What if it were your father?

Humanity

CJEM 2007;9(3):180-181

Dad wanted to go to the shore. He and mom had grown up back east and spent every summer of their childhood at the New Jersey Shore. They met, married and moved to the US Midwest, where they raised 3 children.

Dad retired about 10 years back, and enjoyed the time with his wife, children and grandchildren. He had his share of health problems and had done pretty well, but this past year something just wasn't right. He was weaker; he got out of the house less than usual, and just wasn't himself. But every summer, for almost 50 years, he had gone to the beach with his wife, then with his children and grandchildren, and he wouldn't hear of staying home now.

So there they all were, at the ferry terminal waiting to enjoy a couple of hours crossing with the breeze and salt air, walk around the park at the other end, see the old forts, white steepled churches and Victorian homes, and later return to see the beach and lighthouse against the sunset.

His daughter stepped away for a minute to get one of the kids a drink. When she came back, Dad was on the ground. She was a cardiac nurse back home and knew what to do. He had no pulse. She started CPR on her father while a bystander called 911 and one of the ferry line staff found an automated defibrillator. The defibrillator initially said to shock, and she did; then it said, "continue CPR."

She performed CPR on her father for about 25 minutes before EMS arrived to take over. They continued for about 15 minutes until they reached the nearest hospital. There, he had a pulse, but was still hypotensive, and his electrocardiogram (EKG) revealed what all had suspected — a heart attack. The doctors at the community hospital stabilized him and arranged transfer for cardiac catheterization. He was intubated, started on pressors and then flown to the nearest big city, where maybe his arteries could be opened and this nightmare stopped — or maybe not.

When I met him, I was the on-call resident in the coronary care unit (CCU). His blood pressure was stable. His cardiac enzymes showed a large myocardial infarction and his EKGs showed it was anterior. Some of his left ventricle was probably stunned or infarcted, but he was holding his own, off pressors, hemodynamically stable. When his daughter arrived an hour later by car, she had a haunted look in her eyes. By then it had been 5 hours since his collapse. She knew she would probably lose him — in her mind she already had. She wanted to make this as easy on her mother as possible. She was very much afraid that she had done the wrong thing. Had she, following all her training, snatched her father from death only to leave him in limbo, neither gone, nor exactly with us?

She ran through every step — pride, regret, confusion and sadness were all mixed together. But she was a professional and she was a loving, dutiful daughter. She knew the situation looked bad; she wanted to save him if possible. But if not, then she wanted to save her father, and especially her mother, any unnecessary suffering. She couldn't shake the guilty feeling that by trying to save him she had made things worse. He didn't have a gag response or corneals. But he was breathing. Even when the ventilator was turned to minimal settings, he was breathing on his own. He could do that for a very, very long time, even if he never got better.

The doctors told her what she had said and heard a thousand times: "Only time will tell." "It's up to him to see how much he can recover." "Let's see how he's doing in the morning."

Did she do the right thing? Could she have done anything else? The CCU staff was abuzz with stories of similar events with other patients, with questions about what we would have done, with a profound recognition of the uncertainties in what we do every day, but ultimately with the conviction that she did what any of us would have done. She did what she was trained to do. She did what she and everyone else expected of her. We resuscitate strangers every day, those we hope to save as well as those we know we are losing. How could we not do for our own parents what we would do for anyone else? But if we fear the possibility of resuscitating our loved ones into a neurological netherworld, what does that say about what we do for everyone else?

He died the next day, peacefully, without further suffering and after his family had a chance to say goodbye. The ventilator quietly and rhythmically helped him to breathe. After it was turned off he breathed on his own for a while, then simply stopped. His wife of 53 years talked about his kindness, his sense of humor and his grace. And his daughter took her mother home knowing that she had done everything she could for her father and that things turned out as could be expected — no better but at least no worse. He went suddenly, doing exactly what he wanted to do, enjoying the beach and the salt air with his family. We should all be so lucky.