Enarm 2007

Nar r ati v e

Matters

Attending Death With Dignity
A nurse finds herself the center of controversy after effectively managing pain for a dying patient.
by Sharon L aDuke
PREFACE: At the end of an illness or in old age, dying without pain at a time of our choosing seems like an entitlement to many of us, especially baby boomers used to controlling key aspects of our lives. Healthdirectives, living wills, and medical ethicists to help mediate between patients’ needs and institutional exigencies are mechanisms at our disposal to help ensure that we die a “good” death when the time comes. Yet such deaths are by no means guaranteed. It is not unusual for institutions and providers to lack the skills, systemic support, and comfort level—even when legal backup exists—needed to deliverthe kind of end-of-life care many of us say we will want. Sharon LaDuke, a nurse who in the 1990s administered pain relief conforming to a patient’s and family’s wishes, recounts the trauma of facing criminal charges for what she believes was appropriate care delivery. Physician Neil Calman encountered what he found to be a moral dilemma: wanting to respond to an elderly woman requesting that hehelp her die but being legally constrained from acceding to her wishes. Despite the increase in pain management and end-of-life training in nursing and medical schools, these two stories show the difficulty providers and patients can still find when dealing with terminal events.

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e r na m e wa s w i l l i e d o b i s k y. The widowed matriarch of a communityoriented family, she had been awife, mother, Sunday school teacher, volunteer, and neighbor. For many years she and her husband had owned and operated The Surprise, a department store in our small rural town. As a child, I had been fascinated by the pneumatic tubes that whisked messages from one part of the large store to the other. Willie once had been beautiful. Now in her eighties, her face reshaped by years of steroid use tocontrol her emphysema, she was “dying by inches,” as her son put it, and had been for months before landing in our hospital for the last time. In the emergency department (ED), lung failure had raised the carbon dioxide level in her blood so high that she did not have the mental capacity to make her own health care decisions. Anticipating this day, she had named her friend Mary, a retired nurse,as her health care agent. She had discussed her wishes with Mary, filled out an advance directive, and provided a copy to the hospital. But when Mary told the ED staff that Willie did not want to go on a ventilator and had completed paperwork to that end, the hospital could not locate the document. And Willie had neglected to give Mary a copy. Willie ended up on the ventilator. Often when patientsgo on the ventilator, they

Sharon LaDuke (ladukes@northweb.com) has been a registered nurse for more than twenty years, working in acute care, education, human resources, and information management. She is the manager of a medical-surgical unit in a rural community hospital and writes about nurses’ experiences with the legal system.

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DOI 10.1377/hlthaff.23.3.222 ©2004 Project HOPE–ThePeople-to-People Health Foundation, Inc.

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Narr ativ e

Matters

can come off again and survive after the reversible elements of their illness are treated. But after a week it became clear that Willie’s ailments were not reversible. Willie was a strong and proud woman whose quality of life had been poor for some time. She had always said that she did not want to live ona machine, and her loved ones supported her wishes. After multiple discussions among her health care agent, her family, and the physician and nurses, the decision was made to have her breathing tube removed. Her family probably thought she would die right away, but she did not. Her relief at being off the breathing machine, which was replaced “Every breath was now a by an oxygen mask, was soon...