"Please Lord... don't let me cry"

"What Sarah Said" by Death Cab for Cutie

And it came to me then that every plan is a tiny prayer to father time
As I stared at my shoes in the ICU that reeked of piss and 409
And I rationed my breaths as I said to myself that I'd already taken too much today
As each descending peak on the LCD took you a little farther away from me
Away from me

'Cause there's no comfort in the waiting room
Just nervous pacers bracing for bad news
And then the nurse comes round and everyone will lift their heads
But I'm thinking of what Sarah said that "Love is watching someone die"

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I know that death comes with the territory of being an ICU nurse. It's simply a part of the job and in many ways it can be a wonderful part of the job. My view on death since I have become a nurse has changed drastically. It is not something I fear anymore... nor is it a negative thing by any means. 

Death in many ways is beautiful and peaceful and incredibly full of grace. 

To be present and actively involved in such a deeply personal moment with someone is truly a gift. 

This week I had a patient die (seems like its been happening to me a lot lately) and it was the most painful death I have ever witnessed. It was expected because the patient had lung cancer with mets to the brain, and bone but still... I don't think there is ever a way to be fully prepared for the death of a loved one. Just a week prior to his death the patient was playing golf with his friend when he suddenly couldn't breathe and was admitted to our ER with a pulmonary embolism. He ended up intubated, sedated, chemically paralyzed and on every medication in the book to maintain his blood pressure, prevent heart arrhythmias, prevent blood clots.... the list goes on.

When I received report from the PM shift nurse... he began desaturating to the low 70's (normal is ideally above 95%). His blood pH was 7.11.... extremely acidotic... not a survivable level by any means. He was on 100% oxygen on the ventilator with peep and pressure support settings maxed out as high as we felt comfortably going. The ICU fellow, intern and resident all crowded into my room and we began thinking of everything we could do to try and fix this.

"I can increase his tromethamine to 20gm? Maybe that will help with the acidosis?"

"ok let's do it..." next blood gas was even more acidotic at 7.10.

 hmm...

"Or what if we increase the peep to 20 and then add vasopressin to increase his pressure and counteract the decrease in cardiac output?"

"We are already on vasopressin... it's maxed out at 0.04... we could try dopamine?"

"No, he has a history of Atrial fib.... it's why he is on amiodarone."

"yikes, ok scratch that idea."

My alarms started beeping... he was now dropping his systolic blood pressure to the 70'sand his oxygen saturation was dipping into the low 60's.

I turned to the resident and reluctantly said "I think we need to bring the family in..."

"I've already sent the intern to call them"

You could hear everyone take a deep breath in and the feeling of defeat in the room instantly filled the air. This was not a battle we were going to win. By the time the family arrived we knew we had only a matter of minutes to have a plan of care discussion. The resident began explaining the situation and the decision was made to withdraw life sustaining measures and to provide comfort care only.

I encouraged the family to take a moment to say goodbye... warning them that it only would be a matter of minutes to possibly hours after I remove all of the medications.

They said they were ready and so I began...

One by one I removed 4 IV poles worth of medication.

I started by increasing the sedation and pain medication and I began with removing the paralytic.

As I wrapped up each IV bag and threw it in the waste bin all I could do was pray... the lump in my throat was growing larger by the moment and all I could think was, "Oh Lord, please be with this family."

"Lord, please give this family grace.... and Lord please.... please don't let me cry."

After all the medication was off I sat in the room with the family and just talked them through what was going to happen. We sat in silence.... the son, daughter-in-law and the patient's wife... all four of us sat in the room and watched my patient's heart rate drop down from 60... to 50... 40.... then at 36 it maintained for a little while.... he was holding on. His daughter and his grandson finally arrived and within seconds the last few beats of his heart mapped out along the monitor and faded away.... he was gone. I stood up and listened to his heart, checked his pupils and looked up at the son and nodded.

Instantly the room was filled with tears. 

"I'm so sorry for your loss. I will give you a few minutes and I'll go get the physician to confirm the time of death." The son nodded back at me and I left the room.

Luckily, my friend Dirk was my neighbor that night and I went straight over to him.... he must have seen the look on my face because he instantly gave me a hug....

"You ok?"

I nodded with a big sigh, "Yeah I'll be fine... this just sucks."

"I know." he replied.

The next few hours were filled with the logistics of dealing with a deceased patient. Setting up the family with the resources they will need. Calling the police to have them escort us to the morgue. Preparing the body, and wrapping him in that dreaded body bag. I held it together for the rest of my shift and when I made it out to my car I tried not to think about the night I had just endured.

Then... I turn on my car and the song by Death Cab for Cutie comes on....

I was instantly frozen... and sooner than I could say "Please, Lord... don't let me cry..." I hear the words

"Love is watching someone die"

Like a ton of bricks on my chest, the reality of what I had just witnessed hit me... and I felt those walls I put up crashing around me... 

and I cried ... I cried that horrible, ugly cry, the entire way home.