I’d like to preface this story by saying that the majority of the intensivists I have worked with have been exceptional, caring, and professional. We had all established a good camaraderie, and we had mutual respect for each other. We worked well together. But there always seemed to be one that was the exception. And as I drive some long miles on a recent getaway to the mountains, the flashback came back to me. Joellen was 64 years old. She smoked all her life. 2 packs of cigarettes a day. She started smoking at the age of 16. Hollywood made smoking sexy and romantic. By the time she was in her late 50s, she had developed severe shortness of breath without exertion. She had difficulty breathing. She wouldn’t put her cigarettes down. Her physician told her, “If you don’t stop smoking for good, you’re going to die.” In and out of the hospital, she progressed to a diagnosis of CHF and COPD. Her physician told her at the age of 64, she was now considered end-stage COPD. There was no regimen of care for her, as her lungs were destroyed by her incessant smoking. She agreed to sign a do not resuscitate as she entered the ICU one last time. She did not want to be intubated. But she agreed to be medically treated. It was now my shift. Night shift. And Joellen had a very bad day. Her breathing was shallow; her lips were cyanotic; her O2 sats were in the 80s. It would have been an optimum time to place her on comfort care, but the patient said she wasn’t ready to die. Throughout the night, I watched Joellen breathe with great painful effort. She sat straight up in bed, shallow forceful breathing. She suffered so. I notified the virtual MD to request morphine for Joellen. She had nothing ordered to ease her breathing. Even a small amount of morphine IVP could help relax and slow her breathing down without as much struggle. The virtual MD said, “no,” he would not order morphine for her. I explained how she was awake and alert and suffering terribly, but he said, “No, I don’t want her to get addicted to the morphine.” I then notified the intensivists on call. That was our chain of command. Before I could explain myself to the intensivist on call, he said to me, “Do you realize you woke me up from my bed at 3 a.m.?” I told this physician how Joellen was having shallow breathing, diaphragmatic breathing, low O2 sats, and she was suffering greatly, and all I wanted was some morphine to give to this poor lady to ease her breathing and her suffering. He let me know he would get back to me after he talked to the virtual MD. One hour later, I received a call back from the MD on call. Lasix 20 mg IVP stat. That will take some fluid off of her, and it will help her breathing. “We don’t want her to become addicted to morphine.” And that was his answer. And here I was faced with a dying woman. Lasix didn’t touch her. Her breathing became more shallow. Her lungs filling with fluid, barely able to auscultate. Her O2 sats slowly dropping to the 70s and 60s. I sat next to Joellen and held her hand. Wanting to breathe for her. Wanting to comfort her. Wanting to provide her with just a small amount of morphine but unable to. I was given the most inappropriate order ever from 2 MDs who claimed a dying woman would potentially become addicted to morphine. Poor Joellen. As I held her hand, her breathing slowed to a minimum. She had worked so hard. Her eyes rolled back, and she let out her last breath. I felt defeated that a simple order from an MD could not be obtained. Joellen died a painful death. Eventually, I found out that there was a review of this case. I’m sure there was a mild reprimand. I drive up to the mountains. The leaves changing into their vibrant colors … And I still see those haunting eyes of Joellen. Source
