The call is for difficulty breathing at a nursing home. A nurse meets us at the curb – a bad sign. “You have to get him out of here quick!” she says. “We can’t get his SATs above 60.”
Another nurse meets us at the door. “This way,” she says and starts walking speedily ahead of us.
In the room three other nurses are gathered around the bed and a crash cart. “We have him on a non-rebreather at 15 lpm,” the nurse administrator tells me, as another nurse says, “I can’t get a blood pressure.”
The ashen eighty-year old man’s eyes are open, but he doesn’t seem to be seeing. He is breathing, but it is borderline agonal. His arms are cold.
“What’s his code status?” I ask.
“Full,” the nurse says.
“Let’s just get him on the stretcher,” I say to my partner. “And out of here.” If he is going to code, I want him on my stretcher and in the ambulance.
He is light and we lift him easily on the sheets. It is then I notice an orange DNR bracelet on his right wrist. I look for the nurses, but they have all fled the room. We wheel the patient out into the hall, and down toward the nurse’s station where the nurses are now busily trying to get the paperwork ready. A nurse approaches us and says, “He was a DNR, but the family is changing its mind.”
There are two women standing in the hallway and ask if they are family. They identify themselves as daughter and granddaughter.
“Do you want us to resuscitate him if he stops breathing?” I ask.
“No, we want him to go to the hospital and for them to do everything they can, but don’t make him suffer.”
“No tubes down the throat to help him breathe?”
“No, just make him comfortable. Save his life if you can.”
“Do you want us to do chest compressions?”
At the desk a large beefy woman, who I learn is another granddaughter, is talking with a nurse who has an advanced directives sheet on the countertop and going over it line by line. “Do you want hydration?” the nurse asks.
“Yeah, hydration, that would all right,” the woman says.
“How about artificial nutrition?”
“Now, what would that be?”
“It’s like minerals and nutrients.”
“Yeah, okay, anything to make him healthy.”
“I’m going to need the W-10,” I say to the nurse.
“We’ll bring it out to you. I’m sorry, we’re just finishing the paperwork,” another nurse says.
“We’ll be out in the ambulance,” I say.
In the back of the ambulance, I switch the O2 to the main. I glance at the monitor. Not looking good. A widening bradycardia. I can’t get a manual pressure, the machine pressure reads 84/60 – higher than I would have thought. I put on an ETCO2 cannula and it reads 8. The apnea alarm goes off and I try to reposition the cannula, but get no improvement. The patient is still breathing, but I don’t know if there is much gas exchange air coming out. The bradycardia continues to slow and widen.
The nurse comes out with the paperwork. She opens the side door and hands it to me. I ask her to wait while I quickly look through it, reconfirming that the patient is a do not intubate, do not resuscitate.
The man’s daughter is sitting in front. I tell my partner to drive, but no lights and sirens.
The daughter looks toward the back and says, “How he’s doing?”
The apnea alarm goes off again and the bradycardia is down to 30. I am trying to get a line, but the patient’s arm is bloodless.
“He’s passing right now,” I say. “If you want to come back for a moment and say goodbye. Now’s the time.”
“He’s dying? He’s dying! Stop! Stop the ambulance and let me out!” she screams. “I can’t handle this! Let me out of here!” We have barely stopped rolling when she jumps from the front seat and I see her running across the nursing home grass, screaming, “Granpa dead! Granpa dead!”
I look out the back window and see other family members, and they all seem to be suddenly screaming or crying in contagion. The large granddaughter approaches and knocks hard on the back door, which I open for her.
The lines on the monitor are beginning to roll.
“He’s passing now, if you want to say goodbye,” I say. “Now’s the time. Maybe he can hear you on his way out. You can tell him you love him and wish him well.” I always like to give family members a chance to say goodbye, for them to believe their last words are heard, which maybe they are.
She muscles past me and grabs the old man by the neck and starts shaking him. “You promised! Don’t you die! Don’t you die on me! You promised.”
The man’s head flops back and forth.
“Easy, say goodbye, it’s his time. Tell him you love him,” I say.
“No it isn’t! You ain’t dying! You promised. Don’t you die and leave us! That ain’t fair! That ain’t right. You ain’t a quitter, don’t quit now!”
I battle against her girth to get her to ease her grip. “Easy, easy,” I say, struggling to get position on her, and get the man’s head back down on the pillow.
“It’s his wishes,” I say.
“I love you, Granpa,” she says. “Don’t you die on me. Don’t you die!”
“Granpa dead! Granpa dead!” I hear from outside. The daughter is still running around on the grass.
“Just get him to the hospital, get him to the hospital now!” the granddaughter says.
“Okay, we’ll see you there,” I say, helping ease her away and out the back door.
“Don’t you quit!” she calls in as she steps out.
I close the back door.
The monitor shows three straight lines.
We’re driving out of the nursing home parking lot now.
The family is scattered on the lawn and sidewalk, still seeming in a state of shock.
The old man’s mouth and eyes are open. His pupils are already fixed and dilated. I place a finger tip on each eye lid and close them.