My patient was in his 90’s, and his family wanted everything done. He was intubated when his breathing became ineffective. We, as nurses, thought that this was awful. We weren’t prolonging life; we were prolonging death.

My patient spoke only Russian. His daughter spoke mostly Russian, but understood just a little English. After he had been intubated for about 2 weeks, it was time to do a tracheostomy. It was on this day that I took care of him for the very first time.

The consent was signed, the checklist completed, he was ready to go. The OR nurses came up to get him, along with an anesthesiologist who bagged him on the way down.

10 minutes later, they called to tell us that they were coming back. What??? Trachs usually take about an hour. I wondered what went wrong – did his sats drop?? His blood pressure? His sats had been very borderline that day, necessitating us to go up to 100% O2 on the vent. He was a full code, so I was getting a tiny bit nervous about his condition, but what else could we do? He was on the most vent support he could be on. He wasn’t on pressors, but his BP was okay.

Anyway, they brought him back a few minutes later, explaining that his anatomy was “weird” and that the surgeon would not be able to perform the operation. To say that I was livid would be an understatement. In that short amount of time, they could not have done anything invasive to determine that his anatomy was weird, so I concluded that the surgeon could have easily determined this while the patient was still in his room, you know, when he was first consulted. The time it took to get the consent signed, the checklist done, the other paperwork assembled… all wasted.

Anyway. I didn’t have a lot of time to ruminate about that, because after he got back, his blood pressure became very marginal. He wasn’t on pressors, but I really wanted to avoid having to start them. As the day went on, his blood pressure got lower and lower. His daughter was there to see him, and we had a heck of a time explaining to her why the procedure wasn’t done that day. Fortunately, her husband (We’ll call him “Viktor”) was bilingual. He was also about 8 hours away, so I ended up explaining everything to him on the phone, and he explained it to her (we’ll call her “Lia”). Great.

Finally, my patient’s BP was too low not to start pressors. This poor man already looked half dead, and I knew that the end was very near for him. At this point, I normally would have taken the Person Making Decisions aside to explain the situation. Unfortunately in this case, I did not speak the same language as she. I at least wanted to make him a no code – if his heart stopped, I didn’t want to have to code him. I explained this to Viktor, and he asked me point blank, “What do you REALLY think? If this was your father, what would you do?” I replied that I would never have let it get this far, I would never have intubated him, and if I had arrived to find him in this condition, I would extubate and let him go. Hey, he asked.

We went back and forth like this for awhile, me talking to Vik on a phone 8 hours away, and he would call his wife on her cell and talk to her, then call me back with what Lia had said. It wasn’t the best system, but it was working for the time being. We finally agreed to make the patient a no code, but Vik wanted to go further than that – he wanted to convince his wife to stop the madness, as it were, and just let the poor man go.

What ensued was telephonic chaos.

I can’t take the husband’s word for what his wife is saying to carry out such a decision. I just can’t. It isn’t right. Therefore, I needed an interpreter. Our hospital does not happen to have Russian-speaking in-house interpreters (bummer!) but we can use a language line – a phone with two handsets that we use to call a 3rd party number who will translate. I’ve never had to use this before, and I’ve never wanted to. It’s bad enough to serve up distressing news through a 3rd person translating, but over the phone? I know I’d be right there, but the dynamics are really very odd, if you think about it. But I had no choice. I had to get it from HER.

I got the translator on the phone, and I told Lia through her that her father was not doing well at all, and that his BP was getting dangerously low. I had to explain to her that using pressors would be a short-term solution, and that in all honestly, I thought he would die sooner than later. She finally agreed to make him a no code, but did NOT want to extubate and let him go. (Yes, Mia, I’m trying to avoid the word “withdraw” :))

It was really hard doing it this way. She had the receiver up to her ear, and was talking to the translator, but was looking down and crying softly. She never looked at me. As hard as it was, though, it worked fairly well. I got my message across, although I found that I missed using body language and facial expressions to convey what I meant. Maybe she wouldn’t have looked at me if it was just the two of us regardless, but suffice it to say – it was different.

Figuring I just took a step in the right direction, I called Vik back and updated him. He was disappointed that his wife did not tell me to extubate him, as they had agreed upon. He said he wanted to talk to Lia some more. While they were on the phone, a shift change had occurred, and as luck would have it, a Russian speaking student was nearby. Holy Toledo!!

At that point, things went from merely complicated to downright complex.

Vik called me back and told me that Lia had decided to take her father off of the ventilator. For real this time. I asked him if she understood that he would in all likelihood die very quickly. He said that she did.

I thought I could use the student instead of the language line to verify this, but I soon learned that this was a very misguided thought. Being a student, and therefore being somewhat naive (hey, I was there, too), she was not accustomed to telling daughters that their fathers were going to die, and couldn’t we just let that happen peacefully, without ventilators and tubes and wires? I think the student managed to get the point across, but as she did so, I could tell that she was getting a tiny bit emotional, leading me to wonder if she was saying EXACTLY what I was telling her to say. I had no way of knowing if she was “softening the blow,” so to speak. Those words are very hard to say.

So, still feeling skittish about the whole thing, I really wanted an objective person involved. I could tell that Lia was extremely sad and torn and just wanted to do the right thing. So I called the language line back, and had to go through the whole thing over again, asking her if she understood that extubating him would be the end, and that I needed to hear that from her. I felt so incredibly…. stupid. I felt so bad for making her say it AGAIN. Note to self: do not use naive and inexperienced student to translate for such a weighty issue EVER AGAIN. She was so sad, and I felt like the bad guy. Lia’s only request was that I wait for some of her family to arrive before doing it. I agreed.

I then called one of the doctors on the case, and although he knows and trusts me (I think), he understandably wanted to hear from the daugher (as I did) before giving the order. I think I successfully convinced him to just trust me on this one, and to get the specifics from Viktor.

Soon, some of Lia’s family came and they were also blessedly bilingual. I had to go over the whole thing with them, as they were previously led to believe that they might have weeks with the patient, not hours, certainly not minutes! By this time, my poor little patient had no blood pressure that was measurable, but was still breathing and had a pulse. I patiently went over everything again, and said that I was really quite sure that there was absolutely no chance of meaningful recovery. In the past, having this same conversation, I have always had little fringes of doubt when saying this. This time I meant it 100%. I explained that I would give him as much morphine as was necessary to ease his breathing, and then I told her that she was absolutely doing the right thing. She actually seemed to take a lot of comfort in that, for which I was grateful.

So wouldn’t you know it, the time to extubate happened RIGHT at my shift change. I’d been with this woman and her father for 12 hours, and we’d been through quite a lot in that time. To hand the whole situation over to another nurse seemed cruel, and that nurse made sure I knew it :) So I stayed for the extubation. I helped extubate him, and I gave him adequate morphine. Usually, at this point I exit the room so the family can be with the patient, and that’s what I did this time. After a few minutes, I went back in with some more morphine (more to ease their discomfort than his) and they were surrounding his bed, stroking his forehead, whispering things to him. He had been completely unconscious all day, and he remained so, but I told them that it was possible he could hear them. This time I stayed with them at his bedside instead of exiting. After the monitor flat-lined, I turned it off and told them that he was gone. Lia then turned to me and gave me a hug and just sobbed.

I am not a typically touchy feely person, especially with people who are practically strangers, but at that moment I was so relieved. I had been very focused on advocating for the patient, and it’s difficult to do that and help the family come to terms with a painful situation as well. So when she did that, I felt as though I had been successful on both fronts. It was completely worth staying after my shift to be there for that.