Death in an Hour

It is uncommon that someone dies in the Emergency Department who wasn't already well on their way to dying in the field. It is even more uncommon to watch someone die right in front of you and do nothing other than perform "medical management" (fluids and medicines).

I took care of a woman last night who was sent in merely because her pulse rate was too high. Mrs. Hall was sent from a nursing home where she was a resident and her husband was at her side. She had advanced Alzheimer's disease and hadn't been able to communicate with anyone in almost two years. Prior to that time she and her husband had decided that she did not wish heroic measures to be used to save her life when the occasion arose. In other words, she had a valid "Do Not Resuscitate" order executed prior to my meeting with her.

I still don't know what happened to Mrs. Hall. She came in with a pulse of 140. I assumed she was dehydrated and probably had a urinary infection. Given that she was non-communicative however, we proceeded with a very thorough workup. "Do Not Resuscitate" does not mean "Do Not Treat"... That's for hospice patients. I was sure we would find a pneumonia or even a pulmonary embolism or something that we could fix. We did not.

Mr. Hall was at her bedside the whole time. As I did what I thought I had to do to reverse and treat this poor woman, she got worse. Her heart rate went up despite IV fluids, she began to sweat profusely, her breathing rate increased but the breaths themselves became more shallow. Finally, her heart rate began slowing. She was dying, and dying quickly.

Her husband was very courageous. As I explained to him that she had, perhaps, minutes to live without heroic measures, he did not change his mind about her DNR order. He did not give into the very strong temptation to have me intubate her and do all kinds of stuff that wouldn't have mattered anyway, but might have given her a few more hours or days in her state of limbo.

In fact, she breathed her last not two hours after her arrival. Her husband cried and told her he loved her as she died. All of us around the bed were moved. He let her go and, I truly believe, her soul is joyfully alive somehwere out of the prison that was her body.

What happened? I think she either had a huge heart attack after her first EKG was done, had a huge pulmonary embolus, or had massive internal hemorrhage from a thoracic or abdominal aneurysm. It doesn't matter. Whatever it was took her quickly, and, as I explained to the husband, even if he had changed his mind about the DNR order nothing I did was going to change a thing. Humbling. Christmas is it?