Christmas in the Cardiac Critical Care Unit

Last year I spent Christmas Night on-call in the cardiac critical care unit. The charge nurse, as she was leaving at noon to be with her family, gave me some advice, ‘don’t let anyone die until midnight. Don’t make families remember Christmas as the day their mother died.’ But we had a woman in the unit who was very sick and twelve hours was a lot to ask.

She had a myocardial infarction several days prior and was not doing well. She was on a breathing machine with a tube down her throat and was bleeding from her gut. Her heart was not strong enough to maintain her blood pressure, so we had her on IV medications that were flogging her heart to work harder.

By early evening she was worsening. She had been bleeding previously, but now blood was pouring from her rectum. The vent settings were not adequately oxygenating what blood she had remaining in her vascular system. Her blood pressure was falling. It was only eight o’clock. It would have taken many units of blood to keep her around until midnight. I would have to retool the vent settings to keep her breathing. This was simple enough to do, but I would have to force the air down her throat with such high pressures I risked popping her lungs and causing a pneumothorax. I would also have to add more medications to flog the dying horse that was her heart.

I called the family into the quiet room. I explained the futility of what we were doing. I explained that though we had been extremely aggressive already, I was going to have to become so aggressive that I felt we were crossing the line into pointless torture. The patient’s family and I spoke at great length. When they understood it was not an issue of whether or not she was going to die, but how she was going to die, we arrived at a decision. We were not going to advance her care. We were going to attempt to salvage some dignity for her in her final moments.

I went back into the patient’s room. The sheets covered her, but I knew what was going on under them. The smell of blood mixed with shit is distinct. If you smell it once, it’s easy to recognize. It’s not pleasant, and the room reeked of it. I had four or five machines attached to her. The machines were noisy: whirring and chirping and heaving and blinking. The exact picture of how most of us would not want to die.

The nurse cleaned the sheets, as I removed the blood pressure cuff and the pulse ox monitor. I removed the restraints from her wrists.

The restraints had been placed to prevent her from removing the breathing tube that went down her throat, the feeding tube that went down her nose, the central IV line that went into her chest, just above her right breast.

I turned off the IV medication pump that was maintaining her blood pressure. With the blood pressure lower some of the bleeding would slow. Maybe stop. The blood in her colon would likely continue to seep. But the morphine we were now hanging would help slow some of the seepage.

With that done,I removed the breathing tube from her throat.

Her mouth was suctioned and the sputum that she gagged up was cleaned. A fresh blanket was placed over her torso and she was tucked in. Her breaths were shallow, regular, and—most importantly—not agonal. I turned off the overhead exam lights. The room was dimly lit now and quiet.

Her family was brought back in. They went into the room and surrounded her bed. They took her hand. They stroked her forehead. They kissed her cheek. At this point, they looked at me with that awkward look families always have right before they ask, ‘how long will this take?’ I usually give a very honest but non-commital response because patients can surprise you. With her I was able to say, ‘not long.’

I had turned off the monitor in her room, but from the monitor in the nurses station I watched as her heartbeat slowed. Over the next hour the pace slowed more and more until it stopped. I went in and told her family she was dead.

This was a fairly good death. She was too young, only her early seventies. It was unexpected. But in her final moments she was with people who loved her. They were tender with her. And she went peacefully. Her family will have to deal with the association of Christmas and her death. But, at least in the last hour, she went with grace. She went with dignity. She was without pain. She went with the people who loved her at her side.

Sometimes that is the most that I can offer a patient.