1. Koch, Arlene RN

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Ray Troyan was curled in the fetal position, rocking back and forth. A severely perforated bowel caused him so much pain that on a 1-to-10 scale, he rated it a 20. He was 87 years old and had been admitted 48 hours earlier with chest pain, but now the pain was localized in his abdomen. His daughter, Kathryn, had been called in during the night. Neither of them had slept.


Ray had to make a choice. If he chose surgery, it would have to be done immediately. Not having surgery would mean death. Ray's age and the magnitude of the surgery were two factors working against him. The surgeons couldn't guarantee a good outcome.


After Ray's pain was under better control, he lay stretched out on the bed, holding Kathryn's hand. They were deep in conversation, as if no one else in the world existed. There was no other family member to help them make this decision. I left them alone while I checked on my other patients; when I returned to Ray's room, he told me that he and Kathryn decided there would be no surgery.


He said it was an easy decision, and he was at peace with God. He'd lived a great life surrounded by the people he loved, and he had no regrets. If it was his time, it was his time. Kathryn appeared calm, strong, and remarkably comfortable with this decision. Whenever I asked if either of them needed anything, she always declined, saying, "No, I'm fine, thanks." Once I shooed her out to take a short walk to stretch her legs. She reluctantly went only after I promised to stay with Ray until she returned. I worried about her. I wasn't sure she understood what the next 24 hours would be like for her father.


The most valuable care I could give him was comfort. These would be his last hours on earth, and I wanted to make sure they were peaceful ones. I knew that as long as I kept his pain under control, Kathryn would be able to withstand the ending. After a few hours, Ray remained sleepy but alert. His condition worsened much faster than I'd anticipated, and although I was glad he wouldn't linger and suffer, I felt sad for the short time he and Kathryn had left.


When my 12-hour shift ended, I was asked to stay an additional four hours. Tired from such a busy day, I knew there was no one else to fill in. Ray deteriorated quickly; his vital signs fell, and his extremities became cold and mottled. He didn't respond to voice or touch. His lung sounds were coarse and audible without a stethoscope. He showed no outward signs of pain.


It had been just Ray and Kathryn for years now. Ray's wife, Wilma, had died from cancer three years before. It was a long, harrowing illness. They'd been married 57 years. By evening I felt close to Ray and Kathryn, like they were becoming a part of my own family. I told Kathryn I would be her father's nurse until 11:30 pm. She seemed relieved.


Shortly after 11 pm, Ray took his final breaths and was gone. Kathryn was there, telling him it was all right to go. He didn't fight his death; he let it consume him peacefully. It was only then that Kathryn cried. We stood at his bedside hugging.


I left Kathryn alone with her father. It was important that she have the time with him to say good-bye. When she was ready to go, she thanked me for all that I had done for her father, even though I had played such a small part in this once-vital man's last days. When I got home that night, I was at peace with how that long day turned out. I, too, had no regrets.