Aug 18, 2013

Predicting Death

It was 5:30 am and my fourth call night in a monotonous string of calls every third night. Work fatigue was kicking in and stress hormones running high as the phone rings after a long silence through the night.
"Are you fully awake?" the nurse asked.
"Go on," I replied with my best effort to mask the groggy voice.
My patient in 667-2, Mr. G had a pulse of around 200 beats per minute and experiencing severe chest pain. He suffers from metastatic colon cancer and was admitted due to septic shock treated with broad spectrum antibiotics. He is losing a slow battle against cancer as the malignant cells had metastasized to his bone, lungs and liver. During his current hospitalization, DNR, palliative care, and advanced directives had been discussed with him and his family more than once. He had explicitly expressed the desire not to continue any form of IV drugs as they limit his out of bed mobility and elicited severe pain when the nurse changes the catheters every 3 days. As a result of his request, his antibiotics were switched to oral form but evidently that didn't work very well. He was again in shock this morning.
As I approached him he was breathing laboriously through a non-rebreathing mask with his hands clutching his left chest. His heart racing against stresses exerted by infection foci in his lungs and spine as well as the pain from cancerous cells eroding away the bones. His extremities were cold and clammy with very weak pulses. Blood pressure is 80/40 mmHg.
"Mr. G, how are you feeling?" I asked.
"The pain on my chest is very bad. Can I have some morphine to make it go away?" He said.
I ordered 10 milligrams of morphine while trying to evaluate my situation.
Mr. G had passed the point of no return. While I can try to convert the heart rate back through pharmacologic methods or defibrillation (cardiac shocks), it wouldn't last very long as he is still in septic shock and his current antibiotics isn't strong enough. Ultimately every medical effort would drain his hopes of dying comfortably at home surrounded by his family.
Mr. G mumbled something inaudible.
"Come again please?" I asked while lowering my ears against the hissing of his mask.
"Can I go home, please?" He asked.

I gathered his family by the window. The easterly sunshine had just penetrated the darkness minutes ago casting a warm golden hue into the ward.
"I think the end is near. I'm so sorry but I don't think we can do anything further here," I said.
"How much longer do you think he has, doctor?" His daughter asked.
"I can't be sure but given his unstable hemodynamics and very rapid heart rate, he should tire very quickly. As we discussed previously he wishes to go home for this and I think we should respect his decision."
The family took a while to decide while I waited by the nursing station. Ordering more morphine shots to relief the pain and shortness of breath.
"He might still struggle for a while still," The nurse commented while preparing shots of the opioids.
"How come?" I asked.
" experience," she said.
After gathering more family members, rushing here in the early morning light still in pyjamas, they decided to respect Mr. G's wishes to go home. I hastily wrote more prescriptions for morphine and prepared all required documents while the daughters called an ambulance to transport Mr. G home. Within the hour the hissing oxygen mask and silently ominous family was gone and 6W resumed its morning rituals. I said a silent prayer while washing up preparing for the day ahead. Please, God, let him pass painlessly.
Before morning reports I told my supervisor about Mr. G. He agreed with the nurse that I may have discharged the patient too early and he may be suffering even worse pain and shortness of breath at home now.
"But how do we know how long a patient has left?" I asked.
"That is truly a difficult question to answer." Dr. Pan said.
At 4 pm I received a call from his family physician. It turns out the patient is still alive at home and in great pain. I felt a great pang of guilt as Dr. Zheng told me he was much better as soon as he arrived home. Dr. Zheng felt that the discharge might be too hastily decided and the family not properly taught on how to handle Mr. G's pain.
"Usually if he is in a hospice ward, the nurses will teach family members to administer morphine for the patient. I understand 6W is an acute ward and you don't have such resources, though."
Dr. Zheng said Mr. G and his family understood the circumstance when I decided to allow them to return home, believing it would all end by sundown as I told them. And they do feel more comfortable at home.
"Maybe we could teach them ways of managing his symptoms and allowing them a few days to learn and practice before discharging them 'the next time,'" Dr. Zheng added.
"I will definitely do that," I replied, feeling very guilty. I had predicted the death of a patient way too early and discharged him home for needless suffering. I felt sorry for Mr. G because he could've stayed longer and took more morphine to relief his pain and shortness of breath. Maybe we could've converted his heart rate back to normal, maybe he just need some adenosine, maybe, maybe, maybe.
After several days swimming in guilt, I finally came to the conclusion that while I might not have done the right thing for Mr. G by discharging him too early, I most certainly respected his wishes to go home. I might not have communicated the things I can do for him here, though they are honestly very limited. If I were to be in Mr. G's shoes, I would most definitely want to go home, too. I thank Dr. Zheng for supplying Mr. G with all the analgesics he needs and hope his family members forgive me for a somewhat rash decision I made that fateful morning. I still have a lot to learn on predicting deaths and I hope Mr. G forgives me from wherever he is now. I hope he is in peace.


Frank Lu said...

Palliative home care has been tried out in many places in Taiwan. Hope it would spread out more for more people to benefit from that.

SleeplessInKL said...

I'd say you did the right thing by respecting the patient's wishes to go home. Perhaps just need to give more detailed instructions to family members on palliative care in the future.

It all sounds so easy when I'm just typing away on my keyboard. Doctors have to make tough decisions on the go. Hang in there!