Fresh Air

Spring was upon us. Parts of the country were coming out of a freeze the likes of which many had never experienced before. Recovery from the kind of cold that made one's face hurt simply by thinking about being outside was underway. The kind of cold that caused people in the Midwest to blast their heating units just to keep their pipes from bursting. It reached a point where entire states nearly ran out of usable energy. As if staying home for nearly a year due to a global pandemic wasn't taking enough of a toll, new thoughts of life without electricity for days, weeks, or even longer forced their way into peoples' minds. People yearned for warmth, sunshine, a chance to be outdoors with those they love. It was no different when our palliative care team was asked to meet Mr. B. Like many other patients with cancer, we were asked to meet Mr. B to help with his vexing symptoms. The treatments for his particular disease left him quite weak, in pain, and a petri dish for opportunistic infections. A pneumonia caused him to cough repeatedly throughout the day. In addition to years of low back pain, present long before cancer reared its ugly head, he ached from the inability to function outside of his own bed. The pain led to fatigue, fatigue led to poor appetite, poor appetite worsened fatigue. Mr. B was in a tough spot. Within a few days, the cough and pain were better. However, as is often the case with advanced cancer, the fatigue was unrelenting. A short therapy session, or even an extended conversation with family, would require an hours long nap for Mr. B to refill his tank. His strong spirit was willing and determined to build strength and go home to his family. His body, in contrast, was weak and continually showing that it had other plans. It was evident that time was growing short despite our best efforts and that Mr. B was likely dying from his illness. Our conversations with him and his family shifted to exploring what might be most important if we could not help his body get stronger. His sister and son were steadfast at his side, one at a time due to COVID restrictions, throughout his hospitalization. Their front-row seat to his decline afforded them the gut-wrenching clarity that we needed to work quickly if we were going to get him out of the hospital alive. When he was awake to participate, brief periods to be sure, Mr. B was supported and encouraged by his family. They promised to get him home so he could be around his kids and grandkids. Hospice would help support his family and him, providing whatever care he might need to stay home and be comfortable. He nodded in agreement, indicating this was indeed his wish to be comfortable and surrounded by his loved ones. The evening prior to his planned departure, Mr. B's body again had other plans. His breathing slowed and his blood pressure dropped. His already declining mental status worsened and it became very difficult to awaken Mr. B. In the early hours of that morning, a rapid response team was called. As is often the case for people with similar vital signs, a trip to the ICU was offered to help stabilize Mr. B. His family at bedside became his voice. They recounted the conversation from days prior and indicated he was gearing up for his last trip home. No, he wouldn't want machines. No he wouldn't want bigger IV's and invasive monitoring. The medical team acknowledged his wishes and recommended medications for comfort. The palliative care team was paged to his room first thing in the morning. "We need to get him home ASAP" was the imperative. As we walked into the room the difference was palpable. Mr. B was no longer waking. He rested with his eyes half open, each breath seemingly more shallow than the one prior. His skin was starting to mottle and his radial pulses were barely, if at all, palpable. Mr. B's body was telling us that we maybe had minutes to hours before his last breath. His son, loving and worried, confirmed what we were seeing. "Dad's dying," he said. We acknowledged and agreed. He reinforced his hope that we could load him into an ambulance and move him home, about an hour away. They had connections with a hospice company and were hopeful they could move him home within the hour with hospice care. We listened intently and promised an expeditious response. "He is sick enough that he may die before we get an ambulance set up. We will do everything we can to try and get him out. While he is here we will take the best care of him that we can." His son appreciated the effort. He indicated other family members were on the way. They knew the end was near. And then… "Can we open a window? I think dad would love the fresh air." A simple request, though nobody on his care team could tell you when the last time the windows in that room had been opened. "If you find me a screwdriver I can have it open in seconds," his son remarked. Feeling the son's sense of urgency, Mr. B's nurse called maintenance with the request. We stepped out of the room to give them some space and began calling ambulance companies. The likelihood of a discharge was shrinking with each passing second. I shuttered at the thought of not being able to even grant the wish of an open window. Such a simple request ought to have a simpler answer. No more than five minutes had passed and a maintenance woman appeared with her tool cart. She said few words, though clearly recognized the seriousness of the situation. The window was opened in seconds and she left the room almost as quickly as she entered, as other family members arrived. An exception had been quickly granted so that they could be with Mr. B in his final moments. True patient-centered care was the priority from the bed side care team to the maintenance woman. The sun was shining at this hour for the first time in what felt like months and a cool breeze gently swept through the open window as our team returned several minutes later. For a situation oft associated with distress and disquietude, there was peace in that room. Mr. B's family held his hand and hummed a soft hymn. The stillness in the room alerted us to the fact that Mr. B had died a short time after his family arrived. Through tears and condolences his son thanked us for our care. He recalled a story about his dad from just prior to his hospitalization. "About a week before we came to the hospital dad was on his way out of the house and said he just wanted some fresh air. He loved the outdoors. We hollered for him to wait for us. I think he knew he had to wait for his family and fresh air before he felt like he could go." No funding