Mrs Jones' final lesson

2014
Martyniak, Karolina

Some of life’s experiences can be explained with words to such precision, that a listener can internalize the true essence of the moment without ever having lived it. When I was learning how to throw on the potter’s wheel, my instructor told me that when the clay was centered, I would know because of the calmness that would come over the mass of clay. When I centered my first cone of clay, I instantly recognized the feeling because I had already lived it in my imagination. For other experiences, no amount of words would ever suffice to capture the true essence of the moment. For example, the overwhelming adrenaline, hormonal fluctuations, emotions, and physical relief of the very second a mother holds her baby for the first time. What more, labour and delivery is naturally made unique to each individual based on their past and current life situation, the course of the labour, the people in the room, etc. As such, the feeling of delivering a baby is not readily described by words, but rather only understood when one has had the honour of living this experience. 

Likewise, in the medical profession we are privy to the unique opportunity of experiencing the unexplainable. How could one possibly imagine what it feels like to make a clinical error that leads to the demise of a patient whose trust we have gained, and whose relationship we have fostered for the duration of our medical career? Are there words to describe the incredible feeling of hearing from your patient, “you know doc, I quit smoking thanks to you!” In this same way, my first experience of pronouncing a patient deceased may differ substantially from someone else’s. But at the heart of that moment, I understood the true meaning of being privileged to care for persons throughout their various stages of life.

I was in my final year of medical school, on a rural elective. I had been around death and dying, read about it, and been mentored around it. Yet all of that was different from truly experiencing the death of a patient with whom a relationship was formed. Midway through my morning inpatient rounds, my preceptor called me and said, “Mrs. Jones has passed away. Would you mind pronouncing her dead? You’ve done that before, haven’t you?” I was surprised with his ease of conveying this sad news, as if he’d done this before. But I hadn’t.  I quickly admitted my naivety in this clinical task, with hopes that he would do the pronouncing. But instead, “Well here’s your chance. You can’t really make a mistake, she’s dead after all”. Dead. The word hung in the air heavily. Lifelessly. Mrs. Jones. The same one who was in clinic last week talking about her two-month-old great granddaughter who she got to hold – one last time. Dead. What is the protocol for pronouncing a death? What do I tell the family if I see them? My anxiety made me realize I wouldn’t be able to focus on my morning rounds without seeing Mrs. Jones’ (body) first.

I made sure no one was in her room. I didn’t want my inexperience with this kind of situation to be evident to anyone.  I walked into the room, and there she was. Beautifully 93, body covered, eyes closed. She could have been alive and sleeping. Yet, walking into the room I had never felt so alone. Here, was another person, but the person was also gone, and in her place, was the clear absence of a person, that punctuated how very alone I was in this room. She looked peaceful. Serene. At first, I just looked. The more I looked, the more I convinced myself that she was simply sleeping. She hadn’t lost all of her colour. In the dim lighting she was simply missing the usual pink on her cheeks.  The linen above her chest wasn’t rising and falling rhythmically, but that could just be the dampening effect of her heavy blanket. Below all those sheets, I envisioned her lungs drawing in air, the alveoli expanding, collapsing, as they had done for the last 93 years with great practice. I touched her hand. That was okay to do, even if she was just sleeping, wasn’t it? It was warm. I felt confused – didn’t bodies turn cold after death? Perhaps it was just natural physics, as my hands were always cool and hers had taken on the ambient temperature of the room. My cold hands suddenly bothered me. “Cold hands, warm heart” a patient had once reassured me. Patients often reassure us. Mrs. Jones seemed to reassure me even now, with her peaceful gaze and soft skin.

I felt for her pulse. In fact, I felt a pulse. This time it was my mind playing tricks. My fingers were not trained to be placed over the radial artery without sending tactile feedback to the brain – “rate, rhythm, and amplitude” – the mantra that picks up diseases, but also ascertains life. These were absent. It took a while for my fingers to learn that the absence was actually a finding. I listened over Mrs. Jones’ sternum, then over each of the markings used to auscultate the heart. All I heard was my own blood pulsating in my ears, and the distant chattering of nurses in the hallway. What else was required to pronounce a death? I remembered the pupillary reflex. Suddenly, the idea of lifting her eyelid felt very invasive. We often palpate pulses and auscultate the heart without directly asking for permission, but to touch someone’s eyelid often requires verbal communication to avoid inadvertently palpating the eyeball. I swallowed my hesitation and lifted the lid. There it was, the evidence of Mrs. Jones’ passing. Her glare was void, her pupils non-reactive, her life gone.

My eyes welled with tears that I quickly had to stifle. I was a professional after all. At least trying to be one. I would save the tears for later, safely over a cup of a tea in the privacy of my apartment. Here, I grabbed my bearings and allowed only the permissible thoughts and emotions to run in my mind. I hadn’t known Mrs. Jones very well; I was, after all, an elective student. But I had met her once, and read her chart extensively. I knew parts of her story. The other parts I filled in with an active imagination, because after all, Mrs. Jones could have been my great-grandmother, my neighbor, or my grade school teacher. Most importantly, she was my patient. Someone I took care of and with whom I had a trusting professional relationship. Someone who, by her fate, helped me appreciate one of the most important lessons in my career. We as family physicians have an incredible privilege: a privilege to care for the young, old, healthy, sick, and dying. We have a privilege to learn from so many different people who come from so many different walks of life. We experiences things that even the most elaborate of words cannot properly communicate. May we never lose our wonder at the great honour we behold.

Theme: Death and Dying | Décès et le mourir
Theme: Patients | Patients
Theme: Relationships | Relations
Theme: Teaching and Learning | Enseignement et apprentissage

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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