The man is breathing like a fish cast up on land. He is quiet, then with all the effort of his chest, he gasps. He's quiet, then he gasps again. His wife says he started losing conciousness an hour ago. He has terminal lung cancer. It has all been very quick. It started with back pain a month ago.
I tell her she can come with us, but she'll have to ride in the front. She says we've let her ride in the back before. Okay, I say.
We put him on oxygen by nonrebreather. My preceptee puts in an IV. He looks at me and says, "I'm thinking he needs to be intubated."
I ask the wife if she has discussed what measures they want taken. She looks like she isn't certain she understands.
Your husband's breathing is getting to the point where we may need to put a tube down his throat to help him breathe. I don't know for certain, but from his pattern of breathing, he may close to the end. Did you want everything done?
No, no, she says. He has suffered enough.
Do you have a DNR ? Do not resucitate order?
She shakes her head.
Have you discussed it with a doctor?
Yes, she says. He was going to put an order in his chart, but its been so quick.
When we get to the hospital, I say, they are going to need to know how you feel about this.
She nods.
When we get there, I will introduce you to the doctor, and you are going to need to tell him how you and your husband feel, and the name of the doctor you've discussed this with.
I tell my preceptee to call the hospital and explain the situation. Man with agonal respirations, terminal cancer, no DNR, but wife doesn't want advanced measures. We're holding off on intubation.
When we get to the hospital, we go to the critical care area of the ER. As we move him into the room with its space aged medical equipment and waiting medical staff, the wife bursts into tears. A family services worker puts her arm around her and leads her away. While my preceptee gives his report, I excuse myself and walk quickly down the hall after them.
She needs to talk to the doctor, I tell the aide, and turn them around and bring them back to the room.
I catch the doctor's eye and introduce her as the patient's wife, and tell him they have discussed measures with his physician. He nods and then talks quietly with her. The medical staff has the intubation tray out, and is waiting on the doctor.
The doctor and the wife speak for several minutes, then the doctor tells the staff to give the man morphine and some ativan.
"No intubation?"
He shakes his head. "Supportive measures. Let's at least make him comfortable."
The wife turns to me. "We've been married for forty-nine years," she says, her voice breaking. I put my arms around her. Her chest heaves as she sobbs.
