I really hoped she was dead.
It wasn’t personal. It was as far from personal as possible. I had never met the patient while she was alive.
Every four days, my team and I are on call at the hospital. For about 16 hours, we must make decisions about people we have never met. The people range from sick and stable (patients from other medical teams and new admissions), sick and unstable (rapid responses for acute changes in mental status or vital signs), dying (cardiopulmonary resuscitation and/or emergency intubation), and dead (pronouncements).
My last name and pager number were plastered on the oncology floor, which increased the odds that pages I received would be about the dying or dead. The first one was.
“I need you to pronounce,” said the nurse when I called her back.
As a two-week-old intern with a largely theoretical knowledge base and minimal understanding of a new hospital’s electronic and interpersonal quirks, I appreciate algorithms. “If x, then y” gives me relatively secure footing to rest decision-making upon, mainly because the decisions are pre-determined.
There’s not much that’s more algorithmic than a pronouncement. If called for one, go into the patient’s room. If the family is there, say that you’re sorry for their loss. Then verify that the patient is dead. Shine a penlight into the eyes and note that the pupils are fixed and dilated. Place a stethoscope on the chest and note the lack of breathing and heart sounds. Place a finger on the carotid artery and note the lack of pulse. Look at the clock. Pronounce the patient dead at the given time. Repeat again to the family that you are sorry for their loss. Ask them (and remind them that you must do this for everyone) if they want to do an autopsy. Leave the room, document the encounter.
My co-intern and I had debated if we preferred the family present or absent during the process.
Absent, I said. I had no desire to walk into a stranger’s funeral as a stethoscope-wielding technician who offered stock condolences.
But my colleague had done several without the family present and described it as something I didn’t expect.
“It’s creepy,” he said. “It’s just you and… you know.” That stranger on the other end of a one-sided interaction. He had almost had to bring the nurse in the room with him for company.
I had laughed then.
“The family was here last night, but they’re not here right now,” the nurse told me as I approached.
After getting a brief history of the patient’s medical course from the nurse and the chart, I opened the door to her room.
The efforts of the palliative care team were obvious. The shades were drawn, and the room was quiet except for the sounds of a waterfall playing in the background. I closed the door behind me to keep out the florescent lighting and beeping monitors and chatting of the nurses.
But with the closing of the door, I also kept out the sounds of the living. The intern had been right.
I inwardly cursed him and every horror movie I had seen to date. I cursed my reptilian brain for its very strong impulse to back away from the bed. I cursed my irrational thoughts that maybe she wasn’t dead after all, and wouldn’t it be terrifying if she sat up while I was trying to find her pulseless carotid.
I really hoped she was dead.
I watched 120 seconds tick by on the clock. This woman’s time of death was being delayed because I was too stupidly scared to confirm it.
I was not going to call the nurse for company.
Finally, a combination of embarrassment and obligation kicked in. I was called for x, so I did y.
Then I left the room and did z. I wrote a note, making sure I used the word “dead” (required). I called the primary provider. I filled out the death certificate.
I called the patient’s family, and they sobbed into the phone. Physical presence or absence was irrelevant, I realized. I felt like a stethoscope-wielding technician who offered stock condolences.
I’m thankful for the algorithms so carefully outlined in my resident handbook. Their explicitness is exactly what a new intern needs. But pre-determination does not preclude meaning. Unwritten between steps are a grieving family’s pain, a messenger’s fear, and a stranger who I will never meet.
If x, then y. But damn if x isn’t really, really hard.
To my first pronounced patient: your time of death was five minutes earlier. I’m so sorry for the delay. It wasn’t in the algorithm.