Monday, 21 January 2013

A Beautiful Death

"97 year old female, DIB, terminally ill"

There is always a sense of appreciation when you are sent to someone so elderly. So many years of experience and knowledge. It's hard to comprehend being alive in 1915. George V was king, Herbert Asquith was Prime Minister and the world was at war. It's an era most of us are lucky not to have been a part of but similarly it's an era and generation where respect is embedded. We arrived relatively quickly, despite the weather and the traffic and were met at the door by the patient's son-in-law. A welcoming smile greeted us and we were thanked for coming. It may sound silly but we a rarely thanked for coming, it's not that I look for thanks or notice when it's not given, but I do notice when it is given and appreciate the gesture. We followed him through the house and up to the bedroom of the annex. 

Our patient was laying in a cot-bed with her daughter at her side. She looked very frail, very pale and exhausted. Her respiratory rate was about 50 and you could hear the bubbling on her lungs as you entered the room. Her oxygen levels were extremely low so we started her on full flow oxygen. She was suffering an acute episode of heart failure. Basically, the heart wasn't pumping properly and fluid was backing up on her lungs. She needed hospital and she needed it quickly. I started to set up the chair in preparation for moving her while my crew mate did her blood pressure.

"We don't want her to go to hospital. She has said she doesn't want to go."

Unfortunately, she was now in such a bad way she was unable to talk, her eyes fixated on the ceiling, breathing was taking every bit of her being. There was no DNR (Do Not Resuscitate) order in place or any palliative care program despite her late stage kidney disease and heart failure. She had been seen by her GP a few weeks previous, who had stopped all of her medication and recommended palliative care but as yet nothing official was in place. This put us in a the very grey area of capacity and our duty of care to act in the patients best interest. We knew that if we left her at home she would die and if we took our oxygen away she would die, but we also knew that with no DNR in place, if she was to die in front of us now, we would have a very difficult job to justify not starting a resus. As horrible and futile that would be on a 97 year old we have to start unless a DNR is in place.

We explained all this and the family were very understanding of our predicament but also quite rightly adamant that they wanted what was best for her and her wishes.

"She wants to die at home, with us and not in a hospital, we are scared that if you take her she won't come home."

She was right, she probably wouldn't. Our thoughts were, that this episode of illness was terminal and it was going to be a matter of hours not days. We needed a plan B and we needed it pretty quickly! We called our local out of hours GP service and explained the situation. After much much debate and various phone calls later, the GP said he'd be with us within the hour and would be able to provide a DNR for us and some medication for the patient. That was a great relief to the family. It was now not about taking her to hospital but about what we could do to make her comfortable. We spent the hour monitoring her and talking to her daughter and son-in-law. Despite the obvious emotion of the situation they showed great interest in us. We talked about the job, what we did before the job, our families and health care. All the while our patient was lying in between us all, fighting hard. Nothing we had done had improved her breathing, it was as bad as it was when we arrived and that was hard to watch. 

Before long the GP arrived. His professionalism and bedside manor was excellent. He engaged with us in everything he was doing and we assisted him drawing up various drugs. He explained everything he was doing to the family and explained he was making her as comfortable as possible. The DNR was openly discussed, written and signed. Everything was in place now for her to die on her own terms. 

We had been on scene for just over two hours before her breathing started to settle down. Her blood pressure was gradually dropping, 102/68, 93/52, 77/44, 63/38. My crew mate was outside the room with the GP and the son-in-law whilst I stood with the daughter, who was holding her mums hand tightly. 

"Is she going to die tonight?"

I knew the answer but didn't know how to respond. Partly because I was choked up and holding back the tears but also because telling someone that their mum is about to die isn't something that is said easily.

"Stay holding her hand, she knows you're there."

She knew what I was saying and asked us to remove all of the monitoring equipment. I left her by the bedside. She told her mum how much she loved her, how much she has inspired her and how much her grandchildren loved her. I ushered the son-in-law back into the room and we stood in the doorway as they said their final goodbyes. The time was now. She wasn't afraid of death and neither was her daughter. Her respiration rate slowly dropped and dropped until she drew her final breath. Very slowly her eyes closed and she let go. There was a peaceful smile on her face It was in that moment her daughter turned to me with a look of fear and desperation and said:

"No, Has she gone?" with tears pouring down her face.

It was as if as much as she knew it, and had made peace with it, but in the moment of death a fear of death had gripped her. I just nodded my head. I walked over and removed the oxygen mask, unable to hold back the tears trickling down my face. We shared a look, one I'll never forget. A look full of appreciation that our inaction had been the greatest gift we could have given their family. It was one of the most heart breaking and distressing things I've ever witnessed yet beautiful at the same time. To be there with someone who isn't afraid of dying and is ready to die, and share that with the family is a humbling experience and one I will never forget. I was so thankful that we avoided a resus because it would have seemed such a tragic way to end what had been a wonderful lifetime.

We went downstairs and in a very British way made them a cup of tea. That is, after all, the done thing in such circumstances. After saying their final goodbyes they came downstairs, teary eyed yet almost relieved. Relieved that they had been able to fulfil her final wish. Death in any circumstances is difficult, but ultimately it's the sacrifice we must all pay for living.

'To die proudly when it is no longer possible to live proudly. Death of ones own free choice, death at the proper time, with a clear head and with joyfulness, consummated in the midst of children and witnesses: so that an actual leave-taking is possible while he who is leaving is still there.'
                Friedrich Nietzsche


61 comments:

  1. Bought a tear to my eye. Bravo.

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  2. Beautifully written. People have no idea the many different things we have to deal with in out daily job. Thanks for writing this.

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    1. I think thats the thing, its the variety of situations we are involved with.

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  3. Thank you for sharing this. You have an amazing job.

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    1. Thank you, it can be the most rewarding of jobs but often also frustrating!

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  4. Such a moving post. Bravo to you and the other health professionals, beautifully handled, a peaceful passing.

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  5. Oh heck, I really shouldn't have read that at work. I'm now surreptitiously wiping tears form my eyes, hoping no one's noticed. A beautifully written tribute.

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  6. Heart wrenching, bought tears to my eyes. keep up the good work.

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  7. Wow. That was beautiful. I've never had to deal with something like this myself, but I've heard stories of similar situations and they've never sounded as well handled as the way you describe. Thank you for sharing it with us.

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  8. So beautifully and perfectly written. Reminded me of my nursing days - its a privilege to be able to make someone comfortable in their final hours, and enable the family to say their goodbyes peacefully. It gets me every time, i cannot help but shed a tear. You'll remember those few hours forever.. dealing with these jobs make all the shit ones worth while. Head Up, Heart Strong.

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  9. Wow Ella, you are really special. That family will never forget you for all the right reasons x

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    1. Awww thank you, what a lovely thing to say!

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  10. I was just about holding it together until I saw your picture of 1915-2013, and that simple kindness tipped me over the edge. Beautifully written, touching, and a fitting legacy for a life well lived. RIP.

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  11. Absolutely beautiful. Thank you for sharing an aspect of your career that people would often not think about.

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    1. Thank you, thats all I want from my blog, to share this part of my life.

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  12. Such a powerful post. I used to work in a hospice and have witnessed 'happy' deaths like this. Although it is undoubtedly hard, it is great knowing that the person died peacefully, and with dignity. You guys are fantastic people.

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  13. As always Ella you said it all perfectly. I hope when my time comes (as it does for us all) I have the courage to face it with such dignity. R.I.P to a gracious lady

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  14. Beautifully written. In my trust we are allowed not to start CPR even if there is no DNR in place if there are multiple co-morbidities so in this case we would be justified in not starting. It is a huge relief to not be put under pressure to start something which is distressing and not what the family or the patient want.
    I have sat and held a patients hand as they died without a DNR in place and where the family were too scared to come close. It is a privilege to be part of this part of life and I am very proud to have been trusted to do this by the family.

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    1. Thank you! We can not start too if the is terminal illness but usually with terminal illness there is palliative care and relevant paperwork to show it. In this particular case although she was terminally, it had only been decided a week previous that meds were stopping end EOLC would begin. It was just bad timing!

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  15. Sounds like you did a brilliant job, it's what we joined for though isn't it? I love my job at times like that, makes you feel that you really make a difference.

    Love reading your blog, I'm an ECA/student paramedic and it's an inspiration as I wade my way through the four years training. Please keep posting.

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    1. Thank you! How far are you in to training?! I will keep posting!

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  16. Just half way through the first year with the OU, at least the trust are funding me and give me two shifts per month off for study. I'm very lucky.

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  17. Even being in the job does not enure you to such emotions.
    A tear or two fell as i read the post.
    Good call, btw.

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  18. So beautifully written! I cried buckets. Thank you for doing the right thing. I just hope that if I ever find myself in that situation as either relative or patient I have an Ella there. That family will remember you forever! Thank You for sharing!

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  19. Hi, was moved so much I just wanted to thank you for writing about a sad event with such empathy. I work for NWAS and will never forget a very similar job where we had to take a terminally ill young man home to die. Unfortunately the journey was three hours long and he passed away just as we pulled up to his house. His family were amazing; even though they had just lost their son, they insisted we sat with them for a cup of tea before our long journey back home. They even tried to comfort me when I very unprofessionally burst into tears, which made me even worse :) I will never forget that job, such a humbling experience. Thanks again.

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    1. I don't think it's unprofessional at all. We can't be robots, as hard as we try we do get emotionally involved with our patients, 3 hours is a long time with someone who is dying. If rather that than someone void of emotion. It shows you cared. Tough jobs x

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  20. It's undeniable that this is beautifully written and like many others it has left me with tears streaming down my face but it also feels slightly wrong, writing in some detail about the very private and personal last moments together of a Mother and Daughter. It might be because I'm sensitised to it, having lost my own Mum and been through those last goodbyes but it just didn't sit comfortably with me when you were sharing what was said in those last moments. It was a beautiful tribute to a life, but that part just made me feel uncomfortable on behalf of the daughter who was no doubt saying those things and not expecting them to end up on a blog. X

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  21. I understand what you are saying. Without wanting to spoil the essence of the post, I am always careful to change specifics about jobs like ages etc and of course I picked up on things that were said but didn't relay the conversation as it occurred. I also don't post near to the time something happens. I appreciate what you're saying though which is why I always change what I do and use poetic license where appropriate without taking away from what happened. Thank you for the comment x

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  22. Beautifully written, thank you for being there and caring so much in the job you do despite all the pressures from management, ticking clocks, and tickey boxes.

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  23. thank you for that, your courage, dignity and practicality are an example to us all

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  24. So beautifully and eloquently written. Good job to crew and Gp for taking the time to honor the requests of the pt.

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  25. Beautiful. My Dad passed in May, and I couldn't make myself stay and watch what we all knew were his final hours. My Mom later said it was a beautiful death, that he was there one minute, gone the next. I know that he is no longer suffering, and Mom recently had a "visit" from him, which finally put her at peace. I have been with others when they left this world, but was unable to watch my Dad go. Some of my other 8 siblings were also unable to physically and mentally be there. My oldest brother could not even step into his room the last few days. Don't know why I am sharing this. All life is beautiful. Many deaths are not, so to be a part of one that was is a blessing, indeed.

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    1. Thank you. Sorry for your loss. Grief is hard for all and people deal with it in different ways. x

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  26. I had a very similar call once. Repeated phone calls with the GP. Dispatch calling us "why aren't you transporting yet? How long are you going to be on scene?" Difficult, but ultimately the best choice.

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    1. We had the 'friendly' message down our radios after an hour saying 'everything ok on scene' which translates to 'hurry up, we have other calls for you'!!

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  27. Wow what a post Ella.
    I cried reading this. It's lovely what you did.

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  28. Never had to deal with a case like this yet, similar where palliative care and a dnr was in place so I'm not sure why we were called but put it down to that last minute panic, change of mind. But we left after lots of reassurance and before the patient passed away.
    And as we were chatting, I wondered what to say, how to say it? I've only been in the service 3 years, Tech for a year and about to apply for para!!! Gulp!!! This is one thing they never taught me on my tech course!!! Well, along with a lot of other things you can only learn out on the road. Luckily, I work with some very experienced and wonderful people who have helped me on understanding what is turning out to be one of the best and worse career moves ever!!! Lol
    Reading your blog is really helping me to understand how to deal with some situations I've yet to encounter. Thanks, keep up the good work.

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  29. My father had just turned 83 a few weeks earlier. I was sat alone with him, it was Sunday the the 21st October 2012 I was holding his hand (as I had been for the last 3 hours) as he passed from this life to the next. It was 11.55pm. He had signed DNR and a death at home agreement with the care home he had lived at for the past 7 years. It was in force just 55 days before it was called on.
    After my Dad had signed (= the scribbled a mark had to and was witnessed by his solicitor) the document. He was able to relax, safe in the knowledge that he would die in his own bed in his own room. He was happy that the care home would not be moving him to hospital when his time came. (as was the usual policy) He was able to concentrate on letting go of this life and having people he knew around him where also in a relaxed state. He was able to let go gently and die with dignity, as did the lady in the story. Thank you to the crew that attended the call out to the old Lady and Thank You to the Control Centre Staff for giving them (the crew) the time off the road to allow the lady to die with dignity. Being at a beautiful gentle death is an honer indeed. I am 59 years old and I am no longer afraid of death, if that is how it comes. It is nothing like the T.V. portrays it.

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  30. I wish we had the ability to do something like that in the US. If they do not have a DNR we have to take them. One no doctor is going to come to the house and sign a DNR. Two we would not be allowed to stay on scene that long. Three we would have got in trouble for not starting full care once we found out she did not have a DNR.

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  31. Thank you for sharing and for the beautiful way you wrote this. It reminded me so much of my own Mum's lovely (can I say that?) death with both my sister and I holding her in our arms as she went. Also many thanks to you all for the wonderful job you do.

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