It has been about six months since the last time I had to give The Talk™. It’s not something I’m particularly good at, although I’m better than I used to be. In the end, it’s about getting to the point: your loved one is dying, and everything we’re doing to her/him is only prolonging suffering. Will you give us permission to stop these things, and focus on making her/him comfortable?

S. describes the situation eloquently, hauntingly, in words that I wish I were capable of. I’ve forgotten the names of some of the patients I’ve led to that Final Darkness, and I regret that. But I remember their faces. Their families. Their tears.

I can’t even get death right

Despite what the reassurance of ICU docs and the oncologists (the specialties which seem to live and breathe death), I’ve never felt at ease with letting someone slip off into the next world. Even when I knew that nothing I could do would change anything. Even when I knew that, for all intents and purposes, they were already dead.

Sometimes I like to think that I was able to give their family members a chance to come to terms with things, and time to have some sort of closure. Most of the time I’m doubtful, and it distresses me that I can manage to screw-up even the process of dying.

Like that time they started chest compressions on a septic lady who had been on five pressors for nearly 24 hours, struggling futilely against the bacteria floating around her bloodstream. The grotesqueness of it all made me nauseated, and I called it as soon as I got there. Asystole never calls for electricity, and with the epinephrine running full blast since 4 a.m. the last morning, we had already been effectively coding her. I had to make The Call™, and they came in at the middle of the night. It’s terrible when the first time you meet them is when their loved one dies, and I don’t blame them one bit for not trusting me.

And then there was that time when I ended up intubating a poor woman who had metastases filling both of her lungs. There was something awful about knowing that I would never be able to get the tube out without killing her, and I still wonder if it was really the right thing to do. Maybe I should’ve just gone into the The Talk™. But I’m not sure her family was ready to let go.

The bloodiest disaster yet, though, was this poor guy who had cancer invading his larynx. It was starting to erode into a major artery, and soon, the guy was bleeding profusely out of his mouth. The surgeons threw up their hands, knowing that there was no way to repair a ruptured vessel that was eaten through by cancer, and we were left to comfort his family as he literally bled to death in front of us.

Somehow, that last one was the death that turned out best.

Rituals

I liked S.’s description of that final, futile ritual we doctors have in the face of the ineffable. We take out our stethoscopes and listen for sounds we don’t expect to hear. The time of birth actually has a lot of clinical ramifications (Do we need to start antibiotics on the baby? Is her/his bilirubin level too high? Can we call the blood cultures negative? Is it too soon to discharge?) But the time of death seems to be a medico-legal nicety, something with which to trap malpractice witnesses with on the witness stand. The words “I’m sorry” seem so woefully inadequate, and I worry that it sounds too insincere, but I end up saying it anyway.

My Fate Was Fixed

I envy S.’s ambivalence about her job, despite the fact that she does it well. The longer I stay in this game, the more and more I take it as a given that there was no way to avoid it. I have so many family members in health care, I didn’t even know there were any other possible career choices for me until I was 17, by which time it was too late.

One of my preceptors on a 4th year medical school rotation teased me in a sing-song fashion, “You’re doomed, you’re doomed!” And then he went into a Darth Vader impersonation. “It is your destiny!”

I worry that I’m not as good of a physician. I’m doing this because, ultimately, I can’t imagine doing anything else. Certainly there isn’t anything I’m particular better at. If the choice is this versus working in some godforsaken cubicle, the choice is easy, but even this late in the game, I have doubts about my own abilities.

But I have this One Thing™. Do I really have any right to ask for more? (And yet I do want more.)

Now I realize there is no way to avoid The Talk™ no matter what I do, even if I never set foot inside an ICU ever again. Sometimes death comes lightning quick. One day you’re walking, talking, laughing, having a good time, the next you’re gorked in the ICU with some fumbling intern jamming a catheter accidentally into your femoral artery. But the worst cases are when death comes slow and lingering, so slow that no one believes its coming, so slow that they’re angry at you for even bringing it up.

But I can smell death from the next room. I can see death a mile away. Just from the story you tell me, I can hear death at the end of the tale.

There’s no other way out of this universe. Sometimes all that is left to us, the healers, is to make sure you get to the exit without suffering too badly.