It’s never much fun accepting hand-over patients from other doctors going off shift – especially at eight o’clock in the morning. The doctors are usually tired and anxious to get home. The patients are usually exhausted - awake most, if not all, of the night with pain and or vomiting plus or minus diarrhea and bleeding. Some have had hallucinations or delirium. Not only that, but, because some ancillary staff such as x-ray , laboratory, psychiatry and social work people don’t work in dark hours, the patients often still have a long wait ahead of them.
Such was the case when I received an elderly gentleman who had collapsed in the lounge room at home late the previous night. His wife called the ambulance and he was conveyed, unconscious, to our hospital. The night shift doctor had done an excellent job of assessing the patient and documenting his findings. It was apparent, simply on the clinical findings, that he had suffered a catastrophic stroke. All that was needed now was confirmation by way of a CT scan of the brain. The patient’s wife and son were told during the night that things looked pretty grim. They had gone home in the early hours to try to get some sleep.
I did my own assessment of the patient concluding that the night doctor was entirely correct. The orderlies came to take him for the CT scan. Within the hour he was back in ED. The CT scan showed a massive bleed inside the skull. The brain was displaced and the pressure was squeezing the lower parts of the brain downwards into the space occupied by the spinal cord. His condition had deteriorated significantly. There was absolutely nothing that could be done for him. Surgery was out of the question given his age, the large blood loss and the damage done to the brain. All we could do was make him as comfortable as possible and await the inevitable.
I called the home phone number shown on the patient’s chart. His daughter-in-law answered saying her husband was in the shower and the patient’s wife asleep on the lounge. I told her then that I felt it would be wise for the family to come to the hospital as soon as possible because of the rapidly deteriorating condition of the patient. She seemed a little put out by this news and enquired why they could not come in later. I started to explained the situation again but was interrupted by the son. He was more receptive and said he would come in immediately. He asked if he should bring his mother given that she had been up most of the night and was aged and frail. I gently told him that I felt she should come because it was most likely the last opportunity she would have to say a goodbye.
The son and his mother arrived shortly thereafter. We stood around the bed, the patient comatose but breathing slowly and shallowly. The monitors above the bed flashed the ECG and respiratory traces, beeping as they do, the blood pressure cuff automatically inflated and deflated with the result showing on the monitor screen below the oxygen saturation level. I explained the situation again. The son nodded appropriately and asked a question or two. His mother, gaunt and haggard, stood alongside him staring at her husband, saying nothing. There was no physical contact between mother and son.
Then I came to the most difficult part of the process – raising the issue of resuscitation. As gently as I could I asked, “Have you given any thought to what we should do when his heart stops?” The lady looked up at me suddenly with a look of horror. “What do you mean?” she asked.
I did not have to explain as the son immediately said, “Yes! We discussed this situation quite often and Dad always said he would rather die than become a vegetable. If his heart stops and you get it going again he would be a vegetable – wouldn’t he?”
“Yes.”
I thought the lady was about to faint and put my arm around her shoulders. Instead, she sagged, deflated and leaned against me before regaining her composure. We, all three, stood silently for a few minutes, the only sounds in our awareness those of the beeping monitor - the background noise of the ward not perceived by any of us. The poor, dear old lady stood bewildered, lost and lonely still with no physical contact from her son. Some people are like that while others are very “touchy- feely”. I think she may have been contemplating her future without the soul-mate of many years and wondering how she would cope.
“May I ask you both to sign a standard form that permits us to not resuscitate patients who have no chance of survival?” They both agreed; the son saying “Yes” and the mother nodding. I produced the form and we completed it on the bedside table. She signed last, hesitantly and with a shaky hand.
“We will move him to a private room in the hospital now. They will make him as comfortable as possible and you may stay with him as long as you like. I have spoken to your family GP and he will take over the medical care now.”
The son thanked me and his mother looked at me, distantly, then extending her frail hand, took mine gently shaking it and saying, “Thank you, doctor.”
The orderlies came and wheeled the bed away to the ward. Mother and son followed. He finally put his arm around her shoulders and drew her close to him as they walked slowly beside the bed.
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