Breathe Out

My phone rang at one a.m. this morning, the hospital nurse informing me that one of my favorite and most challenging patients had peacefully passed away.

This pleasant woman had been terribly ill and suffered greatly over the past nine months, and her death came as a relief and a blessing. Her devoted husband, who lovingly cared for at home right up until the end, called me yesterday, concerned that as she approached death her suffering had become unbearable. We arranged transport to the hospital so that we could administer comfort care and pain medications in this final paragraph of the final chapter of her life.

She was a medical disaster, with severe disease infiltrating nearly all of her organ systems. I began caring for her in the hospital early last fall, with one complication rolling into the next, her body succumbing to the full brunt of years of accumulated damage. Her legs were useless, painfully swollen appendages filled with blood clots; she had festering sores all over her body; she had relentless nausea; she had horrific back and neck pain. Yet through her trials, she somehow attempted to remain pleasant and cheerful, endearing her to myself and the hospital staff, though we all knew she produced her cheerful greetings by stifling her painful grimaces.

Sometime before Christmas, we had a conference with her and her family and decided to change course in her care: rather than try to "cure" her, we would shift our focus towards allowing her to go home and enjoy some form of quality of life. This meant changing her therapy goals from re-learning how to walk to accepting a wheelchair and a home hospital bed, and even more it meant conceding her fate to the ever-encroaching diseases that would eventually consume her strength and then her life. But she had fought long enough, and now she just wanted to go home. In early January, I released her from the hospital, and while she continued to suffer, we all took comfort in knowing she was where she wanted to be. I saw her regularly in clinic through the winter and spring, and we both waited patiently for the end.

When she came into the hospital yesterday morning, she was still coherent enough to hold a conversation with me. She asked me in short gasps if she was going to die. I told her yes, but that I would make sure she was comfortable. She tried to smile, grasped my hand and whispered, "Thank you." I stroked her forehead and told her what a privilege it had been to know her and care for her. As she closed her eyes to rest, I felt my missionary compulsion to wish her peace, to comfort her my with belief that soon she would open her eyes and be embraced by the light of a new life, where she would be free from these awful mortal shackles. But she was already asleep, and I fought back the words and a few tears and said nothing more, just squeezing her hand, answering a few questions from her tearful husband and daughter, and returning to my afternoon clinic.

By early evening she was slipping from consciousness. I spoke again with the family, guessing with them that she probably would pass away later that night, and consulted with the nurse about giving as much pain medicine as necessary to keep her comfortable. I then went home and enjoyed the evening with my family, though her impending death hovered in an easily accessible recess of my brain. Her husband, who had not slept for the previous two nights, left her hospital room around ten p.m. to nap in his car. He awoke at one a.m. with a feeling he needed to hurry back to her room. As he crossed through the doorway, his daughter and the nurse stood watch at the bedside, and when he approached her she took her final breath. The nurse called me at home a few minutes later to report her death.

When I talked to her husband this morning, he expressed relief and even joy at her passing, knowing that she was no longer suffering, and concurrently feeling the emotional and physical burden of providing her care lifted from his strong but aged shoulders.

I believe that doctors are conflicted about death. We are inevitably, unceasingly exposed to it and the threat of it, and thus we treat it as the enemy and wage mortal combat against it. Yet this is asymetric warfare, as death always--eventually--wins.

But death was no enemy last night, rather a rescue vessel that pulled my drowning patient from an ocean of turmoil to carry her home. Having never died myself, I have no personal experience with what happens after we take our last breath, only a strong, nearly tangible faith that something perfect and wonderful awaits us.

I have cradled hundreds of newborns as they take their first breath, and cared for hundreds of the elderly as they take their last. These first breaths mingle with the blood and sweat of birth and are met with tears of joy by parents and doctors. These final breaths too often are taken amidst furious chaos as doctors and nurses scramble to administer oxygen, CPR and medications, and as sobs of fear and sorrow grip the throats of the surviving family.

But sometimes the howling storm briefly subsides, and the final breath is taken in a moment of tranquility, like a sigh of relief or the soft swish of a boat slipping from dock and drifting into the ocean, and the spirit journeys on and on.