1. Randall, Lorraine RN,C

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Marissa arrives at 4 pm in the oncology ward of my hospital. She can barely stand to walk from the wheelchair to bed. Her breathing is labored under her tremendous abdominal girth, and her hands and feet look painfully swollen. I apply a nasal cannula and she swats it away, mumbling. I glance at the orders; the admitting diagnosis scrawled on the order sheet: end-stage liver cancer with mets.


"We're here on vacation," her husband Anthony says. "My wife has been very sick. We just got married three months ago. We're from Staten Island, but her father thought the Florida sun might help her get better. We just got here and she's been real bad."


As I listen, I notice a "do not resuscitate" form attached to the chart. There's also an order for a morphine drip, which is needed immediately-she's agitated, moaning loudly, and struggling for breath. I explain to Anthony that we'll talk later after I make Marissa more comfortable and settle her into bed. Does he understand that she won't be going home, I wonder?


I find Anthony in the waiting room with the rest of Marissa's family. I whisper to him in the hallway. He holds his head so low that I strain to hear him. "The doctor says she's dying," he says.


I take his hand in mine. "It will probably be very soon."


"Yeah," he says.


"Does her family understand?"


"Well, they know she has cancer. But she didn't want them to worry. I'm not good at this. Can you talk to them?"


Anthony introduces me to Marissa's dad, stepmother, and younger sister. He returns to his wife's room, and I explain that Marissa has little time left. I suggest if anyone needs to be with her, they should come now. They gasp loudly, and I'm faced with incredulous expressions. Her father asks me, "Are you saying my little girl is going to die?"


I feel embarrassed at my reply. "I know this is a shock, but I believe time is of the essence. Do you need me to arrange for a clergyman?"


They all rush to Marissa's room.


I give them some time and then return to her room. Her family stares at me angrily when I enter. I'm accustomed to it-it goes with the territory. And I'm okay with it because I hope someday they may appreciate my candor about Marissa's imminent death. Maybe they'll be thankful that they were able to spend those last moments with her before she died, instead of sitting in the waiting room hoping that she would get better.


Marissa continues to be incoherent, but her agitation has abated and her breathing is less labored. Her father follows me out of the room and asks me if I could be mistaken about her condition. "I don't think so," I tell him.


"Well, I'll talk to the doctor about that," he says. "Her mother is up in New York and won't be here until tomorrow. That will be plenty of time, right?"


I don't think so, but I tell him I don't know and that they should spend the night in her room or the family room.


When I arrive at seven the next morning, Marissa is in a coma. I find the family in her room as I make my rounds. Marissa's breathing is very shallow; she is close to death. I wonder how she made it through the night. Maybe, I think, she's waiting for Mom. Her family doesn't seem to understand she's in a coma and not sleeping.


When the doctor arrives they are waiting to hear him say that I have made a mistake, that Marissa is going to get better and leave the hospital. But the oncologist reiterates what I said yesterday. Softly but precisely, he tells the family he does not expect Marissa to hold on much longer. There is a collective sob from her family.


Within the hour Marissa's sister calls me into the room. "She's not breathing!"


I reach for my stethoscope, but before I can listen, Marissa gasps loudly. Her sister screams. Everyone else is silent.


Our hospital began a policy of playing "Twinkle, Twinkle, Little Star" over the loudspeaker with every birth. While I stand with my arms wrapped around Marissa's sobbing sister, the tune floats into the room as Marissa dies. It is 10:45 am.


The family begs me not to move her until her mother can arrive. I place a DO NOT ENTER sign on Marissa's door and go about my duties. The day wears on and I am in the next room assisting in a central line placement. As I prepare to hand the doctor a syringe filled with heparin, I hear a tremendous wail. Hurrying next door, I find Marissa's mom draped over her daughter's body.


The family has arranged for Marissa to return home to New York City. It's 3:30 pm, less than 24 hours since Marissa and her family arrived at the unit. I offer my condolences and we embrace, and when they are gone, I accompany Marissa's body to the morgue. Getting off the elevator I hear "Twinkle, Twinkle, Little Star" from the loudspeaker again.