The Resurrection

The nurse, the wife, the niece, and I sat together in the small family room, quietly thinking. I felt insulated from the sounds of the busy hospital even as my pager chirped a warning that our ICU was about to get even busier. I resisted the temptation to sit on the edge of the seat and betray the anxiety I felt and the urgency of the conversation. We were gathered to discuss the critical decision to intubate a patient, a man who lay struggling to breathe in a bed just down the hall. We had been trying for days to stave this moment off with a tight facemask that forced pure oxygen into his lungs, but he had been ripping it off in his confused and deteriorating state. He was tiring out rapidly and an internal clock in the back of my mind was counting down towards that tipping point when even intubation might cause his heart to stop and actually hasten his death.

I looked at the wife and remembered our first meeting a few days earlier, when the patient first crashed into the ICU. At that time, she told me how she had been living in the hospital for two weeks, watching helplessly as his first round of chemotherapy set off a series of nasty complications. She told me that the one day she went home to get some rest was the day she got a frantic phone call telling her to come back in and this time to the ICU. I told her she had permission to not feel guilty about going home and she burst into tears of relief, sorrow, and exhaustion. We talked then about his tenuous condition and how sufficient recovery to tolerate the next round of chemotherapy was difficult but not impossible.

But in the days since he only did worse. In the disorientation brought about by his decline, he was in a constant state of fear, agitation, and anxiety. And now, at the edge of his viability, it became my job as the supervising resident to tell her that we were reaching the point of extremis: that his survival depended on breathing through a tube which we might never be able to remove, that his respiratory failure came at the end of a chain of other failing organs, and that even if he survived the ICU stay it was unlikely at his age and in his condition that he would ever recover enough to tolerate the next round of chemotherapy. So I told her what she already knew and we sat still for a moment in that waiting room, listening to my pager and the muted sounds of hospital chaos outside.

Then she cried. She cried as she told us how just a month ago he had been fishing with his grandson without any cares or illness. She cried as she told us how he had just asked his son to fetch his gun from home so he could shoot himself. She cried as she told us that she didn’t want to see him suffer, that she knew it was time to let him go, but that she still didn’t want to lose him either. I watched the niece cry and even the nurse cry as we felt the force of all her helplessness and fatigue and grief.

I have rarely felt the gravity of a moment as I did then, weighing the value of every word and pause against the ticking of that clock. We decided to let him pass, to stop our modern medical torture and transition him to hospice. And even though I and every other specialist had known from the beginning that this would be the best outcome for the worst and final situation of his life, it still felt like utter and hopeless defeat.

In that moment, I asked if he was a man of faith. His niece offered that he was, and remembered that he always insisted on holding hands and praying together before meals every Thanksgiving and Christmas and Easter. So I offered to pray for them and we did. We gave thanks for the life of love that he lived and the deep affection of family that was the reason why these moments and decisions were so hard. We prayed for the release of his suffering, that in Christ our death is not final but will be overcome. And, in an unusual moment, we even had the audacity to pray for joy.

We left the room and I rushed off to set up the incoming arrival of three sick patients to the ICU. It was so busy that I could not return to the patient’s room for several hours. When I finally sat down at a computer to plug in some orders and take care of paperwork, the nurse came up to me and asked, “Have you been back in the room yet?” I sheepishly said I hadn’t, it had been so busy…

“It’s a completely different room,” she said excitedly. “Before that conversation, it was like a funeral; now they’re talking and laughing and joking and sharing stories about their memories together. I have never seen a doctor pray like that before.” I was stunned; I hadn’t expected such a change either. I stopped by the room and drew back the curtain to see it exactly as she said. I saw the wife’s face transformed, smiling even through her puffy red eyes, the great weight having visibly been lifted from her.

I didn’t cry once throughout the entire encounter but for some reason can feel the tears brim in my own eyes now as I write about it. It has been years but the memory is still clear and bright because, to me, it is the closest thing I have ever seen to a resurrection.

He is risen!

The Resurrection

Death and Resurrection

He was a young man, and I could see fear in his eyes as he gripped the railings of the bed and struggled to breathe, sucking in heavily through the plastic mask feeding him oxygen. His body was wasting away from cancer, and the infections that had crept into his lungs were now forcing every compensatory mechanism into extremis. He wanted to fight and live, but there was little left for the ICU to offer. I had been pleading with him for days to consider hospice and a more peaceable passing at home where he could be surrounded by family and friends, but to him that meant giving up.

He was a young man …

So we had continued to do everything, and as predicted we eventually came to that point where every biomarker and technological parameter heralded physiologic disaster. “Your breathing cannot hold on its own. We will need to intubate you soon, but your body is so sick that we will probably never be able to take the breathing tube out.” I paused. We had had this conversation before. “Do you still want us to do it? I need to tell you the truth; you will almost certainly die either way. If we transition you to hospice, you can go home and pass away with your family and friends, and we will make sure that you are comfortable. But if you still want us to do everything — intubation, CPR, shocks — you will still die, but it will be here in this hospital, and it will be brutal. Do you want us to intubate you? Do you want CPR?” He nodded vigorously, still afraid, still adamant.

He was intubated. Continue reading “Death and Resurrection”

Death and Resurrection

Rituals of Annotation

I am not exactly sure of what prompted me to do it, but I began keeping a tally of all the pronouncements I have done. I never really knew this before, but pronouncements are done in a remarkably simple and impersonal way. Most patients who die in the hospital do not go with a bang but with a whimper. While some situations involve spectacular theatrics involving beeping monitors, charged paddles, and the cracking of cartilage from chest compressions, most patients die with a quiet, gasping sigh. I am still not sure which is more unnerving, but the former is what we typically imagine or see on TV during a pronouncement: a sweaty and distraught doctor ripping off latex gloves in frustration and listlessly intoning, “Time of death…”

What usually happens, however, is that the person will expectedly but spontaneously expire. Death is typically spotted from a fair distance and in most cases the family is cognizant of this. Sometimes hospice arrangements are made and the patient goes home to die surrounded by family and friends. Sometimes a volunteer in the hospital will keep a death vigil of sorts, sitting in a chair while reading a book or watching TV to pass the time as they wait to fulfill a promise “not to let anyone die alone.” Sometimes a nurse will make the rounds and discover that the patient is simply dead. It happens at all hours and in most floors of the hospital. Regardless, whenever the death is discovered a page is put out to whichever resident is on call to come by and make the official pronouncement, even though everyone already knows the truth.

This means that I usually know nothing about the patient or the family. I have to make an effort to commit the name and overall disposition of the patient to heart long enough to speak with the family and request their permission to grant or deny an autopsy. It typically takes thirty seconds to do the examination and less than thirty minutes to speak to everyone and document everything I need to before moving on to other things.

My little tally is nothing fancy, nothing more than a series of hatch marks in a small booklet of mundane medical information tucked into my white coat. So far, there have been five marks in two weeks. I can hardly remember the patients at all, much less their names or even what they died from.

But I remember the families. I remember the different reactions of different people, some joking and laughing about the whole affair, some quietly sniffling in a brother or a sister’s shoulder. I remember their words, which are often filled with appreciation and deep respect for everything that has been done for this house of memories. And I feel unworthy and deeply unsettled because I had no part in it… in fact, I never knew the patient, because the only reason I came into contact with him or her at all was because there was only an it left.

If the family was particularly effusive, I will write a little note of it in the chart: “No pulse, no audible heart beat; no corneal, pupillary, or gag reflexes. Family expresses deep appreciation for all staff.” And every single time, I am tempted to then write, “Kyrie eleison,” as has become my habit to say whenever I am otherwise speechless with sorrow. But not all the patient’s family members might appreciate that sort of addendum, so I say it to myself, place a little tick in my booklet, and move on.

To “pronounce” means to state, often with a degree of finality and certainty. But to me, it has also meant to describe and therein impart an element of meaning. Pronouncements have become a ritual of annotation, one that is suffused with meaning precisely because it is routine without being mundane. Small wonder that the closest I have come to intimacy with God in this heavily secularized profession have been in moments like these, where that which is ephemeral proceeds into the eternal.

Making a note of it is the least that I can do.

But someone may ask, “How are the dead raised? With what kind of body will they come?” How foolish! What you sow does not come to life unless it dies. When you sow, you do not plant the body that will be, but just a seed, perhaps of wheat or of something else. But God gives it a body as he has determined, and to each kind of seed he gives its own body…

So will it be with the resurrection of the dead. The body that is sown is perishable, it is raised imperishable; it is sown in dishonor, it is raised in glory; it is sown in weakness, it is raised in power; it is sown a natural body, it is raised a spiritual body.

I declare to you, brothers, that flesh and blood cannot inherit the kingdom of God, nor does the perishable inherit the imperishable. Listen, I tell you a mystery: We will not all sleep, but we will all be changed— in a flash, in the twinkling of an eye, at the last trumpet. For the trumpet will sound, the dead will be raised imperishable, and we will be changed. For the perishable must clothe itself with the imperishable, and the mortal with immortality.

- 1 Corinthians 15 

Rituals of Annotation