Archives
Exemplar
Saying the last goodbye consciously
Yenna Salamonson
Senior Lecturer, School of Nursing, University of Western Sydney, Sydney NSW
Abstract
Mr V, a 78-year old patient, was initially admitted to the surgical ward with fractured ribs following a motor vehicle accident. A young male driver failed to stop at the traffic light and hit Mr V's car. The driver's side of Mr V's car sustained the full impact of the accident.
The following day, Mr V complained of severe left-sided chest pain and was later diagnosed to have suffered an acute anterior myocardial infraction. Thrombolysis was not an option because of his internal injuries. Mr V had a history of having two previous myocardial infarctions, hypertension and had suffered a minor stroke 4 years ago. He was transferred to the Intensive and Coronary Care Unit (ICCU) for further management of his AMI. Unfortunately, Mr V's condition worsened. He became hypotensive and aliguric and was diagnosed to be cardiogenic shock. Intravenous inotrope infusions were commenced to restore an adequate blood pressure and urine output. The option of increasing his cardiac output with an intra-aortic balloon pump was discussed with a cardiology registrar in a nearby tertiary hospital. In view of Mr V's poor condition and poor prognosis, it was decided that Mr V was not a suitable candidate for intra-aortic balloon pump. A consensus was reached that Mr V was to be managed in our ICCU.
It was 11pm. I had just come on night duty in ICCU and was assigned to care for Mr V. Aside from the intravenous inotrope infusions, he was on 100% oxygen saturation. His urine output in the last 24 hours had been less than 400 ml. By 1am, his oxygen saturation had dropped form 95% to 90%. Despite the severity of his condition and his effort to breathe, Mr V's mental status remained excellent. The night ICCU registrar was keen to intubate and mechanically ventilate Mr V in view of his deterioration in oxygenation. My heart grieved at this possible course of events. I understood why the registrar would be thinking of intubation and ventilation. After all, that is what we in the ICCU are good at, responding to the numbers that reflect the physiological status of our patients. But I wondered what could be gained from this reactive mode of intervention in Mr V's case. His overall condition was worsening. If intubation and ventilation were to occur, Mr V would have to be fully sedated and would possibly lose the opportunity to say goodbye to his loved ones.
The registrar discussed the option with Mr V, who asked me to ring his wife. He wanted to discuss this treatment option with her. I was touched by the obvious closeness of their relationship.
Later, I had the opportunity to discuss Mr V's management with the registrar. We discussed the futility of introducing further invasive interventions. After much debating and bargaining, he agreed that if I could maintain Mr V's oxygen saturation above 90%, he would not intubate MrV.
Throughout the night, I nursed Mr V in the upright position and attended to his general comfort. His wife was there by his side. When possible, I would remove the CPAP mask to give him some ice to suck and he would talk briefly to his wife.
The following night when I came on duty, I found out that Mr V had passed away at 9pm that evening. He had said his last goodbyes to his daughter, his grandchildren and passed away shortly after the arrival of his son from Queensland. He was fully conscious until a few minutes before he passed away.
eContent Home