Karen Schoonmaker is a clinical risk manager at Cambridge Health Alliance, Cambridge, MA. Contact author: firstname.lastname@example.org. Reflections is coordinated by Madeleine Mysko, MA, RN: email@example.com. Illustration by Jennifer Rodgers.
A nurse struggles with medical decision making for her ailing father.
The priest was the first person I saw as I rounded the corner and entered the ED. It must be all over, I thought. He's already gone. I rushed in and laid my head on my dad's chest; something hard met my cheek. It was an ECG lead. I remember feeling so confused about that hard nub. I was relieved he was still alive. I looked toward my mother sitting off to the side. She looked at me knowingly, as if resigned.
Figure. Illustration...Image Tools
She'd called me two hours before. My father had collapsed at their home. He'd spent the previous week preparing for Hurricane Earl, boarding up windows and tying down boats. In the two hours since the call, things had gone from bad to worse. At the hospital, he was quickly intubated and ultimately transferred to the ICU. He'd had a large MI, was in pulmonary edema, and his body was shutting down.
That night, as the hurricane blew up the coast, our family sat huddled in a storm of our own. We took turns sitting in the corner of his ICU room. Dad was sedated and intubated. The monitors showed blood pressures that were much too low. He required large doses of medication to sustain his blood pressure. His nurse moved purposefully from monitor, to IV pump, to ventilator, back and forth. Throughout the night she never sat down, pausing to speak with us only briefly to offer support, to offer short explanations, or to give my mother a blanket.
In hushed tones, my mother and I discussed how sick my father appeared. We understood a hard conversation and a difficult decision were imminent. Things looked so bleak we were sure we would have to let him go.
Early the next morning, we gathered for a family meeting with the physician. I realized my siblings and I are not so rare. As we became adults, we became more distant. We were joined together by a dying parent, about to make a life-and-death decision.
The physician shared the plan—a cardiac catheterization and an intraaortic balloon pump were needed. A cardiac surgery might well follow. Since contrast dye was required, my dad's already failing kidneys might be further damaged and dialysis could become necessary.
The gravity of the situation was paralyzing. We spoke with the physician, weighing comfort measures over treatment. We spoke about how to proceed. My mother and I, both of whom were nurses, felt compelled to describe what the overall state of his health might be if he were to survive his hospitalization and what type of care he might then need to make a recovery. We all knew he was a proud and strong man. Was this the kind of life he'd want?
Then I remembered a brief conversation I'd once had with my dad. I'd asked him if he wanted everything done, and he had replied emphatically that yes, he did. During the family meeting, I retold this story. It galvanized our family. We realized that despite the horrible odds, this is what he would have wanted. Once we'd made the decision, we felt as if we'd been thrust onto a path with an uncertain destination for both our father and ourselves. We were fairly certain that his chances for survival were slim, and even less so for a full recovery.
As we got up to leave the room, my father's nurse emerged from the background. I felt her arm around my shoulder. “You're doing the right thing,” she said gently. I didn't believe her, but I was relieved to have the decision made and to have respected my father's wishes.
Nothing can prepare you for having a critically ill parent. Given the choice, nurse or daughter, you are always a daughter first—but the nurse in you knows too much. It is a bit of a curse. I knew my father wanted everything done, but I didn't know if in choosing everything he'd realized what that meant. Neither choice was clear; the absence of an advance directive made decision making even more challenging.
It's been a year since that family meeting. Another storm threatens to batter our coastal town, this time Hurricane Irene. I am outside the cottage battening things down. As the wind picks up, I remember how I felt a year ago, the unbelievable circumstances I found myself in. Like many other families with a sick loved one, we were faced with nearly impossible decisions. Did we do the right thing?
I see an old red truck approaching the house; behind the steering wheel is my dad, and he smiles with delight. He has come to make sure we board up the house in preparation for the latest storm.
© 2012 Lippincott Williams & Wilkins, Inc.