Celebrating life at the end of life

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We walked the tightrope daily trying to keep her comfortable
We walked the tightrope daily trying to keep her comfortable

My most memorable patient? There are too many from which to choose in any category (that happens when we get “long in the tooth”), but a favorite story that I have told my graduate students, friends, and family is about Grandma R, as she liked to be referred to.

I had only been an NP for 2 years at the time. Grandma's granddaughter was a professional colleague and friend who had been one of my preceptors 15 years prior when we had worked together as staff nurses in critical care. She was a demanding professional and taught me to be an aggressive patient advocate, no matter the costs. I knew that this would be difficult but was honored that a nurse whom I had held in such high esteem would request that I care for her loved one.

Grandma was 97 years old with aortic stenosis so severe that one could hear the murmur when you walked in the room; she also had decompensated heart failure and recurrent bouts of acute on chronic renal failure. We walked the tightrope daily trying to keep her comfortable. The consulting cardiologist had nothing left to offer, and so we would find ourselves pulse dosing diuretics and searching for ways to keep her out of frank renal failure, which sometimes required a small IV fluid bolus.

Grandma had a bright disposition and was deeply religious; she called me to her room one day to say that she had been praying and decided that it was time to go meet her Lord and that she wanted to stop her medicines, except for the ones that would keep her comfortable. I consulted with her son who had power of attorney. He was one of 12 and needed to ask his siblings. Subsequently, all agreed but they did not want hospice services. They wanted me to manage her end-of-life care.

We did switch gears a bit and added morphine to reduce preload and the forthcoming anxiety and restlessness was expected with cessation of the diuretics. Grandma was insistent that she wanted to be as alert as possible to the end.

Things went well for a couple days when she summoned me to gather her family at the bedside, as she wanted to say her final goodbyes. Her son arranged that, and there was a lovely gathering from the late afternoon into the evening. Grandma wanted to nap and asked that nobody leave, including me.

The evening wore on, and, hard to believe, all 12 children were in the room with intermittent visits from some of the grandchildren (and me, of course). They never left her side. When Grandma awoke, she exclaimed, “What a wonderful rest! Now I feel like I can go on!” She asked her children to line up according to age, then began to speak. She called each child by name and remarked about how proud she was to have been blessed with a child of God that she had been entrusted to raise. She told of an accomplishment of theirs that made her feel like her life had been worthwhile. She told of a lesson that she had hoped they learned about life. She told them all that she would have never, ever traded one moment if she could live again.

With a wink in her eye, and not a dry eye in the room, Grandma said “Well, I have to go now. Remember that we will all be together again someday. That is God's promise.” Grandma waved goodbye and said, “I love you” and closed her eyes. We stood in amazement, nobody uttering a word. Grandma stopped breathing within moments.

The funeral was truly a celebration of life reaffirmed! The family was abuzz with the experience and there was no grief, only happiness and stories about the best mom that ever lived!

In my years of practice since that time, I have attended “good deaths” and “bad deaths” but none so profound as Grandma's death. My prayer for all is that we can somehow find our way in this life to have courage, forgiveness, and blessings like Grandma R and her family. I think of her often.—Jeffrey Douglass, Sr, FNP, NP-C, Westland, Mich.


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