An old woman had some chest pain and shortness of breath, or at least that’s what she told the staff at her nursing home.  Saying things like that leads to a predictable series of events.  The supervising doc was notified, a trip to the ER was approved, and the patient was loaded up into an ambulance and transported next door to us.

Who knows if she was really experiencing these things — she had fairly advanced dementia and the validity of anything she said was questionable at best.  Just a few weeks prior, however, she was brought to the ER and ultimately admitted for what turned out to be a small heart attack.  With her advanced age and declining mental function her cardiologists opted to treat her non-invasively with medications only.  End of life discussions were held, but a DNR order was never authorized by her family.

She had a pleasant kind of dementia.  She smiled when I talked to her and thanked me for listening to her heart and lungs.  She had big pale-blue child-like eyes that stared vacantly into mine as I told her we’d run some tests to make sure she was ok.

Those tests came back essentially normal leaving me with a decision to make.  What I wanted to do was send her back to the nursing home, knowing that this was all probably nothing.  Even if something more omnious was lurking on the horizon, I reasoned, heroic measures at this point in her life were just kind of silly.  I wished that she had family with her so I could explain the situation and have them assist me in the decision.  But she was there alone, and at three in the morning I wasn’t going to wake someone up to have that kind of conversation over the phone.

So instead, I decided to admit her.  I did it because I knew there was a small but real chance that she might significantly worsen over the next few days, and if she did that I would probably get sued.  Nevermind that she’d been around since the Woodrow Wilson era, with a body now naturally giving out and a mind that progressively continued to withdraw into itself. 

I called the cardiologist, who was unimpressed by her clinical details and not particularly empathetic to my situation.  I next went to tell the patient she was being admitted, and watched her eyes fill with tears.  She begged me to let her go back to the nursing home so she wouldn’t have to be separated from her husband any longer.  She became more and more agitated to the point where she started throwing up, and I finally had to sedate her with some ativan.

I later sat back and reflected on everything that had happened, feeling generally lousy about the whole thing.