Kristin Prentiss Ott, M.D.

The Low-down on Death (PAP series 6/6)

“People are People” Part 6 of 6

 


Deaths in the hospital usually happen one of two ways: full code intensity or comfort care attentiveness.

Codes are loud. There are shouts of, “it’s been 2 minutes since the last epi!” The room is packed with people (most of whom have never met the patient). There are chest compressions, broken ribs, shocks, and dose after dose of medications trying to stimulate the heart to beat like it has since before the patient was even born. The men and women who do chest compressions get out of breath and wipe sweat as they step away to make room for a new person with fresh energy. We press fingertips into cool necks and groins checking for any thread of a pulse.

Whether right or wrong, I can tell you that it’s harder to stop a code on a young person than an old one. The younger someone is, the more it seems like we should be able to win. Most of us code kids past the point we’ve lost hold of real hope. It’s just so hard to stop.

In any code, we exhale a little if someone exclaims, “I’ve got a pulse!” But all too often, the same patient’s heart gives out again a little while later. And the cycle is repeated.

And there are times you never get a pulse back. Eventually, you have to call it. You say, “Time of death….8:47.” Then people strip off their gloves and walk out. And suddenly, the room is quiet.

When patients survive a code, they require life support. The hope is always that this is only for a little while, but sometimes it becomes clear that the future holds only tube feeds and ventilators. Unless people have talked openly about their wishes regarding life support, family members can feel like the weight of life or death is on their shoulders. They can feel like “pulling the plug” is the same as taking a life. But that isn’t how healthcare professionals see it at all. From a medical perspective, moving to comfort care is simply allowing nature to lead.

Sometimes family members don’t agree about these decisions. It’s hard to see two siblings support the decision and one fight it. Or a long-time girlfriend clearly state that the patient wouldn’t have wanted to live like this – while the patient’s children say they’re not ready.

Christian families in particular seem to want to hold out for a miracle. The best palliative care doctor I have ever met would sometimes say, If Jesus is pulling on your loved one’s hand, how hard do you want to pull back?”

These families will sometimes talk about not wanting to put limits on God because they want to believe that their loved one can wake up and be who he/she was. But isn’t it limiting God to say a miracle can only happen if the ventilator is on? After everything medically possible has been done, big faith is believing God is big enough to intervene if we leave it entirely up to Him.

It’s hard to predict death with any amount of certainty. It can take minutes, or hours, or days. During that time we can provide comfort in the form of morphine for pain and to decrease air hunger. We can ease anxiety with Ativan and dry secretions with Robinul. Comfort care deaths are so different from codes. Instead of strangers in nitrile gloves, the patient’s hand is held by the warm hand of a loved one.

I have seen a husband sit vigil for days to be there at the very end. I have caught the scent of fried chicken and peered into a room to see an entire family assembled, sharing a meal around the hospital bed of a beloved matriarch. She was ushered out of this life by stories and tears and laughter and the heart-warming aroma of soul food. I have heard a 10-person version of Amazing Grace mixed with sobs outside the door of a dying 2-year-old. Their voices swelled and broke as they sang:

“Through many dangers, toils and snares,
I have already come;
’Tis grace hath brought me safe thus far,
And grace will lead me home.”

When death is near, breathing slows and becomes irregular. Some people exhibit “guppy breathing” – which looks like heaving gasps. And then at some point, there isn’t another breath. And finally the electrical currents – that have been coursing through that person’s heart since it was the size of the eye of a hummingbird – cease to flow. And everything is quiet.

When death comes unexpectedly, the question I hear repeated in whispers and wails is, “why?”

Why this person? Why now? Why?

Why???

No one – no one – understands why death comes when it does. There is no sense to loss. And it is heartbreaking that after more than fifty years of blessed companionship, the surviving partner has to carry on alone. It is tragic that parents die before their kids are ready to live without them. It is maddening that children get cancer.

I don’t know why people die; I only know, that regardless of the circumstances, it feels like a holy thing to be with people from the beginning of passing – to the end.

People are people – whether they have minutes or years to live – and it is a privilege to care for them.

PS – The choice to publish a piece on death on a Friday won’t mean something to everyone, but it will to some of you. It’s Friday, but Sunday’s coming. (“Though the earth cried out for blood, Satisfied her hunger was, Billows calmed on raging seas, For the souls of men she craved…On Friday a thief, On Sunday a king, Laid down in grief, But woke with the keys…”)


EPILOGUE:

This post is the last in a series about some of the parts of medicine that aren’t suitable for dinner-party chatter. Every post ends with what a privilege it is to care for people – because it is. It is a privilege to care for people with a wide range of penchants, pasts, body types, abilities, injuries, and life expectancy. Thank you for reading. 

#peoplearepeople

Cover photo credit: Flikr, “Deb,” photo cropped and turned black and white. Creative commons license.

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Kristin Prentiss Ott, M.D.

Author of the viral post: 10 Things to Know Before Your Next Visit to the Emergency Department. Board certified emergency medicine physician, wife, mother, aspiring novelist.
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2 Comments

  1. Danielle

    Thank you for writing this.

  2. Kassi

    Sermon Worthy. I remember the great preacher, Tony Compolo, doing “It’s Friday, but SUNDAY’S COMING!”
    “If Jesus is pulling on someone’s hand, how hard do you want to pull back?”
    You have given us a compelling, powerful gift to keep in our hearts, if and when we find ourselves with loved ones near the end. I also want my kids to read this, to help them know that it’s OK to let go.
    Thank you for sharing such a vital, human and humane piece of work.

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