N.A., a 76-year-old woman, was in the ICU in the terminal stage of multisystem organ failure. She had been admitted to the hospital for bacterial pneumonia, which had not resolved with antibiotic therapy. She had a 20-year history of COPD. She was not conscious and was unable to breathe on her own. Her ABGs were abnormal, and she was diagnosed with refractory ARDS. The decision was made to support her breathing with endotracheal intubation and mechanical ventilation. After 1 week and several unsuccessful attempts to wean her from the ventilator, the pulmonologist suggested a permanent tracheostomy and family consideration of continuing or withdrawing life support. Her physiologic status met the criteria of remote or no chance for recovery.

N.A.’s family discussed her condition and decided not to pursue aggressive life-sustaining therapies. N.A. was assigned DNR status. After the written orders were read and signed by the family, the endotracheal tube, feeding tube, pulse oximeter, and ECG electrodes were removed and a morphine IV drip was started with prn boluses ordered to promote comfort and relieve pain and other symptoms of dying. The family sat with N.A. for many hours while her breaths became shallow with Cheyne-Stokes respirations. She died surrounded by her family, joined by the hospital chaplain.

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