by Tilda Shalof
“It’s hard to say for sure. She can’t tell us. Her son is the next of kin.”
I helped the doctor with the line insertion.
For Mrs. Templeton, I could not fathom how there could be any benefit in performing this painful, invasive, and risky procedure, other than academic. Sure, a more exact diagnosis could be made and medications adjusted accordingly, but I did not believe that the outcome would be any different. Perhaps the only good that could come of it was that the resident was gaining much-needed practice that would one day benefit other patients. How else could I continue restraining her arms and offering her useless, reassuring words, as she struggled to get away from what we were doing to her, if I didn’t rationalize it in some way or another?
It made me recall a night shift I worked once on a geriatric floor in another hospital. A patient had died and the porters hadn’t yet arrived with the gurney to transfer the body to the morgue. As I passed by the dead patient’s closed room later in the night, I noticed a light under the door. That was strange. I opened the door to find the medical resident and his intern putting in a central line in the corpse. In a second the expression on their faces flared from guilty to self-righteous.
“Dean has to learn this procedure,” the resident explained. “He’ll be a resident in a few months and has never put in a central line. He has to learn. Isn’t it better to practise on a dead patient than on a live one?”
His protestations were wasted on me. We all knew that what they were doing was wrong in all ways – legally, morally, and ethically. However, I could also see they had a point. Was it possible that something could be wrong, but also have benefit? If no one was harmed or hurt, was there really a problem?
“Take it easy, guys. I’m not going to report you,” I said.
We all knew that they would be in trouble, seriously reprimanded, or even worse. I didn’t even stop to think if knowing and not reporting them implicated me, too.
Justine sauntered over while the resident and I were still working on Mrs. Templeton. “If I ever get like this,” she said loudly, not caring who heard, “shoot me.”
“We need to find out what’s going on with her,” said the resident defensively. She was still having difficulty threading the catheter into the superior vena cava.
“I’ll tell you exactly what’s going on with her,” Justine said. “What’s going on with her is that she is trying to check out. In the olden days, before all this high-tech stuff, they used to call this ‘dying,’ plain and simple. That’s what it’s called.”
“But the son is calling the shots,” answered the doctor. “He wants –”
“Does he really think we can turn back the clock, offer her the fountain of youth? Tell him there’s no cure for old age. Poor thing, she was trying to die and we won’t let her. Someone should tell her that’s not allowed around here.” Justine took the old woman’s wrinkled hand in her strong grip and shook her head in disgust.
After the line was in, the son came back and pulled up a chair beside his mother. I lowered the bed rail so that he could get closer and hold her hand.
“Thank you, nurse. I’ll sit here, give her a little ginger ale, and she’ll get her strength back, you’ll see.”
The resident returned to review the situation with him one more time.
“Mr. Templeton, the question here is whether to intubate or not. If we do, your mother will be back on the breathing machine. She will be in some discomfort, which we could manage with sedation, but we cannot offer any guarantee whatsoever that we will be able to wean her off the ventilator.”
“I want everything done for Mother,” he said.
The resident shrugged her shoulders and rushed off as her pager was beeping.
I sighed and faced him alone. “Mr. Templeton, it must painful to see your mother in this condition, but try to imagine what it is like for her and what she would want. Would she want us to keep her alive on a ventilator with an intravenous, urinary catheter and feeding tubes? Her mind is deteriorating and she suffers from an incurable lung disease. How much time does she have left and is the suffering worth it? Is it possible she wants to die?”
“Are you saying she is dying?”
Now the word had been uttered.
“Are you suggesting giving up on her, just like that? Pulling the plug? I’ll take you all to court! I want a second opinion. If you’re not going to do everything for her, I’ll take her somewhere else.”
I drew a deep breath to calm myself. “Mr. Templeton, nothing will be done against your wishes. We will do what you decide. We just want to make sure that you understand the implications of putting her back on the breathing machine. Think about what is best for her. What would she want?”
He was aghast at my apparent cruelty. “There is nothing to think about. I want everything possible done to bring her back. How can you ask me to put an end to my mother’s life? Give her all the life support available!”
It occurred to me that once you call it “life support,” how could one justify withholding it from anyone? Who could ever withdraw it?
I reached out to touch his arm to comfort him, but he pulled away and got up from the chair to confront me. “You’re trying to kill my mother! Do you know who this woman is? She was Miss Georgian Bay, 1923. She sews award-winning quilts. Just last week she walked to the hairdresser, and we had lunch together at Eaton’s. You think these other people have more right to live than an old woman?” He waved in the direction of the other patients, then pointed a long finger at me. “How dare you give up on her! Are you the Angel of Death?” Spit flew from the corners of his mouth.
I became small, and shrank away from his accusations. Was I just supposed to do what I was told and not think? Was I just there to carry out orders?
I escaped for a moment to the nursing station and sat staring at the central cardiac monitors that displayed all of the patients’ heartbeats by remote view. I pressed my hand to my forehead, which seemed to throb along with the beep … beep … beep of the patients’ heartbeats. The various alarms ringing in the different rooms and the ventilators whooshing in and out played on, like a never-ending soundtrack.
Rosemary came over and sat down beside me. “I’m worried about you, Tilda. Maybe you need a change of assignment. Maybe you’re not ready –”
“Of course not, Rosemary. I’m fine.” Did she think I wasn’t coping? Did she think I was – Laura’s epithet – too sensitive?
“Come on, Angel of Death, it’s time for lunch.” Justine came over and pulled me along. “I asked Pang-Mei to cover for you. I’m going to get you a T-shirt with a skull and crossbones, or a black gown with a hood, like the Grim Reaper.”
I followed Justine to the cafeteria where we joined the others.
“We’re trying to be helpful, compassionate, and we get this kind of insult?” I complained over lunch. “The Angel of Death! It’s the exact opposite of why I’m a nurse.”
Frances said, “I remember in nursing school, back home, they used to tell us, ‘When you come to work, leave your self at the door.’ It’s probably the best advice, if you can do it.”
“Dying is a natural process and they used to let it happen to the elders of our society, for God’s sake!” said Justine, eager to resume her rant. “The public buys into this belief that everything can be fixed, that even dying can be reversed. And the doctors themselves like them to think that way so that they can be God. I said to Dr. Bristol this morning, do you know what’s the difference between God and a doctor? God knows he’s not a doctor!”
“Listen, Tilda, don’t take the son’s anger personally,” said Nicole. “It’s like, families need to express these feelings and it’s easier to take it out on the nurses – they’d never talk like that to a doctor. It’s hard when they say hurtful things, but you have to rise above it and not blame him for it.”
“Oh, I blame him. He’s nuts.” Justine stabbed her fork into a huge slice of lemon meringue pie. “Why should we have to take th
is bullshit? We have a right to be treated respectfully. Besides, this guy has got to be told to let go. The time has come. It’s cruel what we’re doing. Does he actually believe that his mom is going to walk out of here, come home and cook him a meatloaf? Her lungs are like empty paper bags. There’s nothing left to perfuse. But he wants to have a breathing tube, the size of a garden hose, shoved down her windpipe, and we have to be the ones to carry out the torture. She’s eighty-six, for God’s sake, and not exactly the picture of health.”
“Ah, make that eighty-five,” I said. “For the record.”
“But she’s a young eighty-five,” said Tracy mischievously. “She has the lungs of an eighty-year-old!”
“Doesn’t look a day over eighty-three!” added Justine. “How long does the public believe that people actually live? By the way, does anyone ever consider the costs to the health-care system that this type of situation creates?”
But by then we were doubled over, trying to contain our howls of laughter.
“But what if we’re wrong?” I asked. “Is it possible that she really would have wanted this done? Is it possible she could pull through this?”
“If someone really knew what all of this entailed, I mean really knew the truth, the details, if they knew what nurses know, not just the way they show it on TV, who would want this?” asked Laura. “If there’s a reason to believe there’s some benefit, that’s another thing.”
“It’s like the Bruce Cockburn song.” Justine sang out in a startlingly lovely alto voice, “They’re all waiting for some miracle to come along.”
But was all this indignity and discomfort that we were inflicting on Mrs. Templeton worth it, for the long shot of a miracle? If Mrs. Templeton did make it, if she did survive this ICU admission, it wouldn’t be a miracle, it would be an oddity, an aberration, an anomaly, an exception, a blip, a delay of the imminently inevitable.
“Well, what about miracles?” I asked. “Have you guys seen any?”
“Not unless you count a child’s smile or a rainbow,” said Laura in a syrupy-sweet voice.
“I believe in miracles,” said Tracy. “But I’ve never seen one around here.”
“What about Mr. Collacutt?” Frances reminded us. “He had a miraculous recovery.”
“You mean Mr. Cold Cuts?” said Justine.
“Yes, Mr. Collacutt was on a ton of meds, three or four inotropes, and the next day he was off everything, don’t you remember?”
“Yeah, that’s because he died, Frances. You were off that day.”
“He died?” said Frances. “I thought he got better.”
“You’re slipping, Frances. Haven’t you been keeping up with the obituaries?”
We all knew that Frances made a habit of reading the newspaper memorials to search out ones for our patients who had died. She blushed at having her morbid hobby exposed.
“Haven’t we all heard stories of people who were thought to be irretrievable, who were in a deep coma, and then suddenly woke up?” I said. “Those stories give a lot of people reason to believe that it could happen to their loved one, too.”
“Yeah, but not someone so old, with so many serious, irreversible medical problems,” said Laura, shaking her head.
“It’s not just that he wants her to survive, he wants her to get up, and come home and be his mother. We all want to go back to the dream of being a child again,” said Nicole in a way that made me think she might harbour that dream herself.
As we headed back upstairs, I decided what I would do. I just needed to find a few minutes alone with my patient.
We returned to the ICU and since there was no sign of the son anywhere, I went over to Mrs. Templeton, lowered the side rail, sat down beside her, and took her dry, papery hand in mine. I looked at her wrinkled face and bony chest and I caressed her soft white hair. Her chest heaved and rattled like an old furnace. I put my hand on her damp forehead and brow in a way that I hoped was soothing.
“We want to do what you want, Mrs. Templeton,” I said. “Do you want all of this, what we’re doing here, or is it enough? Are you ready to die? Give me a sign if you can.”
I willed her to speak. I explained about the breathing tube, the ventilator, the iv in her neck. She turned her face to the window where her cloudy blue eyes seemed to meet with the cloudy blue sky. I had no idea if she understood a word I said.
Laura appeared at my side and shook her head sadly.
“She needs a ticket on the Morphine Express but unfortunately, we can’t give her that ride.”
We felt certain in our belief that she was dying. The way she pulled at the tubes and her IVS, the way she shut us out with her eyes, and the way she turned inward and away from the world, made us feel sure about this.
There was something else that was making me feel uneasy and I was trying to shake off the question in my mind. How would I be able to work here, if these cases affected me so much? I tried to switch off, tune out, go under, and close off my heart from what was happening. I looked at my watch to see how many more hours of my shift were left. I could wander out to chat with Frances and have a few laughs with Tracy or Justine.
Then I remembered morning rounds with Dr. Bristol and the distinction he had made between treatment and care. While I didn’t agree with the treatment in which I was obligated to participate, I felt wholehearted about the caring, which was the essence, if not the very definition, of nursing itself. I knew what nursing was all about – I had seen the best of it in Frances, Laura, and Tracy and Nicole, even Justine, too, in certain moments. I knew what I had studied, from Florence Nightingale to all the modern nursing theorists: Watson, Rogers, Parse, and Leininger. Nursing was about pain relief, hygiene, nutrition, comfort, spirituality, kindness, and empathy. All those things I could still offer Mrs. Templeton.
I saw the son striding past the nursing station toward his mother’s room and I met him halfway.
“Mr. Templeton, you know your mother best. You know what she wants.”
“You people just don’t realize how strong my mother is. She’s going to make it. When will the doctor …?”
4
A DAGGER IN THE BED
I peered deep down into my cup of coffee. It was a ritual of mine, a thing I did at the beginning of every shift in the ICU, just before going into my patient’s room.
“Oh, you lucky dog,” said Laura. “You’re going to have a busy day. You’ve got that leukemia patient they admitted during the night and he’s sick. I see the whole family have moved in with him.”
“Yeah, that’s good. I haven’t had a busy patient for a long time.” I pretended that I, too, was a seasoned veteran and craved action like the others.
“It’s busy when they’re dying. That’s usually the busiest,” said Laura.
We put up with Laura’s sarcasm because she was such an astonishingly good nurse. I had recently watched her stand at the foot of a patient’s bed and pronounce: “Congestive heart failure. This man needs Lasix, 40 mg, IV.” Not only that, but she went ahead and prepared the drug and told the doctor what she planned to do.
“Yes, I agree,” he said. “I haven’t had a chance to take a look at the X-ray.”
“I have and it’s ‘wet,’” said Laura. “Signs of early pulmonary edema.”
“I’ve been meaning to come and write that order …”
Laura had stalked off, muttering something about his incompetence.
“What makes you think that patient is going to die?” Frances said to Laura, returning me to the day ahead. “You’re so negative. Lots of leukemics do well these days.”
“C’mon, it’s time to get to work,” interrupted Tracy.
Pamela was the nurse on nights and I knew she’d be annoyed if I was late getting in there, even by a minute, so I hustled off to relieve her, my coffee cup still in hand.
There were very few windows in the intensive care unit, none that opened. The small one that was in my patient’s room looked out into a narrow alley that led to ano
ther wing of the hospital. Even though it was morning, the patient’s room was still as dark as night. There was only a small ceiling spotlight that illuminated the patient in the bed, like a spotlight on centre stage.
Outside, in the long hallway between the rooms, nurses were turning on the overhead fluorescent lights, one by one, nudging the day to take over the night.
Pamela gave me report.
“Manjit Gujral is a twenty-six-year-old male, diagnosed a few weeks ago with acute myelocytic leukemia,” she said, pausing to yawn. “He’s septic, with a fever of 39.5, elevated white count, and fulminant infection in the blood. He’s on every bug drug, anti-fungal agent, plus chemo, too. The works. He had a bone marrow transplant from an unrelated donor from Sweden, but it looks like rejection. Oh, and the family – they’ve moved in here. By the way, his brother is an orthopedic surgeon and asks lots of questions.”
“Thanks, Pamela. Go home. Sleep well.”
She stood up to pack her knapsack, something we all use to bring our stuff to work in. “They’re nice enough but they’re here all the time, and it really can get on your nerves to have them watching everything you do, you know what I mean? Say, are you going to the Christmas party? One of the respiratory therapists is selling tickets, if you want any.”
“Maybe. Thanks, Pamela. Good night,” I said as she ended her day and I started mine.
In my patient’s room, an old woman stood at the bedside, her eyes gazing heavenward, deep in prayer. She must be his mother, I figured, and I went over to stand with her for a few minutes. We nodded at one other because we did not speak each other’s language, at least not the language of words. We looked down at her son’s long, husky body, mostly covered with a blue cotton bedsheet. All around him was the tangled spaghetti of plastic tubing, wires, and electrodes. Green numbers and lines marched across the monitor. The ventilator whooshed in and out as oxygen was pushed into his lungs, and then released. Tubes were running in to his body delivering fluids, nutrients, medicines; other tubes were running out of his body, directing the flow of urine, stool, and other fluids into tidily hung bags or bottles around his bed. The patient was at the intersection; his body was the meeting point. What a person can withstand, I stood at his bedside thinking – the onslaught of illness, plus a counterattack with our weapons of chrome, metal, plastic, and chemicals.