Jumping For Joy In The E.R.

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OK, so the E.R. is not the place where you can usually find doctors jumping for joy, but certainly stranger things have happened there, so why not?

I had just started my afternoon shift in the area we call the “trauma pod” and as I left my first patient’s room, I was spinning around giving a fist pump in the air and exclaiming, “YES! Now that it the way it is supposed to be!!”

Needless to say, this had the attention of all my nursing staff and the doc I was relieving.

“What’s going on out there?” the “leaving” doctor asked me curiously.

Before I answered him, I called out, “You guys come listen to this. This is a success story!”

As you might imagine, a small group of curious Emergency Department staff had crowded around me in attempts to understand the commotion.

Speaking in low but excited tones (to maintain compliance with the federal privacy regulation known as HIPAA), I gushed the following story:

“So, I just walked into room 48 to see Mr. Bronson. He’s an 85-year-old man with COPD who had arrived in respiratory distress, and the respiratory therapists had already started BIPAP because the patient arrived on his own machine and it wasn’t doing any good. So, here’s the kicker… he was too short of breath to even speak a word and when I listened to his lungs, I heard no air movement. There was no one in the room family-wise whom I could turn to for a discussion of next steps (meaning no surrogate decision maker). Just as I started to feel a twist developing in the pit of my stomach, assuming that I might have to intubate him without understanding his own personal wishes, the nurse whips out a piece of paper from behind his home med list and starts waving it at me.”

“Voila!” she said, smiling. “I know that you would want to see this.”

With two steps in her direction, I was across the room and pulled it from her hand like a young child getting her first mail.

“ALABAMA STATE DO NOT RESUSCITATE ORDER” were the first words on the document, but up in the right-hand corner was something even more surprising than a real-live “actionable” advance directive… up in the corner was my own messy handwriting (barely legible, of course…the only bad grades I ever made in elementary school were in handwriting…fated to be a physician some would say). In my own messy scratch were the words, “Patient wants CPAP and BIPAP [non-invasive respiratory treatments] but no intubation”. The rest of the document was filled out correctly and dated about one year ago- signed by the patient and myself plus one other physician.

Suddenly, I remembered Mr. Bronson. He had “gently” wrecked his car while shopping because he had become so short of breath last year. I recall that I sat on his hospital bed and we talked about his illness.

“I seem to be getting worse,” he said back then, and I listened as he described an accelerating course of COPD exacerbations.

I recall identifying that pattern for him bluntly but compassionately, “We see that pattern when someone with COPD begins to approach the end of life. Have you thought about creating an advance directive to prepare yourself and your family for the inevitable?”

He stared at me expressionlessly (not uncommon when bringing this up). “Yes,” he said, “I should probably do that. But I want to ask you one thing, young lady (being 42, I was flattered of course). Why hasn’t my lung doctor or family doctor brought this up before?”

“I have no idea,” I replied. “All of your doctors should be educating you about where you are on the map of life. How else can you know or prepare for what lies ahead?”

He sat pensively. Then, surprising me, he said: “Let’s do one of those right now. At this rate, tomorrow could be my last,” he said with a smile. I could tell that he liked shock-value!

Well, that day was not his last, neither was this instance. But, had it been, I would have known EXACTLY what HE wanted me to do or not do—such is the power of a proper Advance Directive.

You may not consider this a reason for me to be jumping for joy in an ER, but after seeing what I have seen, I think that this is as good a reason as any other. My staff agreed.

(Please read this excerpt from It's OK to Die to understand my rationale.)

Final Thoughts: New generations of advance directives (ADs) are being created. Of course, given our technological age, many online resources are now available to store your advance directives and wishes. Of note, one of the most comprehensive online ADs (in my opinion) is available for www.mydirectives.com. See especially their discussion guide, it’s one of my favorites.

Monica Williams-Murphy, MD, an emergency physician, is an author and public speaker whose focus is empowering patients and families in critical and end-of-life decision-making. Her book, "It's OK to Die" and companion website are devoted to transforming the end of life into a time of peace, closure and healing. To buy the book and learn more about Dr. Williams-Murphy’s work, visit www.oktodie.com.