What do you do when your patient dies in an airplane over the middle of the Pacific Ocean with a grieving wife at his side? After 3 years as a flight nurse, this was the first time I'd had to ask myself such a question.
My flight partner and I received a Medivac jet request to fly to the Hawaiian island of Kauai to pick up an 82-year-old patient with end-stage pancreatic cancer and his wife for transport to California. They'd been visiting Kauai on a cruise when the patient, Mr. R, had become acutely ill and was taken to a nearby hospital. Now he and his wife wanted to go home.
When we arrived at his hospital room, Mr. R was alert but struggling to breathe. Any patient who looks bad on the ground will only look worse in the air, so this wasn't the way we wanted to start a 5-hour transport. Within minutes of our arrival, Mr. R thrust an advance directive at me, clearly stipulating that he wanted no endotracheal intubation, chest compressions, or other artificial life support measures.
I discussed with the couple the profound effects of high altitudes on a critically ill patient, including the very real possibility that the trip could prove too much for Mr. R. Nevertheless, they were united in their desire to get home to California.
The ambulance ride to the airport was uneventful. But Mr. R's oxygen saturation level plummeted during the quick ascent from the Hawaiian coast to an altitude of 7,500 feet.
In an over-land flight, simply dropping to a lower altitude would have been an option to improve oxygenation. But we were over the Pacific with just enough fuel and reserves to reach our destination. The pilots were adamant that we couldn't fly lower or slower. My partner and I were determined to honor Mr. R's stated wish to “never have a breathing tube,” so endotracheal intubation was out of the question.
Despite maximal oxygen supplementation, Mr. R's condition slowly deteriorated until he was bradycardic, hypotensive, and unresponsive. Mrs. R's loud sobs filled the plane as she grasped her husband's hand and repeatedly implored him to “just hang on” until they reached home. After 2 hours, however, agonal respirations and a widening QRS complex told us this was clearly not to be. It was time to talk about letting go.
First I asked the devastated Mrs. R to describe her husband's life and discovered he'd spent his career as a Navy pilot, with a passion for both the sea and aviation. Then, I gently explained Mr. R's present condition. Softly, I explained that some people seem to need permission from their loved ones to move on from life. Mrs. R sat quietly for some time, then stood from her seat, leaned over to kiss her husband's forehead, and placed an orchid lei around his neck. She gave him a long, slow hug and whispered, “I love you, but it's okay to go.” Within 2 minutes, Mr. R was asystolic. As she continued to hold his hand, I supported Mrs. R and helped reframe her loss experience. By the time we reached California, she was convinced that dying in the air, above the sea, was exactly what her ex-Navy pilot husband would have wanted.
It was a sad flight, and a stressful one, but I was thankful to have found some way to keep it from being a horrible flight for all involved. Mrs. R was extremely grateful for those last shared moments with the man she loved and was able to move from a feeling of having failed to get him home to a sense of elation that their final moments together were just as he would have wanted them to be.