Those were the words I heard exclaimed behind me as I sat at the nurse station, working on admit orders for a patient we were admitting today. Since all the floors look pretty similar, I was a little disoriented and didn't immediately realize that I was on the same floor as my patient on comfort care. Turning around, however, and seeing the room, I knew immediately what had happened. Before any nurse responded, I was walking into room 811, which was filled with tearful family members standing watch over their beloved mother and grandmother.
The patient's daughter looked at me with blood-shot eyes and explained, "We saw her gasp, and then she stopped breathing, and her color just now changed." Earlier in the day, I had tried to support the daughter, encouraging her in this hard time as her mother slipped from life into death. As I left the room that morning, she had said to me, "Have a nice day," and I reflexively said, "You too." And I kicked myself, wishing I could say the right thing at all the right times.
What was facing me at this moment, however, was bigger than an ill-timed nicety. I was playing the role of Doctor and was responding to the scene of a death. I had never done this before, and really had never even had a briefing on what to do in this sort of situation. I listened carefully as the family talked, realizing that I would need to examine the patient--for their sake and mine.
In times like this, I can appreciate the symbolism of medicine. Despite my youth--this patient could easily be my great grandmother--the family was looking to me for support and direction. At least that was my sense. And I was dressed in a white coat and was carrying my trusty stethescope. Four years of medical training were not as important in this small room as these two pieces of my "costume."
Leaning over, I listened to her chest for heart sounds. There were none. Wait--was that one? No, I'd just moved my stethescope. Wait, was I sure? I took the patient's wrist and palpated where the radial artery should be. To my surprise I felt rhythmic pulsations, but on a moment's reflection I realized they were too faint to be hers. In my hyper-vigilent state, I was feeling the blood coursing through my own fingertips. She had no pulse.
After a minute, I stood back, and told the family, "Her heart has stopped." Strange as it may be, I still wasn't sure enough of myself to say, "She's dead." I excused myself and explained I would notify the attending, who in turn instructed me to write a "death note" in the chart. She also mentioned various tests I could do to confirm death.
Returning to the room, I asked the family to step out so that I could do a fuller exam "for documentation purposes." Carotid pulse--negative. Apical impulse--negative. Pupillary response to light--negative. Heart sounds--negative. Respirations--none. Still not completely convinced, I decided to test the patient's response to pain. I braced myself as I did a hard sternal rub and then forcibly squeezed my pen into her nail-beds. Cruel as it may sound (which is why I asked the family to step out), these are extremely painful stimuli which will arouse a patient who will be aroused. My heart pounded as I half expected her to cry out in pain. Nothing.
I spent a few more minutes with the family. They laughed in relief, and cried. They thanked me and hugged me. Sitting down back at the nurse station, I began writing. "Time of death: 1430..."
4 comments:
I, too, have had to do a death exam, only I did one in front of a family in India, to show them without a doubt that their relative had passed away. It was one of the harder things I've had to do. It's one thing to do it on a patient with your resident in the middle of the call night. It's another to be doing it in front of the family to "prove" it to them.
What a story to tell...I can't imagine being in a scene such as this. I've never thought that physicians could have a difficult time determining death. I think you handled the situation beautifully. I'm glad the family was relieved. The Lord put you in the right place at the right time...
Well, I think it's really not that difficult to determine death--anyone walking in the room would probably think that she looked dead. The difficult part was going through the motions for the first time when it counted...of being there with all eyes on me, and being afraid of missing the faintest of heart sounds or the slightest of breaths.
Thanks for your comments.
Oh Johnny. Your stories make me cry -- almost every time. I am thankful that God gave you such a tender heart towards patients and families. And of course I can't help but think of the death of our Joy. I think you do beautifully in dealing with the families. God has given you a gift, I believe.
Thank you for your role as physician and healer. Thank you for you love.
Much love to you,
Charity
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