My patient’s life has come to an end, and she lies on the stretcher with a permanently relaxed expression. Her short, silver hair rests on the pillow she brought from home. She died not long after her arrival in our emergency department, and her wishes were made clear long before this point. She did not want to have any chest compressions or a breathing tube, preferences outlined in what is typically called a “Do Not Resuscitate” order. As hospice care continues to evolve, some prefer to designate this as “Allow Natural Death.” I prefer this terminology because it sensitively conveys a clear plan.
Allowing natural death gives the elderly and terminally ill the opportunity to control the end of their life, providing empowerment and a sense of peace during their time of uncertainty. This patient and her family’s forethought allowed us to provide medications to ease her pain and discomfort. When she closed her eyes for the last time, her body relaxed into the sheets, and I pulled the blanket up to her shoulders. Her family said goodbye, and then I began to perform post-mortem care.
The technician and I washed her body with warm water — although it’s easy to forget that the patient no longer cares about the temperature. I removed her IV and any leftover stickers from the EKG performed earlier. We gingerly rolled her onto a fresh set of sheets and then again onto a white body bag. I tucked the ends of her covers into the bag and guided the zipper up her body until she was no longer visible.
About two years later, in my return to medical school, I found myself doing exactly the opposite: unzipping an ominous black body bag for the first time in the cadaver lab. Behind the shadow of the bag, I could see my newest patient — an older man with a salt and pepper five o’clock shadow. I wondered if his death was a peaceful one too.
There is a danger of becoming angry at death as though it were less a friend than an adversary when, in truth, it is neither one more than the other. Say that a man of ninety is brought into the emergency room. As he is lifted to a stretcher he makes what is apparently the last of a series of peaceful, slow exhalations. At least there are none to follow it. So long and delicate this final sigh that it is not difficult to imagine the soul being carried out of the man’s mouth on the current of it. But we do not permit such a serene exitus. Like guards from whom a prisoner is escaping, we fall upon the miscreant, flailing at his chest, punching, stinging, prodding, electrocuting, demanding that he be recaptured. We forbid him to remain dead. Nor do we have the least inkling of our absurdity, but we are caught up in the game of it all. It is a fury to which my heart is no longer equal. I should as soon, I confess it, close the man’s eyelids with my thumbs and tiptoe away. (Richard Selzer, Letters to a Young Doctor)
This is the vivid reality we witness regularly, and an end we will all face one day. The worst time for a patient to make their wishes known is at the last minute when there is a flurry of doctors, nurses and technicians descending upon them. In the blur and chaos of the moment, it can be overwhelming to make and convey difficult decisions. As a physician, I will assist my patients to a peaceful death by planning for the end of life early. Utilizing the interpersonal communication skills that I developed as a nurse to guide me throughout these difficult conversations, I will advocate for my patients, for autonomy in death.
In medical school, we learn how to be the leader of our health care team. But sometimes, being a leader requires taking a step back and giving others the tools to succeed. By allowing patients to direct their own care, I will ensure their wishes are understood and executed by the healthcare team. If I am struggling with what to say, I will lean on my empathy, compassion and active listening skills. Finally, I plan to focus on my patients’ goals by inquiring about what is most important to them. This will help us come up with a plan for death that is thorough, direct and clear.
There are many ways health care professionals can ease a patient’s transition into death, but often we find it difficult to even raise the subject. As I transition from nurse to physician, I hope to provide peace to my patients and their families during the most difficult times in their life. When it comes to end-of-life conversations, I hope to set a positive example and encourage others to share a similar passion.
Image credit: Custom drawing by Megan Pattoli for this column.
After working in the emergency room as a registered nurse for three years, Coco made the transition into medical school at Philadelphia College of Osteopathic Medicine. The column Switching Stethoscopes describes a medical student’s journey from nurse to doctor, while reflecting on the “non-traditional” path some students take to become a physician.