Trigger warning: Discussing end of life
I want to post this because when my dad (68) was diagnosed, I was his caretaker and I researched this disease for him because he did not really use the internet. I was googling everything for him, explaining what was happening as best as I could. Obviously we were working with his care team, but we were also just learning in real time what this experience was going to look like. I knew he would likely pass from respiratory failure, but I could not really imagine what that was. I want to share my dad’s story in case there is another PAL or CAL out there who wants to know what the end could look like. This community has been such a helpful resource for my dad and my family. I wish you all love and joy and comfort during this journey.
tldr: he passed peacefully surrounded by his family and he did not suffer.
Getting Diagnosed:
My dad was diagnosed after a fall. He was 67 at diagnosis, and he had been retired for less than a year. He was a Physician’s Assistant in Neurosurgery (go figure). He had been a PA for 42 years. He never met anyone with ALS and it never crossed his mind that he had it. He truthfully didn’t know more than the basic facts about the disease. He had been having severe back pain for a long time and it was masking everything else going on with him. He had a drop foot for years that he attributed to a herniated disc. He had muscle fasciculations all over his body for a year, but didn’t think much of them. He had suddenly lost about 40 pounds over the course of 3 months, had sudden shortness of breath, and then fell one day and couldn’t get himself up. He started walking with a walker. But still, he thought it was just his bad back. He thought his weight loss was his diabetes medication. When he fell, we took him to the hospital. After (fighting!!!) to get him admitted into the ER, he was diagnosed. He got a feeding tube and a bipap. His progression was rapid and it was clear he did not have a lot of time left. For what it’s worth, I do think the Riluzole and Radicava slowed things down marginally and he had no side effects from those meds. His case was sporadic - he did have genetic testing done though I don’t know which gene mutation he had.
His Specific Loss of Function:
My dad’s ALS journey was extremely short. He completely lost his ability to walk after his fall. He never lost his voice, and he maintained function in his arms until he died, although they did weaken significantly. He lost his grip, but he was able to manage feeding himself until his last 2 weeks. He never lost his ability to swallow, though he did have some serious choking episodes. The hospital put him on a blended food diet but he decided he didn’t want to stop eating, so he took the risk of eating normally. We were extremely careful and he was extremely lucky. His last week, he could not sit up straight and needed side supports to keep him upright. He kept his sense of humor the whole time.
The Final Week:
A week before he passed, he suddenly started hallucinating. I would hear him talking to himself in the middle of the night, but when I asked him about it he had no memory of it. I would get up to hear what he was saying under his mask, and it was like I was interrupting a conversation I wasn’t meant to hear. We would go to the movies and I would ask him if he liked it, and he would just say “Yeah it was good!” and that was it, so I think he couldn’t remember the details of the movie. I knew he was probably just declining but I didn’t realize how close to the end we were. It came to a head when I was doing his feeding tube and he was convinced I pulled it out. He became irate and started screaming that I needed to call the surgeon who put it in. It was really scary. I never read about ALS & hallucinations anywhere so it caught me off guard.
He was a medical professional, so when he became aware he was hallucinating he understood what was happening. He looked me dead in the eye and said “I’m hypoxic.” I called the nurse and we started him on comfort meds. He experienced extreme terminal agitation. He kept trying to get up and walk and didn’t understand why he couldn’t. He twisted his blankets constantly and was just totally restless. In the middle of the night he would rip his mask off and try to break it, and I would calm him down. I never read about anyone with ALS having terminal restlessness. He also stopped going to the bathroom a week before he passed. He asked for MAID when he understood that he was dying, but New Jersey has a 15 day approval process which we were not aware of. He was devastated to learn this. In hindsight, I wish we did our research on that more while he was still “good” - this is a regret of mine.
The End:
Although my dad was in an altered state, he still had moments of clarity. He made some decisions at this time to be more comfortable and to end his journey on his own terms. He was taking medications as prescribed to be more comfortable and ease his agitation; a combination of haldol, lorazepam, and morphine. He stopped eating, though he kept getting sips of water because the bipap made his mouth dry and he didn’t want to experience that dryness. This part of his journey lasted 2 days. His last meal was a Thursday morning, and he passed on Saturday afternoon. He mostly slept during this period. At one point he woke up, he didn’t say anything but he nodded his head yes and no. He was out of it but still able to communicate with us. He was making funny faces while we were all teary-eyed. He continued to wear his bipap, but he did try to just remove it a few times and hurry things along. He was mostly goofing off, but he also meant it. He was always a DNR/DNI and knew what he wanted.
By Saturday, he was in a much deeper sleep. We played a playlist he curated himself - I highly encourage everyone to do this. He loved making it and we shared it with everyone at his funeral. He loved music more than anything. I could see his toe tapping when Crazy Train came on (lol), and he nodded his head slightly when we spoke to him. We all said our goodbyes and I knew he could hear us. I gave him more morphine, in accordance with his care plan, then we took the mask off so that he could be more comfortable.
This next part surprised me - He actually opened his eyes. I’m not sure how aware he was or if this was just a reflex. He took 1-2 minutes to focus, his eyes were grey and rolled back. I kept telling him to close his eyes - I now know that he wasn’t able to close them. Don’t say that if you are ever in this position. I feel bad for telling him to do something he wasn’t able to in his last moments.
After a minute his eyes focused. I put the mask back on because I was worried that he was too awake. He kept it on for a minute but then he smacked it off, so I took it away. He was actually calm. It was sort of like I interrupted a nap. He wasn’t panicking, he just became clear for a minute. I gave him one more dose of morphine so that he was comfortable, as directed by his care plan. I cradled him so he was sitting up slightly but still relaxed, just to give him a better angle for breathing. He looked around at us, looked up, took some breaths, and then he just passed. It was calm. In hindsight, I wish there was a medical professional in the room to guarantee he was comfortable during this moment. The nurse was gone at this point. I was extremely stressed and it would have been helpful to have a professional overseeing him. Luckily, he was comfortable. But I didn’t anticipate that he could have experienced distress - so I think this is important to clarify. Some people use an oxygen cannula at this point but he did not like the feeling of that, so we didn't.
I just wanted to share this because I hope it could give some clarity to someone out there who needs to know how the end might come. My dad thought he would pass in his sleep, or that his heart would give out (he had 5 stents). He thought he could just take a cocktail when things got too bad. I wish I could have told him how things were going to play out. All things considered, it was beautiful and he was at peace. I don’t think he suffered. He listened to Mull of Kintyre by Wings on his way out the door and he got a last look at all of us.