The Patient Who Could Not Die





Wayne S. Barry, MD

Recently a 91-year-old female patient came into the ER by ambulance with a chief complaint of dizziness. The ED nurses pulled me out of my seat in front of the documentation computer to see this patient. Her pulse was slow at 27 beats per minute. Blood pressure was 154/90, and she was conscious and alert. She had a number of chronic medical problems, lived alone, and she had been experiencing episodic dizziness over the past several weeks. Her cardiac rhythm, not surprisingly, showed complete heart block. I discussed with her admission for placement of a permanent pacemaker. She told me she has a living will and did not want any heroic life-saving measures. I tried to convince her that a permanent pacemaker was not a heroic measure, and not only was it an easy fix, but the installation of a pacemaker would be nearly painless. The patient told me she just called 911 because she was a retired nurse, she didn’t want to die alone, and she wanted nurses to be with her when she passed away.

Indeed the ED nurses were very attentive at her bedside while I ordered atropine and external pacer pads. I reluctantly ordered ativan to ease the patient’s reaction to the spasmodic jerks induced by 40 mili amperes of electrical current. I convinced her to let me call the on-call cardiologist who was willing to come to her bedside shortly and evaluate her for permanent pacemaker insertion in the cath lab.

Several minutes later, the nurses pulled me out of my chair again to come to this patient’s bedside. This time her pulse was 17 beats per minute, and she was stuporous. I began to order more atropine and turn up the mili amperage on the pacer pads which never did result in successful capture of the QRS complex to effect an effective heart beat. The ED nurses intervened and pleaded with me to not do anything more for her. She told them she wanted to go. She had lived a long and hard life, though there was some happiness, too, she had added. She did not want a pacemaker, and at this point I agreed with the nurses and complied with her wishes. She had voiced these same sentiments to me earlier when she was clearly in a sound state of mind. I quickly called and reached her daughter in St. Louis, MO, who like her mother was also a retired RN. She confirmed knowledge of her mother’s end of life wishes, and she agreed with our plan to “let her pass away peacefully.” I then called the cardiologist and convinced him not to take her to the cath lab for pacemaker installation. He said he would come by later to pay his respects because he had seen her in his office previously as an outpatient.

By this time I was trying to admit her to the hospital for “comfort measures only” treatment. The hospitalist I contacted was urging “hospice” referral. Meanwhile the ED nurses assured me that they would take care of her in the ER by her bedside for as long as it took despite their other duties in a busy ER that day.

Forty minutes later, the cardiologist arrived to find that she had converted to sinus bradycardia with a heart rate of 47 and blood pressure of 120/80. Twenty minutes after that, her vitals were normal, and she was admitted to the hospital on hospice status. She subsequently moved on to the free-standing hospice facility since others joined her in concluding that it was not safe to send her back home.
I don’t know what to make of this clinical case, as I have not experienced such a case in my 38 years of medicine, 32 of them in the ER. While my medical training and experience failed to help this lady out of her presenting predicament, somehow I felt honored and privileged to be a part of something that transcended my medical training. First there was the absolute kindness and compassion extended to her unquestioningly by the ED nurses. Then there was the opportunity to actually listen to what the patient requested and accede to her last wishes even though I almost witlessly trod over them. Finally, there must have been a higher power than my medical knowledge and the utter compassion of the nurses for the patient operant here. Each and every one of us can try to explain this in a way that is either sensible for our minds or comfortable for our souls. I know that I am thankful to have experienced this humbling event, and I believe the patient might feel this way, too.


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