The crash cart represents an important provision for patients who collapse unexpectedly, but what are hospitals doing for the many patients whose deaths are anticipated, many of whom have opted to “allow natural death?” Nearly 1.5 million patients die in hospital every year, and in many cases physicians and nurses know for days and even weeks in advance that death is imminent. It is important that they avoid letting the fact that they will not attempt to resuscitate such a patient prevent them from providing the very best care right up to and beyond the moment that the heart beats its last.
Consider the case of Tom Stephens, a man in his 50s who suffered a rupture of an aneurysm of the aorta. By the time he arrived at the hospital, Mr. Stephens had nearly bled to death. Although the physicians and nurses involved in his care did everything right, including replacing lost blood and repairing the tear in his aorta, he suffered severe brain damage. For almost two weeks, he lingered in a coma, suffering respiratory failure and other medical complications.
During this time, his wife and two teenage sons were always at his side, eagerly anticipating any sign that he would regain consciousness. But he never improved. The time had come to make some important decisions. Would Mr. Stephens undergo placement of a tracheostomy tube, so that a machine could breathe for him long term? Would he receive a gastrostomy tube, so that he could be fed in spite of the fact that he could not swallow? The family and care team had a series of long conversations, during which they talked about his medical problems, his life, and what he would have wanted under such circumstances.
His family concluded that, in light of his severe brain injury and other serious medical problems, he would not have wanted his life prolonged and would have chosen to be taken off the machines. His comfort would become the priority.
In some cases, at such a point the healthcare team might be inclined to withdraw. Once the goal of his care had ceased being to keep the patient alive as long as possible in hopes that he would recover, what more could his physicians and nurses really do for him?
In fact, there was still much that could be done. It required no less expertise, dedication, and effort than curative therapies. The very day the decision was made not to call for the crash cart if Mr. Stephens’ heart stopped, a different kind of cart was called for.
This was a new kind of cart that is being implemented at a number of hospitals across the country: the comfort cart. Unlike the crash cart, it does not contain a cardiac defibrillator, endotracheal tubes, or powerful medications such as epinephrine and dopamine. Instead it contains much lower-tech but nonetheless powerful items, including music, scriptures in various faith traditions, and a variety of homemade “love” blankets. For the patient’s family, it also includes information on grief, the dying process, and lists of area support groups, funeral homes, and community assistance programs for burial. Finally, it contains a plaster kit for making a cast of the dying patient’s hand.