Chapter Four: Jenn Homer
Jenn Homer was a ninety one year old man who was brought to our ER by his wife of forty five years, a much younger and healthier woman, and their forty year old son. He had been going downhill for the past week and was now unresponsive. An ambulance was called to bring him from home to our hospital. It was the early 1990’s, a time when advanced directives (the legal document which expresses a patient’s wish to not be resuscitated or put on life support machinery in the event of a cardiac or respiratory arrest) were being to be used more routinely. His advanced directive specified that no heroics be performed. Mrs. Homer verified this intention with the sentence, "if he could have seen himself now when he was ten years younger, he would never allow us to do anything to prolong his life." She and her son told us that he had always been a gentle, kind, man and he deserved a swift, peaceful end to his life. He had been admitted to the hospital a week before with kidney shutdown and increasing failure to thrive without a clearly treatable cause. After discharge, he was seen in his doctor’s office with worsening malaise, incontinence, night delirium, and anorexia (loss of appetite). His previous diagnoses included a moderate degree of Alzheimer's dementia.
He appeared quite ill, unresponsive to all stimuli, with rapid heart beat, low blood pressure, low blood oxygen level, and bone dry mouth. His blood tests revealed major kidney failure, an elevated white blood cell count (consistent with severe illness of any nature) and a dangerously high blood potassium, probably from the inability of his kidneys to excrete this mineral. His chest x-ray revealed pneumonia in the left lung. He was dying. Given his morbid appearance, well-documented advance directive, and his family making clear statements consistent with this plan, I wondered why an ambulance was called. Was the family in a hurry to have him die somewhere besides home? Or, has it become a reflex these days to call 911 whenever panic and insecurity replace rational, adult reason?
"Mrs. Homer, your husband Jenn is extremely ill and stands no chance of recovery without aggressive efforts which would include an IV, antibiotics, other catheters, and intensive nursing care. Even with all that, his chances are close to nil. I gather from what you have said that you probably don't want us to do all or any of that. Is that right?"
"Oh, doctor, I know that Jenn would not want us to do anything to prolong his life in this state. I just don't want him to suffer."
"I can assure you that he is not suffering at all in this condition. He is not conscious and so he feels no pain. If you are both clear that you don't want us to do anything, do you want to take him home to die there?"
"Well, doctor, we don't want him to starve to death. Can you treat him just enough to be sure he has enough to eat?"
"Excuse me? Please understand Mrs. Homer that Jenn will not be eating in his present condition. The only nutrition he could receive at this point would be intravenous fluids, mostly water. If we give him this, it could prolong his illness. And then also, if we start an IV for this purpose, should we give him some antibiotics while we're there? This is definitely a dilemma. You should realize that if he dies of this illness, I would view his death as from 'natural causes.’ Pneumonia is frequently the terminal illness for the frail elderly who have run out of steam to fight. This is natural."
"No, no antibiotics, no IV. Just take care of him without those things, please."
"Mrs. Homer, I'm not sure exactly what you want us to do. I understand and agree with the plan to not treat Jenn's illness, to not prolong his illness and possible suffering. If we don't do that, there is nothing we would do here that you couldn't do at home."
"Doctor, could you just keep him here for a couple of days. We are just so exhausted from being up with him all night; we just can't take it anymore. Just for a couple of days, then we can take him home."
I discussed our dilemma with the discharge planner who scratched her head and came up with the following. Because there is a rule about a three-day hospitalization before nursing home transfer, we could justify admission on that basis. Otherwise, receiving no medical treatment, an admission would trigger a Medicare review and the typical punitive consequences.
"Mrs. Homer, what we do in hospitals is treat disease. In this day and age, people cannot be admitted without a solid reason for admission. There must be a treatment plan. There has to be a diagnosis that requires medical therapy not available outside the hospital and the patient has to actually receive the treatment. If what a patient needs is nursing care alone, then there are nursing homes set up for this purpose. I have spoken to the discharge planner who figures all this out, and she is checking with the nursing home now to see if they have any beds. If we need to keep him here for a time before he can be sent there, then we will do so. Do you understand what I'm telling you?"
"Yes doctor, I do."
Mrs. Homer and her son left the hospital for a little while to call their relatives to discuss these issues and problems. The emergency department was otherwise slow at that time so I went to the nursing station to check with Nancy, the discharge planner nurse. While she was waiting for a call back from the nursing home, I went back to the emergency room. I glanced over at poor Mr. Jenn Homer who had very long pauses between breaths. Very long pauses. It occurred to me that this was convenient timing. I went to his gurney side and listened for a heartbeat. He had been a life long vegetarian and had no body fat and not much muscle at this point. It was hard to get acoustic contact with my stethoscope on his chest because of the bony prominences of his ribs. I couldn't hear anything so we got an EKG strip. Flat as a dry lake bed in the desert. Total absence of cardiac activity. I suggested to the nurse that we try to find his wife and son. I also let Nancy know that we wouldn't need her services, but instead, we might give the coroner and mortuary a call.
"You mean he's dead? He's gone?!! No, no", she cried out. She moved her elderly body to his side as rapidly as she could. "Jenn! Jenn! Where are you? Talk to me, Jenn." She continued to carry on for the next fifteen minutes. I was impressed by how unprepared for the end she seemed after making such clear statements about his illness and terminal wishes. Their son was more quietly accepting of the inevitable. Of course, he has his own family, but she is now alone. It is one thing to accept the death of one's spouse at the end of their lifetime. It is quite another to accept one's own terminal aloneness, left behind in the universe.
He said he was ready
All Rights Reserved © 2004 Jon Sterngold