Rachel K. Vanek, RN, MSN, CNP: University Hospitals Case Medical Center, Cleveland, Ohio.

Our medical ICU and the mechanical ventilator were very familiar to M.E. She was familiar with the group of nurses and, most importantly, our unit's acute care nurse practitioner, Rachel Vanek. Rachel had assumed primary responsibility for M.E.'s care during each MICU admission and had coordinated her recent transfer to a ventilator weaning facility.

She noted that M.E. had been slowly weaned off the ventilator at the facility, but was again suffering from hypercapnea. After readmission and workup, it became clear that her symptoms were a result of an exacerbation of her COPD. After four days on the ventilator, Rachel and the team were able to wean and extubate the patient. However, M.E.'s clinical status remained tenuous, and noninvasive ventilation (NIV) was instituted. Unfortunately, M.E. could only tolerate short intervals off NIV.

Finally, it became clear that M.E. had reached the end of her effective treatment options. Once again, Rachel initiated a patient and family meeting to review M.E.'s clinical status and prognosis, and to address treatment limitations. Although she could only speak in short, broken phrases, M.E. was adamant in her preference for no further intubation. The patient confirmed her understanding, stating, "I want nothing to do with the ventilator ever again!" After presenting M.E.'s clear preferences to her family, who unanimously agreed, Rachel reentered M.E.'s room. As the bedside nurse, I watched with deep respect as Rachel connected with M.E., taking her hand, looking into her eyes and saying, "I will not let you suffer." Rachel instituted comfort measures, including a fan, the patient's favorite water fountain with nature sounds, a well-loved and well-worn quilt from home, open family visitation, hourly sublingual morphine titrated to dyspnea and finally a morphine drip. M.E. died peacefully in the MICU two days later with her family at the bedside.