Let Live and Let Die
Posted by Amy on February 15, 2007
A few nights ago, in the wee hours of the night an elderly man was brought in for shortness of breath. I was paged by the nurses as soon as he arrived because “he doesn’t look good”. When I got to the gentleman’s bedside I realized that the nurses were right – he definitely didn’t look good. He was cachectic (very very skinny, wasted appearing) and breathing fast despite the paramedics’ attempt at assisted ventilation (they had him on CPAP, which is a face mask that helps give positive pressure during breathes but isn’t as invasive as being put on a ventilator). My first thought was that this man needed to be intubated. Then I learned that he was DNR (Do Not Resuscitate). So, I tried to make due with the CPAP and continued my history and physical.
He was old (80’s) and had metastatic melanoma. It had started on his back as a little brown spot and now he had cancer throughout most of his body. He and his family and doctors had recently decided that since his prognosis was so poor and he had such little time left that he should be in hospice. He was still living at home with a loving family who took care of him, but knew that it wouldn’t be too long before he had to go to the hospice house to die. I talked to him and he reiterated his DNR order “It’s time for me to go”.
I got a STAT bedside chest x-ray and realized why he was so short of breath. He had a large pneumothorax (which is when the membrane outside the lung gets punctured, allowing air out of the lung in to the space around it, a “collapsed lung”). It turns out he’d fallen on his right chest the day before and it had been getting harder and harder to breathe ever since.
The treatment for a pneumothorax is a chest tube. I described the procedure to the patient (anesthetize the skin, make an incision in the chest near the armpit, put a tube in to that space between the lungs and the ribs and let the air out). He asked if it was painful. I told him that it was. He looked at me right in the eyes and said “I don’t want to be in any more pain. Just let nature take its course”.
A few minutes later, the patient’s wife and daughter arrived and I filled them in on the pneumothorax and the patient’s decision not to act. I told them that this would likely kill him. The family was sad, but they respected the decision of the patient and opted against the chest tube. I took him off the CPAP (which can make pneumothoraces worse by pushing even more air out of the lung) and put him on 100% oxygen face mask. I admitted him to the hospitalist for continued high flow oxygen and pain medication.
He was downstairs in the ED for another few hours and each time I stopped in to see him he was doing worse. It was getting harder and harder to breathe. I felt horrible that there was something relatively easy that I could do for this man to help him and I wasn’t allowed to do it. Don’t get me wrong. I think he probably made the right decision. Chest tubes can certainly be painful and this man had been through enough. He was ready to die.
In this case, doing nothing was the hardest thing for me to do.