This happened at work quite awhile ago. We had a guy come in for abdominal pain. Very vague. He apparently needed CCU because his blood pressure was labile ... it was prone to change fairly drastically for no reason. A general surgeon was consulted to see him, and when she came in, she started pressing on his abdomen, like they all do.

I have to admit that I only know these details second-hand... For that night, I was stuck in CVVH. When you have a patient on CVVH, you are chained to the room. It is a very helpless feeling to see a patient crashing, nurses running about, and there is little to nothing you can do to help. I could make phone calls from the desk, order stuff on the computer, and make really fast runs to get supplies here or there, but otherwise was stuck where I was. It sucked.

So mere minutes after the surgeon left, the patient turned "white as a sheet" as we say and said he didn't feel well. Uh-oh. Why? Blood pressure had gone from low 100's to about 50. Why? Who knows? Just send off about 10 blood tests, and start pumping fluid into him! Which we did. When the blood count came back, we all started to have a small inkling of what was going on.... his blood count was 18. Normal is around 40, but depending on the person, we typically don't transfuse until you're at 24-29.

So they started pouring blood into him as fast as they possibly could, and actually stabilized him enough to go for a field trip to the CAT scanner. CT showed an enormous ruptured abdominal aortic aneurysm ("triple A's" we call 'em). Uh-oh.

Believe it or not, we aren't at the creepy part yet.

Now, granted, the guy was old.... well into his 80's, although he looked to be in his 70's. He's now intubated, sedated, unable to talk, and most likely restrained. Now we learn that he's bleeding out into his abdomen with every single heartbeat. The powers that be decide that he is NOT a surgical candidate (again, I have no details :( Sorry!). So after talking at length with the family, the family decides to "pull the plug" so to speak. Growing up, I always took that quite literally, and was actually surprised to learn that "pulling the plug" doesn't mean what I thought it did. You can't just unplug the ventilator, you have to extubate as well. Who knew? :-)

Still with me here? Good. So the family all goes in there and it finally hits me (from across the unit, where I am chained to CVVH) that the moment we stop pumping blood into him, he'll die. We've turned the sedation off to allow the family to say their good-byes, and all I can think is that the last this guy knew, his belly hurt really bad, and then they stuck this tube down his throat. He has no idea that his fate had been decided just moments before, and that that fate is death. Normally, with deaths in our unit, some are sudden, but "predictable" ... ie someone comes in with a huge brain bleed, and despite our best efforts, they die from it. The brain bleed may have happened a mere few hours before, but it's not a surprising thing to die from. But for this poor guy... all he had was a stupid stomach-ache a mere few hours before, and unlike Mr. BrainBleed, he is now fully conscious.

The family is crying, the nurses working on him were crying... it was a sad thing. We don't often have to tell fully awake people that they are going to die - soon. Within minutes. This then sets off a debate between me and my coworkers. At this point I'm assuming (hoping) that someone has told this guy that he's going to die. I ask the 2 RN's working on him the most (who are out at the desk while the family is alone with the patient), "So... has anyone told him?" And one responds, "Why? I sure wouldn't want to know... just tell me that I'll be going to sleep soon and be done with it." WHAT?! I'm a little shocked by this. Granted, I don't know the guy, but we RN's are only human. We do sometimes project our own beliefs into a situation. To this day, I'm still assuming that the family told him, and even if they didn't come right out and say it, he had to have known because they were all, um, telling him goodbye. But I still think it was up to the nurse to tell him what exactly was about to happen, and at least reassure him that we were going to drug him up with morphine so it wouldn't hurt or anything. And maybe she did do that... at that point, it was near the end of the shift and I had many things to do with my own patient.

Sure enough, he died within minutes of us "withdrawing support." I don't know if I've been able to convey just how weird it was for us (me) to know with a high degree of accuracy when he would die. It was hugely different from withdrawing support from a very sick and for the most part unconcious patient, or at least one that had been on support for weeks. This guy ate breakfast at his dining room table that morning.

So yeah, I know... not the most pleasant topic. But I'm curious to know how ya'll feel.... if you were in his gown, what would you want to know? Who would you want to tell you? I would want to know everything from everyone. I would want to know what was going on, and who decided, on what basis, and is it going to hurt? I may just have some last minute things to think about.