I entered the room with the idea I’d be their support, the sturdy foundation upon which to rest in their moment of need. The truth is I began to crumble the moment I picked up her chart, this plastic blue binder summarizing our entire relationship in progress notes and green order sheets. It felt heavy. The sheets upon sheets of vital signs and lab results were irrelevant now. What mattered were the moments hidden from my frank, objective SOAP notes, which now seemed detached as if written for an archive and not a human being. I held this weight in my palms and saw her smile, heard her laughter. I thought how she’d never wake up beside her husband, or the smell of coffee, or the sun gleaming off the Cataraqui River ever again.
And then I realized, the significance of this binder was not its meticulously detailed record of every nurse and physician who presided over her. This binder was a tangible reminder of my entire relationship with a woman whom I only met because I was in medicine. A profession where I could help and guide people through life’s rigors from childbirth to chemotherapy, and each time I’d have this note, this reminder of what failed, was accomplished or yet to be resolved.
I had something to hold on to.
My first patient on the Clinical Teaching Unit was described as an elderly woman with numerous behavioural barriers to long term care. She had numerous neuro-psychiatric issues distorting her diagnosis. Were her hallucinations delirium or post-traumatic stress from a previous traumatic incident? Were her tremors and rigidity Parkinsonism or extra-pyramidal side effects of antipsychotics? Perhaps both, safer to assume both. To complicate matters, numerous psychiatric medications including haloperidol worsened his aggression and hallucinations. She was in hospital for months.
There were good days and bad days, which were mostly bad mornings. I started visiting in the afternoon when she was most pleasant, when she smiled. When she was cooperative.
I saw her daily for weeks, my unfortunate, puzzling case of acute cognitive decline. How could someone deteriorate so rapidly? The week before her admission she was exercising on her home treadmill. Now, we needed a ceiling lift to transfer her out of bed. She rarely slept, restlessly tossing and thrashing for hours, often found on the floor unable to get up. A sitter was stationed at her door from then on. She grasped at unseen objects, motioned towards unknown places, and seemed perpetually in search of what, no one knew. Her eyes darted fervently beneath clamped eyelids, searching the darkness and imaginings for clarity. The Foley catheter was like fire under her skin. She tugged and tugged and tugged until the detested tube traumatized her urethra and she bled frankly into the collection bag. Safeguard mitts were strapped to her hands. She mumbled incomprehensibly except for anguished howls whose meaning was transparent. My patient was not merely in pain. She was suffering.
I get this uneasy sensation when I know there is nothing I can do to help. I chose medicine because I want to help, so when I can’t, what am I to do? What use am I? Following Hickson’s renown proverb, we tried, tried and tried again. But no matter who was consulted, called, and re-consulted, she never improved. We were unsuccessful.
Over this time, I met her husband. I listened to her concerns, offered what meager information a clerk has and the reassurance that we were doing our best. He was optimistic and willing to try everything in our medical arsenal. He loved his wife, but he heard her cries the same as the rest of us. Before her admission, he says they had had several end-of-life discussions. Whenever I reflect on this experience I am endlessly thankful for that. His wishes were clearly in the best interest of his wife. So when my patient became septic after months of no clinical improvement, he chose to withdraw life support and I understood. I agreed.
He had a simple request: give my wife peace. She deserves that much.
Again, I did my best to explain what options existed and what would happen next. I asked my senior residents for advice, and found a pamphlet at the nursing station about after death planning. But this was my first experience with death, in practice and in life. Terms like palliative sedation, death rattle, and death certificate were things I’d only heard in lecture. But what did these mean for my patient? For her family? I confessed my inexperience to him and he met me with patience, understanding, and support.
Palliative sedation was initiated and for the first time in weeks she was calm. She slept peacefully, tucked warm under the sheets. Entering the room, there was no ominous sense of death or despair, no thoughts of over-sedation, no questions of “Is this right?” or “Am I giving up too soon?” There were only soft, shallow breaths and a man unmoved from his wife’s side lost in the warm glow of a setting sun.
And then, while the hospital slowly awakened in the early hours of the morning, she slipped away.
The first thing I heard that morning was that my patient had passed. We needed to pronounce the death. While my resident rhymed off the checklist of what needed to be done, I struggled to listen. He spoke with candor, having done this multiple times. But this was my first time. I barely had a moment to process the news before I was handed the death certificate. There is no lecture in pre-clerkship that can prepare you for this moment. I was so unsure. How would I respond? What if I disrespected the body? Mistakes in medicine are not uncommon, after all. Could I hold my composure? Would I cry? Faint? Vomit? Perhaps I am too influenced by television and media, but these questions troubled me. Going into medicine I knew I would encounter death, but I’d never considered how holding it, touching it, lifting its eyelids would affect me.
But this had very little to do with me at all. At the end of the hall there was a man and his family who needed help. This was it, the very reason I chose medicine, I told myself.
I often ruminate on what this experience meant to me. What was my role in her death? Have I participated in some masked form of euthanasia? If so, how do I feel about that? As a future healthcare professional, I wonder if I will be too eager to prescribe death, or perhaps too reluctant to accept it, continuing on with treatments to little benefit. Right now, I don’t believe either to be true. I believe death serves a purpose unique to those experiencing it. As a future physician, my goal is to assist others in discovering that purpose. And how does death influence me? I cannot say yet. Perhaps the answer lies in the pages of a blue binder waiting to be picked up.