DNR

I've been working as a floor nurse these past couple of weeks. In an effort to get more nurses acclimated to the Charge Nurse role, I have been accepting the charge position only on those nights when no other nurse is on duty that has been with our hospital more than 2 years. I figure I started taking charge after 1 year, so a standard expectation would be that nurses should take charge (and all of the subsequent frustrations) after 2 years. This doesn't count Traveling nurses.

I received a patient a few days ago. HIV+ with a long history of heart failure, liver failure, renal failure. If he had it, it was failing. Young -- around 55 years of age. I had expected a "train-wreck" (that's nurse-ese for complex patients with lots of issues requiring more time than any nurse had available), and when he arrived from the ER, he was yellow (jaundice -- from the liver failure), gasping for breath, with a pulse oximetry of 70 (most folks are 96, if you smoke you're 92, severe pulmonary disease patients can live at 82 -- when the rest of us would be lightheaded and blue-lipped).

We barely got him from the stretcher to the bed. The automatic vital machine got no blood pressure, no pulse. I couldn't get a BP via auscultation (using a stethoscope) or doppler.

Ordinarily, we'd bring in the crash cart, flatten the bed, start CPR, and force air into dead lungs using an ambubag. But this patient was a DNR -- Do Not Resuscitate. It's a tricky call. Do Not Rescuscitate doesn't mean Do Not Treat, and it's still my responsibility to do everything just short of CPR. How about a fluid bolus to possibly get a blood pressure? How about just ambu-bagging him (no compressions or intubation)?

I am not sure when it happened, and it always makes me wonder what exactly happens inside my mind when these same situations occur, but I made the decision to leave the patient alone. I told everyone they could leave the room (that always gets a few looks), and told the patient's partner that the patient is near death. A knowing nod, a look of thankful understanding, a mutual recognition of a battle long fought but now lost.

He could not stay in the room. "I've got to get out of here for just a minute." He left to make a few calls, to walk outside in the humid monsoon-season air. During those 5 minutes, I stayed at the bedside, using my stethoscope to track the progressive decline from sinus tachycardia to ventricular tachycardia to ventricular fibrillation to cardiac standstill. I'm not sure if it's my own defense mechanism, or if I really feel these patients might be in the room, stereotypically staring down at me from the ceiling lights, or looking over my shoulder. But I always say something, usually about how I'm going to "stay here by your side," or commenting "you have such a nice family" or whatever silly nonsense comes to my mind at times like these. Babble, really.

I straightened out the body, drawing the sheets up to the chest. Thoughtfully, I leave one hand out from under the blanket, ready to receive a parting grasp from family and friends. Boxes of tissues. Personal effects neatly packed into plastic bags. Another RN has listened to the chest with me for 60 seconds, verifying there is no life. The physician has been notified. A well trained staff has assembled all of the Discharge by Death forms, the list of area mortuaries, telephone numbers of our Social Services Department, the number for our Grief Support Group.

The Life Partner has returned from a series of phone calls to various answering machines and voicemails throughout the country. The door has been closed, and we meet in the hallway. Again, that look of understanding -- he was too sick for his RN to be walking in the hallway -- if he were still alive, that nurse should be busy has hell. So he knows. I tell him anyway. "I'm sorry, but Daniel is gone. He has died." (I'm never ambiguous -- no "He's no longer with us," or "He has gone on" or anything so easily misunderstood. I always tell them The Patient Has Died.)

I am surprised at the intensity of the grief. The wail of mourning takes everyone by surprise. Instinctively, I offer my arms and shoulder for support. The offer is accepted, with the weight and gravity of a loss still shocking after years of anticipation. Together, we walk (awkwardly -- he is over 6 feet tall and I am all of 5' 2") but we make it into the tiny room with the copying machine. He melts into a chair, sobbing.

Tissues. I have a fistful in my pocket, ready for a moment like this. He crys loudly for several minutes. I used to say stuff, but really, who wants to hear my stupid drivel when Death takes your lover of 18 years?

After several minutes, he quietly tells me, "I want to see Daniel now." We enter the room, where I have drawn the curtain, enough to hide the face, enough to let family get used to the site of dead feet, dead legs, dead hips, dead hands, before they set eyes upon a dead face. He gets past the curtain, and the intense sobbing starts again. He takes his lover's hand, bends to give a wet sobbing kiss to his forehead (some family members have to be told they can touch the body, that it's ok to talk to the body, that it's not a freak show to kiss, touch, hug). I give him privacy.

Twenty minutes later, he comes out of the room. I am seated at the nurses' station. I point to a seat beside me. Silence is Golden. I quietly assure him all of us are sorry for his loss. Is there anything we can do? Is there anyone else you need to call?

No one else comes. No family or friends for now (it is now 5 AM). He randomly picks a phone number from our list of mortuaries. He has gathered the plastic bag of personal effects. We chat briefly, about their lives together, about the wonderful person, now lost to us all. About the years of struggle against the Monster that Still Is AIDS. We talk about how quiet the Monster has become, during these last years of Cocktails and Protease Inhibitors. But the Monster still has teeth.

We say goodnight and good bye. One final hug. Polite pleasantries before he exits into the darkness into a lonely life.

Comments

[Kimber]

Wow.