She was rail thin and her deeply wrinkled face reflected the years she had spent sucking on her “cancer sticks”, as she called her cigarettes. I had seen Dorothy many times before in the ED. She had trained so many residents on the nuisances of end stage COPD. The 60/60 rule for intubation, PO2 below 60 or PCO2 above 60 just didn’t apply to her any more.
She was rail thin and her deeply wrinkled face reflected the years she had spent sucking on her “cancer sticks”, as she called her cigarettes. I had seen Dorothy many times before in the ED. She had trained so many residents on the nuisances of end stage COPD. The 60/60 rule for intubation, PO2 below 60 or PCO2 above 60 just didn’t apply to her any more. Dorothy lived with a PCO2 above 60. The only question on intubating her was whether the doctor had the cojones to stand there at the bed side and watch her pull with all her might to get every breath. A little CPAP helped – just enough oxygen to help without killing her respiratory drive – as did a few other tricks and therapies we had to help keep her off the vent. We had walked the fine line on numerous occasions, each time seeing her claw her way back to a lower and lower baseline of ‘stable’.
In many ways this night was just like all the others. But we had just experienced a really warm spell and, as we all know, the ER is temperature dependent. The hotter it gets, the crazier the ER gets. Everyone was out sitting on the stoops to their row homes, drinking beer and getting into the arguments that had simmered behind closed doors all winter. Somebody had a huge gaping head laceration and possible depressed skull fracture in room 12. There was a bevy of city cops trying to figure out who to arrest, the patient who was still threatening and swinging at her bedside boyfriend, or the apologetic boyfriend who claimed she threw the brick at him and he simply threw it back with better aim.
In any event, those two were only the beginning of the night. I didn’t have time to stand at Dorothy’s bedside and hold her hand while she walked the tightrope. The easiest thing for me was to just do a quick RSI and get her upstairs. Let the ICU sort out how they were going to get her off the vent, eventually, if that was even possible anymore.
“I’m going to have to put you on the ventilator,” I said to Dorothy after sweeping into the room with little introduction. We knew each other, so I didn’t feel we needed to waste a lot of time with chit chat. She knew the drill. She was getting fatigued, so I knew that she would eventually need it. This way we would just cut to the chase and keep everything rolling in the ER.
“No,” she mouthed, shaking her head as she sucked in a long, desperate breath.
“What?” I questioned incredulously, finally pausing to meet her eyes over the CPAP mask. “I don’t think you’ll make it without a little more help.” She pointed her shaking, bony finger at a woman in a NASCAR sweatshirt who had been pushed to the corner of the room by the nurses setting up for the intubation.
“She don’t want to be on the machine again,” said the woman as she waved a piece of paper. I don’t know how I missed her walking into the room. The smell of cigarette smoke on her sweatshirt was overpowering.
I paused to examine the form. It was a standard Do Not Resuscitate form with Dorothy’s barely legible signature scrawled at the bottom. “This actually says that if your heart stops we are not to do CPR, which would include intubation,” I said in a louder voice as I turned to Dorothy. I wanted to make myself heard over the noise of the CPAP. But I could see from the glaze in her eyes that she was starting to nod out.
“This form doesn’t really apply to this situation,” I said, turning to the woman in the corner. “If I don’t intubate her now, she’s going to die . . . tonight. But if I do, there is a chance she will get off the ventilator later. She doesn’t have to die tonight.”
Tears popped out of the woman’s eyes at my blunt talk. I felt ashamed at my callous brusqueness, but I simply didn’t have time to dance around the issue. Dorothy didn’t have to die, at least not right now, on my shift. I was stymied. I had no interest in leaving a dying woman if I could save her..
The silence of my thoughts was suddenly broken by a flurry of people, presumably family members, entering the room.
“Grandma,” said one of the young women with bleach blonde teased hair as she approached the bedside. “Grandma,” she repeated louder with more anxiety. “What’s going on,” she said, turning to me. “She’s not talkin’.”
“Her lung disease is catching up with her,” I said with a professional tone. “And if I don’t put her on a breathing machine in the next few minutes she’s going to die.”
“Well, do what you have to do,” the young woman said with decisiveness.
“Well, it’s not that easy,” I said pointing to the form in the hands of the first woman. “That form says that Dorothy doesn’t want to be resuscitated if her heart stops. But it doesn’t really say what we are to do before that. Now, Dorothy did indicate to me that she didn’t want to be on the machine.”
“You made her sign that,” the younger woman said, wheeling to face the NASCAR woman. “After her last time in the hospital the doctors told her that the next time she came in they would need to send her to a nursing home. ” The woman turned back to face me. “But Medicare said that she would have to sell her house and use all her insurance and they would pay the rest. She didn’t want to sell the house, so she made her sign that paper.” Each time she referenced the woman in the corner, her “she” got louder and more accusing.
“It’s my house now,” said NASCAR. “It’s all I have.”
“It’s not your house,” the younger woman whisper screamed, starting to cry as she bent over Dorothy. “Grandma doesn’t have to die so you can stay in that damn house.”
“Who is the rightful next-of-kin?” I said, trying to sort out the legalities of the situation.
“I’m her daughter,” said NASCAR.
“My mother was her daughter too,” the blonde almost sobbed.
“Does anyone have a Durable Power of Attorney or anything that says they have the right to make medical decisions for Dorothy?” I looked around the room and everyone stared back blankly. Just then the charge nurse appeared at the door. The tapping foot and the arm full of charts told me that it was time to fish or cut bait on this case. No one trained me for this.
Doctor I may be, but family counselor? Judge and jury? I stood there silently shaking my head in frustration as I turned to face Dorothy. Maybe she had decided to call it quits to save the house for her daughter. But she had been the one to decide.
“I have to go with Dorothy’s request,” I said to the group. “We’ll make her comfortable.”
In the end, if Dorothy was comfortable, she was undoubtedly the only one.
Mark Plaster, MD Founder and Executive Editor of Emergency Physicians Monthly