9:59:59.000,9:59:59.000
{QTtext}{language: 0}{textEncoding: 0}{font: Arial}{justify: center}{size: 18}{backcolor:0, 0, 0} {timescale: 30}{width: 720}{height: 60}[br][00:00:00.0][br][00:00:16.0]Doctor 1: Hi, Dr. B![br][00:00:18.0]Doctor 2: Hi, so I just came from Erica's room, [br][00:00:23.0]she appears more comfortable and her mom and her brother are there, she uh, [br][00:00:27.0]look a little bit more dyspneic, I wouldn't be surprised if her CO2s [br][00:00:33.0]are in the seventies, but I think that since we started the morphine PCA this afternoon,[br][00:00:37.0]she's more comfortable, so it seemed to be-when she-when we pressed-after [br][00:00:41.0]we pressed the button, she got some relief in three or four minutes[br][00:00:45.0]Doctor 1: Okay, and do you think that she seems to know that the end might be near?[br][00:00:49.0]Doctor 2: Yeah, I told the family that I thought the end was close, [br][00:00:53.0]but it's hard to tell. Maybe a day or so, unless a mucus plug [br][00:00:57.0]gets her before that. [br][00:01:01.0]Uh, they're in a much better place now [br][00:01:05.0]than they were a couple days ago when they finally started talking about death, [br][00:01:09.0]and I've encouraged them to talk about good times and the things that are important[br][00:01:12.0]Doctor 1: Sounds good. Do you think that we should be continuing our current treatments, [br][00:01:16.0]I mean we've got breathing treatments, we've got Pulmozyme, the antibiotics?[br][00:01:23.0][br][00:01:31.0]Doctor 1: Do you think that we should be continuing our current treatments? I mean we've got breathing treatments, [br][00:01:35.0]we've got Pulmozyme, the antibiotics?[br][00:01:40.0]Doctor 2: Yeah, I told the family at our last meeting that we'd continue everything [br][00:01:45.0]unless it was making her uncomfortable, so at this point I'd consider the inhaled medications.[br][00:01:49.0] If they're bothering her, then you can stop them. [br][00:01:53.0]As far as the antibiotics, they're not really helping, [br][00:01:57.0]but there isn't a whole lot of harm either. [br][00:02:00.0]If she loses consciousness, toward the end, you can stop them.[br][00:02:03.0]Nurse: You know, knowing Erica, she'd probably tell you,[br][00:02:06.0]"Just save the antibiotics and use them for someone else".[br][00:02:09.0]Doctor 2: You may be right. Sandy, why don't you come with me and[br][00:02:13.0] I'll introduce you to the family and let them know that I trust you [br][00:02:17.0]and that you'll call me with any problems.[br][00:02:22.0]Patient: (On phone) I know right? That's what I thought. [br][00:02:26.0]We'll see. I've gotta go, I'll talk to you later.[br][00:02:31.0]Doctor 2: Hi Erica, how are you feeling? [br][00:02:34.0]You know Dr. Saunders, she's... she'll be the resident here tonight.[br][00:02:38.0] Her job is to make you comfortable. How's the morphine PCA working?[br][00:02:42.0]Patient: Uh, it helped, I think. I hit the button a couple of minutes ago and it helped.[br][00:02:47.0]Mother: How many times can she hit it, I mean too much morphine wouldn't be good, would it?[br][00:02:53.0][br][00:03:00.0]Mother: How many times can she hit it, I mean too much morphine wouldn't be good, would it?[br][00:03:04.0]Doctor 2: Well, that's a really good question. [br][00:03:08.0]Erica, the morphine right now is being delivered through a pump.[br][00:03:12.0] It's being given a little bit continuously all the time. [br][00:03:16.0]And it's not enough to make you sleepy, but it's the best medicine we have[br][00:03:20.0]that can help take away this feeling that you can't breathe. [br][00:03:24.0]Additionally, you have the button you can push [br][00:03:29.0]and it gives you a little bit more medicine over a few seconds. [br][00:03:32.0]That'll help take that feeling away as well. [br][00:03:35.0]It's the best thing we have and [br][00:03:39.0]most people who have advanced lung disease get some relief from it. [br][00:03:45.0]As long as you're awake enough to push the button,[br][00:03:48.0]it's not gonna make you sleepy so you stop breathing.[br][00:03:51.0]Patient: Ok, I am getting pretty tired, though. [br][00:03:54.0]Is there anything else you could try that won't make me sleepy?[br][00:03:57.0][br][00:04:05.0]Patient: Is there anything else you could try that won't make me sleepy?[br][00:04:08.0]Nurse: You know, we can try a fan, that might help the breathing a little bit.[br][00:04:13.0]We could have you sit up or go in a chair or you can lean over your tray[br][00:04:18.0]Doctor 1: We had a patient last year who we tried inhaled fentanyl with,[br][00:04:24.0]maybe we could give that a try?[br][00:04:26.0]Doctor 2: Yeah, that... that's reasonable.[br][00:04:29.0] I don't know if that's proven that it works in every case, [br][00:04:32.0]but it's definitely worth trying. [br][00:04:35.0]The side effects are relatively safe and it might have some benefit, [br][00:04:39.0]so it would be worth doing.[br][00:04:40.0]Mother: I'd like to try all of them, I mean wouldn't you, honey?[br][00:04:44.0]Patient: Sounds good to me[br][00:04:46.0]Doctor 1: Ok well I'll just write an order and let the respiratory therapist know [br][00:04:49.0]that we would like that treatment then [br][00:04:51.0]and I just want to let you know that I am the one who's here overnight all night long[br][00:04:55.0]so anything comes up, Jane can page me, I'll be right here.[br][00:05:00.0]Doctor: Erica, I'm gonna be leaving the hospital in the next half hour or so,[br][00:05:04.0] I trust Jane and Dr. Saunders to take care of you tonight,[br][00:05:07.0] if you need anything, let them know. [br][00:05:10.0]And I'll check with them a little later this evening[br][00:05:12.0]Nurse: And the antibiotics?[br][00:05:14.0]Doctor 2: Thanks for reminding me, Jane.[br][00:05:16.0]Erica, do you know at the family meeting we talked about [br][00:05:19.0]how the antibiotics aren't really doing what we had hoped they were gonna be doing?[br][00:05:23.0] And after this long course of infection... after this long course of treatment, [br][00:05:27.0]there really-at this point... the risk of the antibiotics outweighs the benefits. [br][00:05:32.0]And so if you'd like to stop them, it would be reasonable at this time[br][00:05:37.0]Patient: You know me, Dr. B, I never was that big on taking medications anyway.[br][00:05:41.0] I'd rather you stop them.[br][00:05:43.0]Mother: Wait I-I-I don't wanna stop anything at this point[br][00:05:46.0] that might be helping I mean even if just a little.[br][00:05:49.0][br][00:05:56.0]Mother: "I don't wanna stop anything at this point [br][00:05:59.0]that might be helping I mean even if just a little"[br][00:06:01.0]Doctor 2: Yeah, Ms. H, I understand. [br][00:06:04.0]You wanna do everything you can, even if it may only help a little bit. [br][00:06:09.0]At this point, the risk slightly outweigh the benefits [br][00:06:13.0]and after this long course of therapy I think it's important to listen to Erica [br][00:06:17.0]and let her help us guide what we're gonna do. [br][00:06:21.0]Like in determining what is important.[br][00:06:25.0]Mother: What do you think, Erica?[br][00:06:27.0]Patient: Well, let's see how I feel before my next dose, okay Mom?[br][00:06:31.0]Mother: Okay...[br][00:06:32.0]Nurse: Okay, what else can I get you guys?[br][00:06:34.0]Patient: I'd kinda like a mango smoothie.[br][00:06:38.0]Nurse: (laughs) All right, I'll see if I have the ingredients to make that for you.[br][00:06:42.0]And in the meantime, uh, are you expecting anyone else?[br][00:06:47.0]Mother: Uh... I-I don't think so. [br][00:06:50.0]Jason just went back to the Ronald McDonald house to get his iPod, [br][00:06:53.0]he should be back in a little while. [br][00:06:55.0]Grandma and Grandpa were here this afternoon, [br][00:06:57.0]they'll be back here in the morning.[br][00:06:59.0]Nurse: Right. I'll be back.[br][00:07:03.0][br][00:07:12.0]Nurse: All right, how's the smoothie?[br][00:07:16.0]Patient: It's not bad, but Jason makes better ones at home.[br][00:07:20.0]Jason: Yeah, you liked the one I said had vodka in it, but it didn't.[br][00:07:24.0]Patient: Mom would've killed you if that were true.[br][00:07:27.0]Nurse: Where is your mom?[br][00:07:29.0]Jason: She went to call somebody, [br][00:07:31.0]she's having a really hard time with this.[br][00:07:34.0]Patient: It's harder on her I think than it is on me. [br][00:07:37.0](sighs) I'm just tired of being here, tired of being sick, [br][00:07:41.0]tired of being a patient.[br][00:07:44.0]Nurse: What can we do to help your mom?[br][00:07:47.0]Jason: I don't know, she's still having a really tough time with this, [br][00:07:51.0]but I think she'll be okay.[br][00:07:54.0]Nurse: Who does she have to lean on and to talk to well other than you?[br][00:07:58.0]Jason: She has lots of friends. She has my grandma too. [br][00:08:03.0]Grandma gets... this. She's pretty tough.[br][00:08:09.0]Uh, but, I think she'll still be okay. [br][00:08:16.0]What do you think?[br][00:08:18.0]Patient: She thinks my being sick is her fault. [br][00:08:20.0] But I always tell her to blame my dad.[br][00:08:24.0]Nurse: What's his story?[br][00:08:26.0]Patient: Well... He took off when I was 2, and we never heard from him again. [br][00:08:30.0]Grandpa says he moved to Canada, but I don't even remember him.[br][00:08:34.0]Mom threw away all his pictures.[br][00:08:36.0]Patient: (coughs) Jeannie?[br][00:08:40.0]Nurse: What honey?[br][00:08:42.0]Patient: Can I try some of that inhaled breathing medicine?[br][00:08:45.0]Nurse: Oh, sure, sure, we'll get it right here. [br][00:08:47.0]Umm, Barb, the-the RT, she's right down the hall next door. [br][00:08:52.0]Let me grab her.[br][00:08:58.0]Nurse: Barb? Could you come come in here for Erica [br][00:09:02.0]and get her that Ventolin NMT? Thanks.[br][00:09:07.0][br][00:09:30.0]Doctor 1: Hi Erica, how are you feeling? Did that help at all?[br][00:09:35.0]Patient: I think it maybe helped a little.[br][00:09:38.0]Nurse 2: Hey doc, umm, before and after the treatment her sats were in the low 80s. [br][00:09:42.0]Would you like to change to a Venturi mask?[br][00:09:46.0][br][00:09:54.0]Nurse 2: Before and after the treatment her sats were in the low 80s. [br][00:09:58.0]Would you like to change to a Venturi mask?[br][00:10:02.0]Doctor 2: Well Erica, what do you think about that? [br][00:10:05.0]Do you want to stick with the cannula or do you want to try a mask?[br][00:10:08.0]Patient: Not the mask.[br][00:10:09.0]Doctor 1: Okay, I think we can just go ahead and adjust the flow to her comfort. [br][00:10:13.0]Umm, there is probably some other things that we can do [br][00:10:17.0]to help you feel a little bit more comfortable. [br][00:10:19.0]So we've got several things we're going right now; [br][00:10:21.0]we've got the morphine if we need it, [br][00:10:23.0]we've got the breathing treatment, this oxygen here.[br][00:10:26.0]But you're clipped to a lot of different things here, [br][00:10:29.0]and I think that we can go ahead and take these off of you [br][00:10:32.0]and stop watching the numbers on the screen instead of looking at you [br][00:10:36.0]and you just tell us how you feel.[br][00:10:40.0]Mother: Honey, you tell us how you feel, we'll be right here.[br][00:10:45.0]Nurse: Erica how's that fan feeling? It's okay?[br][00:10:48.0]Patient: Yeah.[br][00:10:49.0]Nurse: Okay, you want me to bring it closer?[br][00:10:51.0]Patient: Mhmm.[br][00:10:52.0]Nurse: All right, you let me know what you need.[br][00:10:55.0][br][00:11:14.0]Patient: Mom? Mom, where is my pink sweatshirt? [br][00:11:18.0][br][00:11:21.0]Mom can you call Mrs. Oster and tell her I finished my homework? [br][00:11:25.0]Mom, where are my sunglasses?[br][00:11:28.0]Mother: Why is she talking like this? She looks so agitated. Can you help her?[br][00:11:32.0][br][00:11:39.0]Mother: She looks so agitated. Can you help her?[br][00:11:42.0]Doctor 1: She does look agitated. [br][00:11:45.0]You know we, we tend to see patients looking like this as the end times approach.[br][00:11:49.0]You're doing all the most important things: you're holding her hand, [br][00:11:53.0]you're showing her that you're here for her, reassuring her.[br][00:11:57.0]Those are the most important things for her right now.[br][00:12:00.0]I think there's probably a medication that we could try [br][00:12:04.0]to see if that'll help a little bit too called lorazepam. [br][00:12:07.0]I'm just gonna run out and get the nurse and we'll get that right away.[br][00:12:11.0][br][00:12:17.0]Doctor 1: Yeah... yeah, okay well just go ahead and give the Tylenol [br][00:12:21.0]and then give me a call back in probably about an hour [br][00:12:24.0]if you think that that hasn't made a difference.[br][00:12:27.0]Okay, thanks.[br][00:12:29.0]Doctor 1: Hi.[br][00:12:30.0]Nurse: Hi.[br][00:12:31.0]Doctor 1: How's Erica and her mom doing now?[br][00:12:33.0]Nurse: Well... The lorazepam helped. [br][00:12:37.0]She's sleeping, you know, still coughing on and off. [br][00:12:41.0]Uh, we do at this point have to shake her in order to wake her up. [br][00:12:45.0]Umm, breathing's about the same just below 40, same retractions. [br][00:12:51.0]Umm, she did have one episode of apnea lasted about... 10 seconds? [br][00:12:56.0]And I thought her mom was just going to lose it, but she didn't-she didn't. [br][00:13:01.0]She uh, actually really surprised me and was calm. [br][00:13:05.0]Um, more teary, not as hyper;[br][00:13:09.0] I think Jason has a calming influence on her.[br][00:13:12.0]Doctor 1: Do you think Erica's gonna make it through the night?[br][00:13:15.0]Nurse: I wouldn't be surprised if she didn't.[br][00:13:18.0]Doctor 1: Have you ever had a patient die on the wards before? [br][00:13:21.0]What else do we have to do?[br][00:13:23.0][br][00:13:30.0]Doctor 1: What else do we have to do?[br][00:13:33.0]Nurse: Well... there is a file. [br][00:13:36.0]Um, some paperwork that you're gonna need to fill out and sign, [br][00:13:39.0]the clerks keep it behind their desk in a cabinet.[br][00:13:47.0]Doctor 1: Hey look, Dr. B. mentioned to me that [br][00:13:49.0]the patient's family doesn't want the autopsy. [br][00:13:54.0]But he also said that Erica wanted to donate any part of her body [br][00:13:57.0]that may help someone else.[br][00:14:00.0]Nurse: Okay, so there is a piece of paper in here [br][00:14:04.0]that has the gift of life phone number on it. [br][00:14:07.0]So what you could do is you could call that now tell them the situation. [br][00:14:11.0]They'll tell you the next steps, and then once Erica passes [br][00:14:15.0]at that point um we get consent, permission from the family, [br][00:14:19.0]call again and they will tell the family the next steps.[br][00:14:23.0]Doctor 1: And do you think that would be a conversation [br][00:14:26.0]that would be better had before she passes or after?[br][00:14:30.0]Nurse: You know they've-they've already discussed it, [br][00:14:33.0]so I think it's okay to wait until after she's gone.[br][00:14:36.0]Doctor 1: Okay. Do you think that the family would want the chaplain to come back?[br][00:14:40.0]Nurse: I don't know... Um let me, let me talk to them about that [br][00:14:44.0]and see who else they'd want to have here.[br][00:14:47.0]Doctor 1: Okay. Well I'm gonna give Dr. B. a call [br][00:14:49.0]and kinda let him know where we're headed.[br][00:14:51.0]Nurse: Yeah, good idea. Okay.[br][00:14:55.0][br][00:15:06.0]Mother: She seemed more comfortable since midnight. [br][00:15:12.0]She said "I love you" to me and to her brother. [br][00:15:18.0]She hasn't been awake for over a half hour though. [br][00:15:25.0]This is really hard. [br][00:15:30.0]Don't you think we should try the BiPAP again?[br][00:15:33.0][br][00:15:40.0]Mother: Don't you think we should try the BiPAP again?[br][00:15:44.0]Doctor 1: You know I did ask Dr. B. if there was anything [br][00:15:47.0]that we could do to help her hang on until the morning, [br][00:15:50.0]but he said that her lungs are so far gone.[br][00:15:53.0]And of course, remember how uncomfortable she was [br][00:15:57.0]when we put the BiPAP on her? [br][00:15:59.0] I mean, we could always put her on a ventilator, take her to the ICU. [br][00:16:03.0]Those things probably would get her through till the morning,[br][00:16:06.0] but they wouldn't help her lungs to heal at all. [br][00:16:10.0]And it would just make her uncomfortable.[br][00:16:13.0]This is just such a terrible disease,[br][00:16:15.0]but from what you say and from what Jason says[br][00:16:18.0]it doesn't sound like it ever slowed her down.[br][00:16:21.0]Jason: Yeah, she went bowling just three weeks ago [br][00:16:24.0]and got four strikes in a game. [br][00:16:27.0]But you know she wouldn't want the BiPAP again, Mom.[br][00:16:35.0]Mother: This is still just so much harder than I thought it would be.[br][00:16:37.0][br][00:17:21.0]Doctor 1: I'm so very sorry. [br][00:17:23.0]Jane, let's record the time of death as 2:54 am.[br][00:17:26.0]Nurse: Okay.[br][00:17:29.0]

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