The Last Transition

The phone rang in the emergency department at two o'clock in the morning.  The unit clerk answered, spoke briefly, hung up, and turned to tell me a patient upstairs had died, and the nurse needed me to come and pronounce death.

It is an oddity of state law where I practice that, when a patient dies in the hospital, a physician must pronounce death.  A nurse can identify the absence of breathing and a heartbeat every bit as well as I can.  But nobody asks me about things like this when they periodically revise the Nurse Practice Act.

I am at a community hospital that is part of our health network.  My primary position the last three years has been at a big teaching hospital, where there are residents (doctors training in specialties) in the hospital around the clock, and so there is no shortage of physicans to attend to such matters.  Here, however, late at night there is only one doctor in the building - the emergency physician - and so all responsibilities requiring a doctor belong to one person.

Sometimes that means attending to emergencies involving inpatients: critically low blood pressure, respiratory distress, prolonged seizures.  Sometimes it means seeing patients at the very end of life.

As I walked into the patient's room, I was reminded of one of the very first times I did this.  A very recent medical school graduate in my first year of residency training, I was accompanied to that patient's room by an equally newly minted nurse.  I entered the room and gazed at the ceiling.  The new graduate nurse asked me what I was looking at, and I explained that when a person has just died, if you watch closely, you can see the spirit rise.  I was lucky she didn't smack me for that twisted sense of humor, instead briefly thinking I meant it and then saying, "Oh, you're teasing me."

Tonight I placed my stethoscope on the patient's chest and listened for a heartbeat as I watched for the rise and fall of the chest that would be present if she were breathing.  No heartbeat.  No breathing.  The nurse handed me the patient's chart, and I signed the "pronouncement of death" portion of the state form.

My note on the chart said, "Called to see patient who had ceased to breathe.  No heartbeat or respirations.  Death pronounced."  I signed my name.

I looked at the patient's face and thought about whether her expression was peaceful.  And I realized I knew nothing about her other than that she was now dead.  I could review the chart to see if I could figure out the cause.  When I read newspaper obituaries, they rarely say anything about the cause of death, unless it's a famous person.  And I often wonder.

But that wasn't what I really wanted to know.  I had a much longer list of questions.

What was she like as a child?  What were her hopes and dreams?  What about as a young woman?  Did she fall in love and get married?  Did she bear and raise children?  Was she a homemaker, a wife and mother?  Did she work outside the home, pursue a career?  Was she a homebody, or did she travel?  What were her aspirations for herself, her husband, her children?  Were they fulfilled?

Did she have grandchildren?  How many?  What was she like as a grandmother?  Did she try to make up for all the mistakes she had made as a mother through lack of experience?  Did she try to give the benefit of that parenting experience to her children and their partners raising that next generation?

If she had married and had children and grandchildren, what were their memories of her, and which ones were their most cherished?  Did she outlive her husband?  How badly, and for how long, had she missed him after his passing?  If he had survived her, how would her death affect him?

Had she had any regrets?  Had she come to terms with them?

Had she ever made a bucket list?  How many of the things on that list had she been able to cross off?  How many were left?  How many were only dreams, things she knew would never be crossed off but she thought still belonged there?

I will never know the answers to those questions, but I will ask them just the same, about every patient I care for who dies, and every one I see for the first time at the very end of life.  I will write on the chart, but nothing I write there is what matters.

Every one of us is a collection of answers to such a list of questions.  Each time I reflect on them, I think about what the answers will be at the end of my own life.  Sometimes I think I should not dwell on my own mortality.  But I believe keeping in mind that the journey is finite can sharpen our focus on making the most of it.  And I happen to be in a profession in which reminders that the journey is finite are all around me, all the time.