Learning to Live with Death

By Kiersten Ball

I am a physician assistant in a hospital in Philadelphia. A little over a year ago, during my residency, I was scheduled to work in the intensive care unit on New Year's Eve and New Year's Day. I will remember the experience for a long time.  It is a story about death.
On the 31^st, the unit was full as usual and it seemed like another normal day in the ICU. We had patients on ventilators, patients doing better and getting ready to move to the floor, and a few patients on what we call CMO. It stands for comfort measures only.

It's often a relief when a patient's family makes the tough decision to put their loved one on CMO. CMO means we stop all antibiotics, drugs that maintain blood pressure, and other life sustaining treatments. We just provide pain medication, oxygen -- if family wants it, and leave the patient in peace.

One such patient was Mrs. J. She had just been admitted the night before and was placed on CMO quickly. She was an elderly woman with recurrent pneumonia who just wasn't going to recover this time. At around 1:30 p.m. one of the nurses came over and said that Mrs. J had passed and asked if one of us residents would go and pronounce her. One of the medical residents volunteered and I asked to go with as I'd never had pronounced a patient dead before.
We went into her room, pulled the curtain shut, and the medical resident began explaining the death exam. He checked her pupils, did a sternal rub to check for a response, and listened for any breath or heart sounds. Then he pronounced her death. As we walked out the nurse informed us that the family, who had been sitting by her side all day, had left to get something to eat just a few minutes before she died. So we let the unit clerk know to be on the lookout for the family when they came back in so one of us could talk to them before they found her.
I ended up being the only one around when the family came back in. I had to be the one to tell them that their wife, sister, and friend had passed while they were gone. There are short lectures in school about how to break bad news but it's nothing like the real thing.

I was at least thankful that the family knew this was coming soon because I think it made it a little easier. I comforted them the best I could and listened to some stories about Mrs. J. She was quite the lady. As sad as it was, this family did the best thing they could for their loved one by letting her go. She didn't suffer and was able to die peacefully.
On Jan 1, another patient was made CMO. This was a young guy who had been in the ICU for over a month. He had suffered a brain injury after a cardiac arrest. He had multiple medical problems for such a young a guy due to uncontrolled diabetes. For a month this man suffered being poked and prodded for labs, and having to remain on a ventilator. His family wasn't ready to let go until after the New Year. So on 1/1/11 we removed this man from the ventilator. He died within 15 minutes surrounded by his family. I was asked to go in and do the death exam. His pupils were fixed, he had no response to a sternal rub, and after listening for heart and lung sounds for a minute I pronounced him dead. After comforting the family I went to fill out the death packet. It's a long process of phone calls to admitting, the organ bank, and then filling out the working death certificate. I finished and got back to work, trying to help the rest of our patients get better or die more peacefully, whichever their choice.
These two experiences won't define my career but they were two huge steps that I will never forget. It is odd the things in medicine that make providers feel like real providers -- little things such as knowing when it is okay to let a patient eat, to the big things like saving a life or letting one end.

For me, being able to handle death, not just witness but determine it, makes me feel like a real medical provider.

Because sometimes the greatest gift you can give in life is death.