When You don’t Know What to Say at End of Life, Try These Four Phrases 

Case Management Focus

I have started watching a new show, The Pitt, which is streaming on MAX. The show's premise is to raise awareness by highlighting issues that the Emergency Department team face as part of their job. The setting is a level one inner-city Trauma Center in Pittsburgh. Noah Wyle from ER is the lead actor.   

A scene from a recent episode really hit me. It reminded me of the role nurses and doctors play when their patients and families face end-of-life decisions. I loved how they handled this and wanted to share it with you. 

The scene was an older man sent to the emergency department due to shortness of breath from a nursing home. His two adult children lived in the area and were called by the nursing home about their father's condition and met him at the ED. The nursing home sent some paperwork, which included the man's advanced directives, which indicated he did not want to be resuscitated. 

Dr. Robby (Noah Wyle) talked to the family to confirm the DNR, as the man was deteriorating and would need to be intubated soon. The son agreed to abide by the father’s wishes, but the sister had reservations. What if putting the tube in gave us more time with him? Why don't you want that? She said to her brother. Dr. Robby explained that his condition was fragile and that putting the tube in would prolong the inevitable. He said their father had put his wishes in his advance directive that he wanted to allow natural death, and they should respect them. 

Dr. Robby tried several things to buy some time, but the man was not responding, and the family had to decide what they wanted to do. They decided to intubate. Dr. Robby was challenged with this, as were the other doctors in the ED, as the man had expressed his wishes, and the advanced directives should be honored. One of the other doctors said they should call an ethics committee in to override the family’s decision. Dr. Robby did not want to do that and went in and intubated the man and put him on a vent. 

After the intubation was done, the brother and sister sat with their father till they could move him to the ICU. Dr. Robby checked on them and found the man very anxious. He had to be restrained and given some medication, but he was visibly uncomfortable. The adult children watched and wanted something done. The doctor explained that this was all they could do unless they wanted to remove the tube. 

At one point, the doctor closed the door and talked to the brother and sister. He told them about a Hawaiian ritual he learned from a mentor that might help them during this stressful time. The saying helps families express the four things that matter most and can ease the trauma of the end of life. The words are: "I love you. Thank you. I forgive you; Please forgive me." He suggested that the brothers and sister try talking to their father, which might help them. 

The son asked, “Can he still hear us?" The doctor said we never know, but talk to him anyway in case he can hear you. 

After the doctor left the room, the son talked to his father and said, "I love you. Thank you. I Forgive you, and Please forgive me.” The son went on to talk about things he and his father did and what a good dad he was. As he spoke to his father, you could see him visibly relax. Then, the sister talked to her father but had a more challenging time as she always felt that she and her father never got along as she was a girl, and the father wanted a boy. By going through the four phrases, she talked to her father and began to forgive him, and she felt he forgave her. After they both spoke to their father, the sister said, let’s take him off the ventilator; it is not going to help. They both hugged and cried. 

The brother went to find the doctor and said they decided to take him off the ventilator. Dr. Robby took the tube out, and the family sat with their father till he passed peacefully. 

It was a moment that many nurses can relate to, witnessing a patient’s death. I have experienced many times that the death experience can be beautiful and peaceful when we take our time and help the family, and the patient move through the dying process. 

Here is a clip of the scene from The Pitt: https://www.tiktok.com/@binge/video/7463346624530533639 

I know I will use this phrase to help me, my family, friends, and patients when facing death. 

April 16^th is National Decision Day, a day set aside each year for people to share their wishes for care through the end of life. Please review the website and plan your conversations. https://www.nhpco.org/nhdd2024 

Thank you for reading this week’s post. 

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