiety mostly, shaking all the time uncontrollably, worried about everything. and since he started dialysis everything else has gone wrong. They lost all their savings beacuse of his medical bills. His wife had to leave retirement to get a job. He ost his eye sight and has been in and out of the hospital on a weekly basis. he tells us all the time hes ready to die. He falling a part and cant take it. He just wants to stop shaking. And today he came back to his chair, we got the needles in his arm and stated the machine. immediately he went into cardiac arrest. After normal procedure,call 911, 1200cc of saline, and five minutes of CPR, he came to and the Clinical manager(dialysis rn for 13 yrs) decided that he needed to dialyzes before going to the hospital so i cancled the 911 call, becuase they wernt their to take over yet. during treatment he knew he wasn’t going to make it and got scared. HE didnt say that but you could tell he knew. I sat with him and had to convince him that it was ok.That we would take care of him and it would be alright. We let him know that we called his wife and she would meet him in the ER. basically convinced someone it was ok that they were dieing, that he wasnt alone. I held his hand and watched him cry and concluded the patents around him while they cried, everyone knew he was going. About an hour after he said he had chest pain. He said someone was pushing on his chest and it hurt. Nitro was given, 3, one every five minutes and it didnt give him any relief. 911 was called again. He was hooked up to and IV and EKG chest electrode. He was shaking, strapped in tight on the stretcher, crying more now than before. Patients were crying watching him leave, knowing this was the last time they would see him and that it could have been them. I am so tired. I could handle this and let it go if i dealt with it every day. but i dont. my job is to keep people alive. and when they die we dont see them GO. Once ever six months we will be having a great normal day. patients are all in a great mood staff working together and then you lose some one that you take care of 3 days a week, 5 hours a day. You know everything about them, their grand kids, their wife , their dogs, their past, their hurts and their good days. Then i had to tell him that it was ok to die
Hi Jennifer – The ward I worked that was most mentally and emotionally draining was oncology, and I vowed never ever to return! It’s much tougher because of the reasons you outline – they are patients that you know a lot about, and it’s more difficult to detach yourself from the situation. I’m sorry you had a tough situation with that patient, be careful of burnout – if a particular area is draining on you physically, emotionally or whatever – go somewhere else! It’s hard to do to start with because we are comfortable with familiarity, but really really great in the long run… All the best
Hi Jenifer, and all who commented are heroic people. The public in large is not aware of it, but many are. Otherwise you could not keep going. Hat off and salute to You.
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i could not imagine watching a patient die. that just might be something that would stick in my head forever.
Hi Sealy – For some people I guess it’s just not their thing… it’s hard to know how you will react until it happens to you. I guess I’ve gotten a lot better with ‘death’ over the years – you can be removed from the situation when it’s someone you don’t know, also.
I have had your exact feelings. I’m a 15 year emergency services member. It is hard to put our jobs and experiences into words. It takes one to feel like one.
Hey Amanda, thanks for visiting… I totally agree, sometimes you just have to see things to believe them – I’ve had several situations where I’ve thought “wow, no one would ever believe that just happened!” All the best for the upcoming year, and thanks for all your hard work in the industry!
Go work in age care, you know your patients well, they become like family and so they die one after the other. Just sitting, waiting for tomorrow until tomorrow never comes.
Death is part of the routine of an age care nurse.
It can be hard watching a person pass away.I work in emergency dept,the really tough ones are the children you cannot save.Debriefing helps,but it can take a few shifts to re-focus. I may not be clinical but some times needed for C.P.R.