It was 7:30 a.m.in the medical ICU.  My shift, one that promised to be busy, was just beginning when I entered Mrs. Paysons' room. Her daughter was softly speaking to her of matters I decided were not meant for my ears.  Trying not to eavesdrop, I checked alarms, verified  intravenous medications, glanced at Mrs. Payson's vital signs, and, satisfied with the gestalt of the room, left to prepare her morning medications.

Mrs. Payson was 76; a little younger than the average female lifespan. She'd been on dialysis for renal failure for 6 years, and she needed surgery for a recurrent, painful bowel obstruction. But before she could have that done, her heart needed some serious tuning up. She had stenosis in 3 of her coronary arteries, the critical vessels that feed oxygen and other essentials to the heart muscle.  Some people can have less invasive stenosis treatment, like balloon angioplasty and stenting, but the only approach to her particular  coronary artery stenoses, because of their unfortunate anatomy, was coronary artery bypass grafting, or CABG (nurses and docs call it "cabbage" because of its acronym).  She would not survive the bowel procedure if the coronary stenoses weren't corrected first, and there was a fair chance she wouldn't survive the CABG.

A CABG is hard enough on someone without chronic renal failure, hypertension, osteoporosis and a slew of other conditions. More robust people leave the hospital after 4 days with chest soreness, activity intolerance, lack of appetite, a list of new medications, armloads of brochures telling them to change their lifestyles, mild cognitive impairment, and, frequently, a whopping case of depression to boot.  These are the after-effects of heart surgery that the surgeon doesn't fully disclose before the procedure, perhaps thinking it will make them happen. They happen anyway.

For Mrs. Payson, CABG was the only path toward relieving her abdominal pain so she could go back to her life, such as it was. 

Just before the cardiology team rounded at 8:30, I entered her room again. Her daughter repeated what I thought I'd heard before.

"Mom, are you thinking there's something you would like to tell the doctors?"

I did not ignore the overheard conversation this time.  I looked at Mrs. Payson's eyes and asked her if she was considering not having the surgery. She nodded. Then I asked if she wished to simply stop medical treatment. Her daughter nodded and answered,

"Mom has some concerns, though."

"Mrs. Payson, I want you to know that if you decide not to have further treatment, we will do everything else for your comfort. We will still take care of you."

"That's what she was worried about."

The cardiology team reached Mrs. Payson's room and began to walk in, four doctors , one medical student and one physician's assistant strong. I stopped them short and reported our discussion. The white-haired attending cardiologist explained again to my patient that we would ensure her comfort and respect her choice in the matter.  He made her a "do not resuscitate," and we transferred Mrs. Payson out of intensive care by 10 a.m.  

I don't know how Mrs. Payson died, or where. I sincerely hope she went home with hospice care. She probably died within several days of stopping dialysis.  Mercifully, as fluid builds up, so do metabolic toxins that blunt consciousness, providing a modicum of comfort as they augment the work of large doses of opioids.  I hope she was given a fairly comfortable death, on her own terms.

Although my contact with Mrs. Payson was brief, I will continue to remember her and her daughter. They are one of my "memorables." Nurses all carry these people with us; the ones who challenge us to grow, teach us something, or leave us unsettled are the most memorable. Mrs. Payson is a memorable because Mrs. Payson let me feel like a hero. In a relationship only 60 minutes old, I was given the chance to stop the medical machine in its tracks and advocate for a quietly suffering person.  I was given the unmatched privilege of articulating what were among this near-stranger's final, most important wishes.

So thank you, Mrs. Payson. And good-bye. 

(Names are pseudonyms in all my posts regarding my nursing practice.)