Being a part time hospitalist, I am frequently on overnight call in the hospital, spending the night admitting sick patients from the emergency room, or dealing with any calamities that happen on the medical floors. I would have to say the that the most dreaded events are: “Code blue” (this means a hospitalized patient in cardiac or respiratory arrest waiting to be resuscitated), followed closely by a nurse calling with: “Doc, you need to come look at my patient, he looks like she’s about to code,” and lastly, while not as dramatic, but equally dreaded, having just put your tired head on the pillow for some rest and dozing off, only to be jolted awake with the harsh beeping of your pager for something else that needs to get done.
But there is another kind of event that I personally dread, even though it is less dramatic, and that is being called to “pronounce” a patient. The term comes from the old days, when there were no monitors and machines that can measure every bit of heart and lung activity, but when the determination of alive or dead was made based on your physical examination, leading you to pronounce the patient as dead after you convinced yourself that their heart had indeed stopped beating, their pupils were properly and permanently fixed and their chest had stopped rising for breaths every so often.
Today, the nurse can see a flat line on the monitor from the outside of the room, but we still need someone with an MD degree to perform this duty and to proclaim a time of death, at least in our hospital. Many sick patients today have a DNR order, letting them pass in peace when disease has taken it’s irreversible toll, and saving us from having to undertake fruitless and invasive resuscitation efforts that usually don’t amount to any meaningful recovery.
The funny thing is that the time of death is the time that I make the pronouncement, not the actual time that the patient has taken his last breath. So I could be stuck in some other emergency, and not get up there for 30 minutes, and on paper the patients life would be a half hour longer than it actually was. That has always struck me as odd, and if there is a record or rhythm strip I now use this as the mark of time even if I am not there, it just feels like the right thing to do.
The reason I dread these calls, is because it is never easy to make a call to a family member whom I have never met (as the on-call doctor only rarely have I actually had any interaction with the patient or their family), telling essentially a stranger that their mother/father/wife/husband/child has just passed away. No one really trains you to do this, and even though the words roll off my tongue easier now, the emotional weight of the moment remains.
So a few weeks ago, the call came at about 6:30 in the morning. “Doc, Mrs. X in Room Y looks like she’s passed.”
I was already up, and walked over to the ward and into the patient’s room. She was in her early 80s, with a head of unruly black hair, the ample grey roots attesting to the fact that she had been sick for too long to touch up her hair color. Her eyes closed, she looked as if she was sleeping, except for the waxy ashen tone that sets in almost immediately upon death. As I walked into the room and looked at her, a thought came to me.
Did anyone know that she had died just now? I suddenly had the strong feeling that someone was already aware of her passing, but it came and went and I gave it no further thought. I did my perfunctory assessment of death, placing my stethoscope on the still chest. As I always do, I rested my hand on the patient’s arm, and paused to let the moment sink in and respect the life just passed.
I left the room and sat down to write the “death note.” Since no one was in the room, I checked the chart for next of kin. Husband’s number. My heart sank. Somehow it is easier calling grown children about their parents passing than the aging spouse. I spoke to the nurse who had taken care of the patient for the last couple of days. The husband was non-English speaking, and the nurse happened to speak their native language and offered to make the call, bless her heart, especially since she already had a relationship with the family. I dialed the number, handed her the phone and watched her speak. As she talked and listened, her face changed to a more sorrowful expression. After she hung up, she told me that the husband had awoken a short time earlier with the strong feeling that something had changed and something was terribly wrong, and he was getting dressed to come to the hospital even before the phone rang.
I had to wonder why I knew that he knew the moment I entered the patient’s room. This is not something I usually think about when I am going to pronounce a patient. I like to think that I was in the line of communication between these two souls, kind of like being in the line of fire. Couples that have been married for a long time are bonded in many ways, physically and spiritually, and may be able to communicate on levels beyond our tangible world. Our world is limited by what our senses are able to perceive, but there are undoubtedly other ways in which we interact that reach beyond our ears and eyes, and connect via the soul or the heart.
If we open ourselves and follow our intuitions, we may be surprised at some of the experiences we have and the depth that’s added to our lives and relationships. I feel blessed and fortunate to occasionally get a glimpse beyond the ordinary in my work.
Eva S. Vertelney is an internal medicine physician who blogs at The Doctor Will Feed You Now.