What do you do when your patient dies in an airplane over the middle of the Pacific Ocean with a grieving wife at his side? After 3 years as a flight nurse, this was the first time I had to ask myself such a question.

My flight partner and I received a Medivac jet request to fly to the Hawaiian island of Kauai to pick up an 82-year-old patient with end-stage pancreatic cancer and his wife for transport to California. They had been visiting Kauai when the patient, Mr. R, had become acutely ill. Now he and his wife wanted to go home.

When we arrived at his hospital room, Mr. R was alert but struggling to breathe. Within minutes, Mr. R thrust an advance directive at me, clearly stipulating that he wanted no endotracheal intubation, chest compressions, or other artificial life-support measures. I discussed with the couple the profound effects of high altitudes on a critically ill patient, including the very real possibility that the trip could prove too much for Mr. R. Nevertheless, they were united in their desire to get home.

Last flight

Mr. R's oxygen saturation level plummeted during the quick ascent from the Hawaiian coast to an altitude of 7,500 ft (2,286 m). We quickly switched from a nasal cannula to a non-rebreather mask with little improvement. It was time to get creative.

My partner and I converted our transport ventilator and the mask from a bag-mask device into a crude continuous positive airway pressure device. It provided enough positive pressure ventilation to stop the plunge in oxygen saturation that occurred as the plane climbed.

Despite maximal oxygen supplementation, Mr. R's clinical status deteriorated until he was bradycardic, hypotensive, and unresponsive. Mrs. R grasped her husband's hand and repeatedly implored him to "just hang on" until they reached home. After 2 hours, however, agonal respirations and a widening QRS complex told us this was clearly not to be.

Mrs. R had her mind set on a scenario in which her husband died at home, in his own bed. This grieving wife desperately clung to the comforting mental picture she had constructed, one that conformed to her own timetable for Mr. R's death. Now, I had to think quickly; it was time to talk about letting go.

I asked Mrs. R to describe her husband's life and discovered he had spent his career as a Navy pilot. Then, I gently explained Mr. R's present condition and how some people seem to need permission from their loved ones to move on from life. Mrs. R sat quietly for some time, then stood from her seat, leaned over to kiss her husband's forehead, and placed an orchid lei around his neck. She gave him a long, slow hug and whispered, "I love you, but it's okay to go." Within 2 minutes, Mr. R was asystolic. As she continued to hold his hand, I supported Mrs. R and helped reframe her loss experience. By the time we reached California, she was convinced that dying in the air, above the sea, was exactly how her ex-Navy pilot husband would have wanted to go.

It was a sad flight, but I was thankful to have found some way to keep it from being a horrible flight for all involved. Mrs. R was extremely grateful for those last shared moments with the man she loved and was able to move from a feeling of having failed to get him home to a sense of elation that their final moments together were just as he would have wanted them to be.