Mr. M was a 75 year old father and husband with stage IV lung cancer. He originally came to the University of Colorado Hospital (UCH) seeking a second opinion regarding the treatment of his advanced lung cancer. On our Oncology unit, he had a progressive increase in his oxygen requirements and quickly reached the limit of what the floor could safely provide. This necessitated moving him to the Medical Intensive Care Unit (MICU) for closer monitoring and additional intervention if necessary. In the MICU, his condition required the use of Bipap, a noninvasive form of ventilatory support. Per his wishes, a “Do Not Resuscitate/Do Not Intubate” order was in placed in his chart. The Bipap, therefore, represented the most aggressive form of respiratory support available while honoring his desire to not have a breathing tube placed into his lungs. Unfortunately, UCH was unable to offer any treatment to deal with his advanced lung cancer. Even more unfortunate, however, was that his current condition required ICU level care and interventions that made it difficult (nearly impossible) to simply discharge him and allow him to return home.

As treatment options had been exhausted, the focus of his care shifted to maintaining his comfort and fulfilling his final wish to return home to a small town in western Colorado, 3+ hours over the mountains. His wife and sons felt very strongly that we honor his request and get him back home to live out his remaining time with the support of home hospice. As he now required the constant breathing support of the Bipap machine, this represented a dilemma. As he required more oxygen than could be delivered by traditional means, and declined to be placed on a mechanical ventilator, ambulance transport companies in the area were reluctant to provide the services necessary to facilitate his return home. Claudia Urenda, a nurse in the MICU, worked tirelessly with the social worker, Marcia Hoeberg, to investigate all potential options to honor Mr. M’s and his family’s wish that he return to his distant home. Eventually, University Of Colorado Hospital’s Lifelink Critical Care Transport agreed to discuss the possibility of providing transportation home. The challenge created by Mr. M’s transport revolved around the general lack of Bipap for transport. Patients are usually either able to tolerate a trip with traditional oxygen therapy or have a breathing tube that would allow for full respiratory support.

It was agreed, after much discussion, that Lifelink would bring their transport ventilator to the bedside and an acceptable alternative mode be explored to provide the necessary support, while avoiding an intubation inconsistent with the wishes of the patient. Shortly thereafter, the transport team arrived at the bedside, apprehensive but willing. Adrian, the Respiratory Therapist (RT) who happened to have both transport experience and familiarity with Lifelink’s ventilator, quickly rose to the challenge, helping develop a plan and inspiring the confidence of all. In conjunction with Claudia, the nurse, and Adrian, the RT, the patient was switched to the transport ventilator. Initially, things seemed okay until the patient mentioned that the mask felt uncomfortable and was cutting into his face. Upon removing the mask a few seconds to readjust, Mr. M’s oxygen saturation plummeted into the 50’s (normal is > 90%) and the entire trip appeared to be in jeopardy. He was quickly switched back to the hospital’s equipment and slowly recovered. After a lot more discussion, the patient was transferred to the gurney and then switched back to the transport vent. More fiddling with the vent and it was decided that it was time to go. Did I mention that we had 3 inches of fresh snow in Denver and the roads were a mess?

Ultimately, after 5 ½ hours and two stops to refill the ambulance oxygen tank, Mr. M arrived safely home. The collaboration and outstanding efforts of a nurse, a social worker, and a respiratory therapist combined to successfully honor the final wish of this special patient and his family. A special thanks, also, to the University transport team who accepted the challenge on this wintery day. As is usually the case, Claudia felt as though she “was just doing her job”, business as usual. I beg to differ. In these moments, we are reminded of the powerful impact our actions, as caregivers, have on the lives of our patients and families. I was deeply moved by these events and it made me proud to be a nurse.