Hospice

The patient had a terminal condition. That much was obvious. He was breathing so shallowly that I expected him to die at any moment.

"What kind of medical problem does he have?" I asked the home health aide who'd opened the apartment door for us.

"Cancer," she said in a Caribbean accent. "Cancer of the liver."

"Has it spread anywhere?"

"Yes, I think so." She went to the kitchen and returned with a stack of medical records. "Here you are. Everything you need is in here."

The chart contained so much information that I could focus only on the essentials: Hepatic tumor. Radiation therapy. Liver cancer. Surgery. Lung cancer. More radiation therapy. More surgery. And the most recent entry: Malignant tumors in both lungs. Inoperable.

The poor guy. It had been a rough six years. At least it was all coming to an end.

One of the EMTs knelt and took a blood pressure. He shook his head gravely. "Eighty over forty," he said.

"Does he have a Do Not Resuscitate order?" I asked the woman.

She stared at me blankly.

"Does he want us to keep him alive if he stops breathing? Did he ever say anything about that?"

"If he stops breathing, he said to let him die."

"Did he ever sign a form?"

The woman grinned. "Oh, yes! The form! I have it right here!" She flipped through the chart and eventually produced a photocopy of a living will that had never been signed.

"This is not valid," I told her.

She looked confused.

"This form is no good. There's supposed to be another form, a blue and white one, not a copy. It should have the signature of a doctor. The patient has to sign it."

The woman shook her head. "I have never seen any such form."

Meanwhile, the man was barely breathing at all. If we didn't find the DNR form soon, we'd have to resuscitate him, whether he wanted that to happen or not.

I spread the papers across the table. The EMTs joined in the search. We looked at every paper, but the DNR form was nowhere to be found.

"Hey, look at this," one of the EMTs finally said, holding up a paper. "It's a hospice enrollment form. And it's signed. This guy is a Hospice patient."

Hospice is an organization that provides education, counselling, and other services to terminally ill patients and their families. Since Hospice exists solely to help patients die, you'd think that the Hospice nurse, more than anyone else, would know how to complete the proper DNR forms.

Apparently not.

The nurse's oversight left us in a difficult position. The patient was dying. He did not want to be resuscitated. But because the proper paperwork had not been filled out, he would be kept alive anyway.

The man continued to breathe all the way to the hospital. We removed him from the ambulance and wheeled him into the emergency department. Two other patients on stretchers waited in line before us at triage. Before the nurse got around to us, the man stopped breathing.

One of the EMTs pressed the mask of an Ambu bag to his face. He squeezed the bag, inflating the man's lungs. The triage nurse waved us into a treatment room. The physician took one look at the emaciated patient and asked, "What's his DNR status?"

"He's got a living will, but it was never signed," the EMT with the Ambu bag said.

"No DNR form?"

"Nope."

"Shit. I guess we'll have to intubate him, then."

Doctors were paged. Nurses, too. And a respiratory therapist. A resident peered into the back of the man's throat with a laryngoscope. Somebody inserted an endotracheal tube. A ventilator began to whoosh.

The man was still alive.

I left the room furious at the hospice nurse. She had been hired for just one purpose: To help the man die. Instead, through her negligence, she had accomplished precisely the opposite, forcing him to remain alive against his will.

It was the saddest, most pathetic kind of irony.