By Joe Cull
When I was a firefighter, if a victim’s heart was not beating, we would perform CPR, as long as they were not decapitated or in rigor mortis. But sometimes performing CPR felt like a violation of a person’s dignity. Pumping on the chest of a frail 90-year-old, it was not uncommon for ribs, sternum or even the spine to fracture due to compressions. The patient was often stabbed multiple times with an IV needle until a viable vein could be accessed. Inserting the plastic tube down the victim’s throat risked dislodging or breaking teeth. It always disheartened me to hear the bones snap or see teeth break, but it was easy to rationalize the discomfort away. Bones can heal and teeth can be replaced, but when a human life was at stake, such injuries were incidental to a greater cause: saving a life. However, there were times I wondered, primarily for patients near end of life – if they or their family had known the intrusiveness of our actions, would they have approved our efforts?
I will never forget the time I was administering oxygen to a petite elderly woman suffering from shortness of breath. Her eyes were full of fear, but in an instant, her gaze turned peaceful. Entranced, I assisted her onto the stretcher where she willingly lay down. I was so fixated on her unexpected aura of tranquility, I almost missed that she was no longer breathing. Her heart had stopped. Immediately we began CPR. Paramedics intubated her and began IVs as we maintained compressions. In minutes oxygen was flowing into her lungs and fluids into her veins. Our response was fast and professional. With sirens blaring, we whisked her to the hospital – where doctors would pronounce her dead in the ER.
The moment of her death was one of the most profound events I have ever experienced. Looking back, 25 years later, it is ironic – we did everything in our power to aggressively stop that peaceful transition. A full tug-of-war ensued in our efforts to reverse the dying process. Six strange men hovered over her as family tearfully watched nearby.
Fast forward 15 years. A small, elderly man returns to the home where he was born and raised, months after being displaced by Hurricane Katrina. His only family consisted of caring neighbors who knew his daily routine. One neighbor contacted EMS when that routine was not followed and his efforts to check on him yielded no response. EMS found him in bed with a weak pulse and shallow breathing. Death was imminent. However, when paramedics attempted to transfer him to a stretcher, he struggled and feebly pleaded “No,” and “Leave me alone.” Paramedics explained it was crucial he be transported for his own well-being. (Paramedics were also legally liable to transport.) It took three people to place and restrain him on the stretcher. He struggled to remove himself and even attempted to cling to the door frame as he was wheeled through. His fight continued until he was placed into the back of the ambulance, at which time his fighting ended, as did his heartbeat and breathing.
Of course, CPR, with chest compressions, intubation and IVs began immediately. His neighbor expressed remorse for having called EMS, realizing his friend simply wanted to die alone at home, in his own bed, not in the back of an ambulance on a stretcher with strangers. He was pronounced dead a short time later in the hospital ER.
When I became a chaplain in a hospital, I learned how common it was for a patient’s advance directives to be overridden by family members. Even as our mother lay dying with cancer, at age 80, her children, including two hospital RNs and myself, a hospital chaplain, questioned whether we should authorize more aggressive treatment. Leaning on each other for support and encouragement, we remained faithful to the advance directives of our mother. Not doing anything turned out to be the hardest thing we could have done, especially since she was conscious and talking up to the time of her death. Doing “nothing” per se (aside from comfort measures) was much harder than having her aggressively treated and transferred into the ICU. None of us regret respecting her wishes, but it was not easy, especially when we were all still hoping for a miracle. And who wants to say goodbye to Mom?
Nine years later, we remained faithful to our father’s advance directives. Like our mother, he embraced his death courageously and naturally. However, it was still hard for his adult children to accept the finality of his illness, especially since he was one of the most resilient people we had ever known. Over the years, when death seemed merely days or even hours away, he always rallied and made it back home to enjoy his coffee and watching the birds at the feeder. Maybe, just maybe, he would rally again? Of course that rally never came, just as it will eventually never come for all of us.
I remember vividly the death of the elderly woman whose anxiety was transformed to an all-encompassing sense of peace and tranquility. Her death helped catapult me into a new realm of understanding—that death is inevitable and no human intervention can indefinitely alter our mortality. But, more importantly, there will come a time when we will meet our maker, and that meeting will transcend any human presence or effort to interfere or intercede.
CPR is undeniably an invaluable life-saving tool well worth learning. Unfortunately, its implementation often entails intrusive procedures and risks additional injury to an already dying person. However, with advance directives, such procedures and risks need not be a concern to those who desire a different option, especially people facing end-of-life care who have the support of loved ones.
Joe Cull, BCC, is employed by the McFarland Institute as a chaplain with the New Orleans Police Department.