1. Forrant, John A. BSN, RN, CCRN


A wedding in the ICU.


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At his morning assessment, Mr. Casal (not his real name) didn't seem like the man I had met 24 hours earlier. Yesterday he'd been full of life, talking with staff and family members, laughing at my attempts to say "hello" and "how are you?" in Spanish. This morning he sat bolt upright, his breath rapid and shallow, his color ashen. I held his cold hands in mine and asked how he was doing. "Not good," he said.


Mr. Casal had end-stage pulmonary fibrosis, and I was convinced he'd soon need to be intubated and placed on a mechanical ventilator. After discussing this likelihood with the resident, I shared my concern with Mr. Casal and his daughter (he understood and spoke basic English, but she translated when necessary). They spoke together for a few moments, and then she told me her father didn't want to be intubated.


She asked whether we'd give her father morphine to keep him comfortable. I asked the resident to call the attend-ing physician. He did so, and was given an order for a single dose of morphine 2 mg iv, which I then administered.


I'd been struck by the joy Mr. Casal and his family seemed to take in one another's presence. Now my primary concern was to keep him comfortable and to make sure he'd be able to interact with them for as long as possible. I returned to the hallway to speak with his daughter. With tears in her eyes, she told me that she was getting married in a month and that one of her father's greatest wishes was to see her married. I suggested I call our chaplain to see if we could arrange a wedding on the unit.


While Mr. Casal's daughter hurriedly called her fianc(C) and asked him to come to the hospital with the marriage license and rings, I called the director of pastoral care, who agreed to the plan and put in a call to one of the chaplains.


When the chaplain arrived, he advised the bride and groom to be prepared for a celebration that would almost certainly cause mixed emotions. The groom replied that he frequently had dreams involving his "guardian angel" and that this morning his angel had visited him and instructed him to go see his future father-in-law in the hospital and to bring the rings.

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Before we could conduct the wedding, the attending physician arrived. He berated the resident and me for what he perceived as a breach of protocol in our addressing end-of-life issues without his permission. I felt dread in the pit of my stomach as I listened, but I didn't believe I'd done anything more than respond to the concerns of a patient and his family.


I reminded the physician that he was required to address the patient's stated preference not to be intubated, but he angrily told me that before we could conduct the ceremony he wanted to make sure Mr. Casal had been offered "every possible" option, including intubation and transfer to a facil-ity that offered additional treatments. During the subsequent conversation with Mr. Casal and his family, the physician kept saying "we would have to breathe for you," but never mentioned intubation and long-term ventilator support. When I explained to the family that the physician meant a breathing tube would have to be inserted, they all looked at me in horror, and the patient again refused intubation.


The physician wrote out a "care and comfort" order for Mr. Casal that included morphine and sedatives to be given as needed. As we left the room, he rebuked me for speaking up, but I told him I had only been trying to clarify his thoughts.


Shortly afterward the chaplain entered the room in his white robe and purple stole. He was newly ordained, and this was his first wedding ceremony. All thoughts of code status and vital signs disappeared as about 20 hastily gathered family members surrounded Mr. Casal's bedside. Feelings of warmth and acceptance filled the room.


Throughout the ceremony a baby slept quietly on Mr. Casal's bed. When the minister asked, "Who gives this woman to be with this man in the sacred covenant of marriage?" Mr. Casal raised his arms, grabbed the hands of the bride and the groom, and declared: "I do. I am her father!!" The groom promised Mr. Casal that he would always take care of his new wife.


Afterward, as the family mingled around a small cake, Mr. Casal's daughter, crying, gave me a big hug and told me I was her guardian angel. Mr. Casal died quietly with his family at his side within 16 hours of the wedding.