May You Dance Freely: A medical student's reflection on death and dying

One of the greatest lessons to learn in the 3rd year of medical school, is how to process death. Walking patients through the process of dying is both an extraordinary burden, and an extraordinary gift. This blog post is longer than my typical, and is a reflection on my first experience with death in medical school, as experienced last fall.  Permission was obtained from the patient's family to share their story, and names and other identifiers of the patient, family, and physicians involved have all been changed.  If you have any concerns, thoughts, or questions about the contents of this reflection, as always, please be in touch!

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It was a cool fall evening in Wyoming. An early blizzard had blown in a couple nights before, and the snow was melting away from branches to reveal newly uncovered fall leaves gently blowing in the breeze.  Having just finished a workout at the local YMCA, I retrieved my phone from my locker and saw a missed call from the local area code.  I quickly dialed up my voicemail, fearful of what I had missed, and sat listening.

“Hi Analiesse, this is Dr. Koreis. There is a patient in the ICU I would like you to see.  Her name is Miriam Shank.  We were called as a surgical consult.  I don’t believe that surgery is appropriate for her at this time, but I would like you to see her, and give me your thoughts.  But, Analiesse, just as a fore warning, I don’t believe she is going to make it through the night.  So, go when you have time, but guard your heart, and probably head over before the evening is over.”

I nodded slowly, trying to understand the sentiment and underlying meaning of the message.  I had seen death in different contexts.  I had seen bodies at funerals, neatly dressed in pressed suits or dresses, lying peacefully in a casket.  I had lost a grandfather I was particularly close to, and spent a significant amount of time with him not long before his passing.  And I walked the streets of Port au Prince shortly after the January 2010 earthquake, when the sight of bodies was not uncommon, and the stench of decaying death clung to my skin and hair for weeks, and remained seared in my memory for months.  But, while death is a common understanding and topic of medicine, and I had cared for patients who were understood to be on their way to passing, never had I been asked to spend time with someone actively dying.

I took my time changing back into clothes appropriate for the hospital, and allowed my mind to wander.  What would I see when I went to visit?  What would I say to the family, or to the patient?  Would the patient be able to communicate?  Would there be crying?   How does Dr. Koreis know that she is going to pass away soon, and why would he give up?  Why could we not do surgery? 

I made my way to the ICU, and after noting that she was there alone, logged into the electronic patient record to determine for myself more of what was going on.  She was an 82 year old woman who had been brought into the emergency room that morning from a local assisted living home, with newly onset confusion, fever, and leg pain.  The notes in the chart made it difficult to determine the degree of confusion and pain with which she presented, but as I reviewed the patient’s vital signs and lab values, it was clear that she was quite ill.  The surgeon’s note from his consult visit had not yet been included in the chart, so I decided to see the patient myself.  I checked in with the nursing staff, and was informed that I would need to put gown and gloves on as patient had tested MRSA (a contagious, and at times very dangerous, bacteria often found in skin wounds) positive, and that I should stick my head out of the room if I needed assistance of any kind.

I donned gown and gloves as instructed, and timidly made my way into the room.  The patient was a moderately set woman, with curly gray hair mildly matted where her head met the pillow.  She lay covered in a sheet, arms bruised where I presumed IVs had been attempted or blood drawn, and she breathed heavily through parted and chaffed lips, with an occasional moan escaping those lips.  I stood staring at the telemetry monitor for quite some time, before putting a stethoscope gently to her chest and listening to her rapidly beating heart.  I then placed the stethoscope at the sides of her chest, and listened intently for lung sounds, for which I was met by raspy crackles.  I placed the stethoscope back around my neck, and watched quietly as she tossed around a small amount.  She furrowed her brow and moaned some more.

Having watched me for a few minutes, the hospitalist physician gently knocked on the door, and joined me in the room.  “Analiesse, good evening.  Dr. Koreis told me you might be by this evening.”

“Hi, Dr. Ashby.  Can you tell me a little bit about what’s going on with Ms. Shank?”

“Of course.  Ms. Shank is an 82 year old woman with long standing diabetes and heart disease, who has been doing fairly well and living mostly independently, but was found in her apartment laying in her bed this afternoon, moaning, and not able to make much sense.  She was brought into the emergency room where she was noted to have a temperature of 103 degrees Fahrenheit, tachycardia (a rapid heartbeat), hypotension (low blood pressure), a severely infected sore on her foot, and cellulitis (red, infected skin) extending from the sore clear to her upper thigh.  There in the emergency room, they immediately started an IV, and drew labs.  After review of the labs, it was determined that Ms. Shank has severe sepsis, and Dr. Koreis was called for a surgical consult.  Upon seeing the patient, Dr. Koreis felt that the patient was suffering from necrotizing fasciitis, likely influenced by the patient’s diabetes.  He was faced with the difficult decision: either rush the patient to the operating room and amputate the entirety of the patient’s leg with only a small chance of saving her life, or treat with the patient’s comfort in mind, and the understanding that she was likely to die no matter any attempt otherwise.  After Dr. Koreis learned of Ms. Shank’s heart condition, he did not feel that she could survive such a significant surgery, and after consulting with another surgeon, decided to not attempt surgery and treat for comfort.” 

I stood there, nodding slowly, watching her heart rhythm trace across the monitor.

“Would you like to see her foot?”

I nodded.  “Yes, please.”

Dr. Ashby moved to the edge of the bed, and gently pulled the sheet back from the patient’s foot, which lay propped on a pillow and wrapped in a blue absorptive pad.  As he gently unwrapped the foot, the smell of decaying flesh surrounded us, and the patient began to moan and toss about more.  When the foot had been revealed, a raw and fleshy wound consumed half the foot, and the remainder of the foot appeared swollen and deeply red, with areas of darkening. The red extended up the leg, and just past the patient’s knee.

“Ms. Shank, are you in pain?”  I asked loudly.  The patient moaned incomprehensibly again.  “Dr. Ashby, I noticed that we are giving her IV antibiotics, but I don’t see that we are giving her any pain medication.”

Dr. Ashby nodded thoughtfully.  “We started the IV antibiotics in the emergency room, and have not discontinued them as I am waiting until the family arrives, is able to understand the situation, and gives consent to discontinue all treatment outside of comfort care.  But regarding pain management, you make a good point.  It is difficult to know how much pain she is in, given that she cannot communicate with us, but it would be fair to say that she may have a good amount of pain.  Little harm can be had by treating her pain, so I will go ahead and order something for that.”

“You mentioned her family.  Are they on their way?”

“Her closest contact lives in Idaho, and is on their way in, but last I heard got stuck along the way due to snow from the storm.”

I nodded an understanding.

“Any questions I can answer for you?”

“Not right now, I don’t think. Thank you, though. Do you mind if I stay in the room with the patient for a little while?”

“Not at all!  Please do.”

Dr. Ashby left the room, and after re-wrapping the patient’s foot, I moved to the head of the bed.  Noting her dried and ulcerating lips, I wet a sponge stick beside the bed, and gently wet her lips.  And then feeling the cool skin of her arms, I tried to communicate with Ms. Shank once again.  “Ms. Shank, are you cold?”  With more moaning in response, I retrieved a blanket from the corner of the room, and tucked her in. 

I stared at the telemetry monitor a while longer, listening to her moans, and then began to talk.  At first, I felt silly.  This woman did not know me, was about to die, probably did not understand what I was saying, but yet I was going to talk to her.  “I’m so sorry,” I cooed, “I know this isn’t fun.  I know.”  As I talked, Ms. Shank’s moans seemed to quiet, and so I continued.  “This storm has caught everyone by surprise, and certainly doesn’t help anything, does it?”

Again feeling silly, I took a break, and walked to the other side of the room, but as her moaning picked up, I returned to her side.  This time, I took her hand in mine, and she wrapped her cool fingers tightly around mine.  It may have been a simple spinal reflex, I did not know, but as I once again began to speak, her tense body relaxed, and moaning quieted.  I grabbed the folding chair from the wall, and set it up beside her, and decided I had nowhere more important to be.  Very aware of the nurses’ stares, I decided that I didn’t care.  “No one should die alone”, I thought.

As the evening went on, I held Ms. Shank’s hand, caressed her hair, and spoke softly to her.  I found myself wondering what her former life had been.  Did she have children?  Was she ever married?  Had she been a school teacher, a secretary, a stay at home mom?  I calculated time back, according to her age, and wondered what it was like to come of age in the 40’s and 50’s.  And as my thoughts wondered over her former life, my thoughts naturally also went to that of what was to come for her.  As a Christian, I find great relief in knowing that following my passing from Earth, I have the comforts and relief of Heaven awaiting me.  But, what would come for my patient?  What were her beliefs?  I said a silent prayer for her, as I caressed her hand in mine.

The evening passed, my patient’s moans became sparse even when my whispers and hand holding would cease, and her breathing began to cycle between rapid breathing and sparse deep breaths.  Recognizing the time, I decided to call it a night around midnight, and noted that she would likely not be around when I came to round on my patients in the morning.

Instead, when I arrived in the morning, she was right where I had left her.  In speaking with the nurses, everyone was amazed that she had held on through the night.  I checked in with her multiple times through the day, and each time checked her heart rate and breathing pattern, and stroked her hair a few times, before moving on to my other patients.  Through the day, she became less and less responsive, until she lay without tossing, and without moaning. 

After I had finished the surgical cases and remaining responsibilities for the day, I again returned to the ICU, this time keeping an eye on her from the nurses’ station, as I worked to glean some of the nurses’ expertise on how to know when death was within hours.  Around 8 o’clock, a woman came bustling in, followed shortly behind by another woman and a young boy.  She looked to and fro a bit frantically, and I looked up inquisitively.  “Ma’am, can I help you?”

“Yes!  My mother is here.  Miriam Shank.”

I shook my head a small amount as I got my mind on queue.  “Yes.  Yes, of course.  She is right this way; room 2.”  I walked around from behind the desk, and guided them to the window looking into Ms. Shank’s room.

The group of three seemed to stifle tears, and Miriam’s daughter’s hands shook.

“I’m Miriam’s daughter, Beth.  And this is my daughter, Julie,” Beth gestured to the other woman with her.  “And this is Julie’s son, Ben.”

The young boy, maybe 10 years old, stood looking frightened, his eyes transfixed on the window that separated him from his great grandmother.  There were four generations in front of me.  I briefly introduced myself, and my role in caring for Ms. Shank.

“We tried to come as soon as her living facility called, but we live in Idaho, and got stuck on one of the mountain passes with the storm.  We came as soon as we could.  Can you tell me what happened??  What is going on?  What’s the plan?”  Beth spoke in a rushed and emotional, but to the point manner.

“Yes.  Let me call Dr. Ashby, who has been caring for your mother.  He should be able to come right over, and talk over with you about what is going on, and where we are in this.”

I stepped away and called Dr. Ashby.  But instead of telling me to delay the family while he made his way over, Dr. Ashby reminded me that I knew just as much of Ms. Shank’s case as he did.  He asked me to go forward with explaining to the family how Ms. Shank had presented to the emergency room, what had been done for her thus far, the thoughts on her likely impending passing, and what could be done for her in the meantime.  He noted that he would join the conversation soon, and would be able to follow up on any questions I was not able to answer. 

Upon hanging up with Dr. Ashby, I nodded my head slowly, trying to quickly gather my thoughts on how to talk the family through this.  Was I in over my head, or was it time for me to step up and try on the shoes of the career I was walking into?  I feared giving a false sense of hope, but also feared hurting the family more than was necessary.

I rejoined the family, and trying to recall the simple and concise way in which Dr. Ashby had taken me through the case the day before, I attempted the same.  The family held onto each other, and Julie and her son cried.  Beth kept a firm lip line, and nodded as I spoke.  Upon finishing my explanation, I asked “Would you like to go in and see her?”

Beth nodded.  I explained to the family the reason for needing to wear a gown and gloves, and walked Beth and Julie through putting them on while young Ben suggested he would like to stay outside the room.

Beth led the way, and Julie and I followed close behind.  Noting her mother's dry and parted lips, coarse breathing, and still and quiet position, Beth slowly shook her head.  “How long has she been like this?”

“When she arrived here yesterday, she was already quite ill and not making much sense.  By last night, she was moaning small amounts,” I explained “But not much was understandable.  We believe she is comfortable now, resting.”

“May we see her leg?” Beth asked.

I nodded, warned them of what they were about to see, and then slowly unwrapped her foot as Dr. Ashby had done for me the night before.  The foot was much worse, just in the 24 hours, and Beth and Julie gasped, while Julie turned away.

“The only thing that could have potentially saved her life, would have been an emergent removal of her leg.  But the surgeons did not believe that she would survive the surgery, and that even if she did, that she would have much of a chance.  And in the small chance that she would she have come through the surgery and managed to get the sepsis under control, she would have still faced a very grueling recovery process.”

Beth nodded in understanding, while Julie stared off into space.  “Mom wouldn’t have wanted to live like that,” Beth noted. 

I pointed to the hanging IV antibiotics, and explained that we were continuing to treat as much as we were able, without surgery, as we were waiting for family to arrive.  Tears began to form in her eyes.

“I am going to step out, and give you some privacy with your mother.  If you need me, I will be right outside the door.”

Beth nodded in understanding, and thanked me for my time.

Outside the door, I stood beside Ben, watching in silence as Beth and Julie began to talk to my patient.  Ben tried to quickly wipe tears from his face.  I quietly put my hand on Ben’s shoulder, and not sensing any withdraw from him, kept it there.

“Do you think my grandma’s hurting?” Ben asked.

“No, I don’t.  She is getting a lot of strong pain medication now, and from everything that we can tell, she is comfortable right now.”

Ben nodded.

“Would you like to go in and see your grandma?”

Ben nodded again, slowly.

I walked Ben through the gowning process, and helped him put on gloves much too big for his hands.  As we walked inside the door, Ben again began to cry.  I put my hand on his shoulder, and told him that he was a strong young man.  With that, Ben took a deep breath, and took to his grandmother’s side.  I explained that it was okay to touch her if he wanted, and with reassurance he took up her hand in his, as his mother tearfully walked to his side.

I exited the room quietly, and took back to my spot at the nurses’ station.  Ten minutes later, the family pulled off their gowns, and joined me again outside the room.  About that time, Dr. Ashby also joined us.  “I am so sorry for how difficult this must be,” Dr. Ashby started after introducing himself, “Are there any questions I can answer for you?”

“How soon do you think?” Beth asked.

Understanding what she was referring to, Dr. Ashby explained that it was difficult to know for certain, but that Ms. Shank would likely pass away within hours or days.

“We have family that will need to try and get here.  I have two brothers and a sister.  What do I tell them?”

“I am happy to answer any questions they might have, either over the phone or in person.  If they would like to see your mother before she passes, I would suggest that they try and get here as soon as possible.”

After some discussion, we all sat around a table in the family meeting room, and placed a cell phone on speakerphone in the center of a large table.  Three times over, I listened as Beth tearfully gave a rundown as she was able, and then Dr. Ashby would take over and answer any remaining questions.  When the initial phone calls were over, Beth suggested that they would stick around and make some more phone calls and come and go from her mother’s room.

Dr. Ashby and I excused ourselves, and after checking in with Dr. Ashby regarding how my conversation with the family had gone, he encouraged me to go home.  “It’s going to be a long night for them.”

I agreed, and left to get dinner.  When I returned a couple hours later, I walked by Ms. Shank’s room and noted her to have had her IV pulled, and her monitor turned off.  The nursing staff explained that they could still monitor her telemetry from their desk, but that they didn’t want alarms going off and interrupting the family.

I found the family in the family meeting room where I had left them, but with an additional individual having already joined them, and a pizza in the center of the table.  Bill, the patient’s son, had already arrived from North Dakota.  One other brother would be trying to make his way over from Oregon by morning.

I took a seat next to Ben.  “How are you doing?”

“I’m okay.  I’ve never seen my grandma like that before.  She looks really sick.”

I nodded quietly.

“What made you want to become a doctor?” Ben asked.

I gave Ben a short explanation of how powerful it was to be part of such experiences, and Ben nodded an understanding.

Bill then spoke up, and suggested he take Julie and Ben to find a hotel for the evening, and as they left, I stood to also leave when Beth spoke up and asked me to stay.

“It’s so different; seeing her like that.” Beth began. “I remember watching my grandma die a number of years ago, but it’s so different when it’s your mom.  I just saw her a couple months ago, and she was talking about the new dance class at her assisted living home.  We had talked about moving her closer to me in Idaho, or closer to one of my brothers, but she wanted to stay because she’s lived here since marrying my father 60 years ago.  I should have insisted. I know that she’s going to a better place, but it’s still hard.”

I sat just listening, and nodded in sympathetic reassurance.

“Do you believe in Heaven?” Beth asked.

I nodded and smiled.  “Very much so.”

“Me, too.” Beth said. “Mom is a really strong Christian, and I know she will be walking through pearly gates soon.”

I smiled, remembering my silent prayers in Ms. Shank’s room the night before.

After a bit more conversation, and the encouragement that the nursing staff could help her with anything that came to mind, I headed home expecting Ms. Shank to have passed by morning.

When I returned to the hospital the next day, as much as I was expecting such, my breath still caught in my throat when I walked by Room 2 and saw an empty bed.  Recognizing me, the nurse at the nurse’s station interrupted my thought.  “We moved Ms. Shank to Med/Surg, as she no longer has any ICU needs.”

I thanked the nurse and headed that way.  I was both concerned that Ms. Shank was still hanging on, but yet strangely relieved at the same time.  The extent to which I was focused on the case concerned me to some degree, but I reassured myself that this was my first case dealing with the dying process, and that it would get easier.

When I arrived to the patient’s room, I was greeted with welcoming smiles and introduced to the second son who had arrived from Oregon.  I listened to Ms. Shank’s lungs, which sounded even more fluid-filled, and noted her ragged respiratory pattern.  After briefly explaining the thoughts from the medical perspective, as handed down to me from Dr. Ashby, I excused myself for my surgical cases, and told Julie and Beth that I would be back at the end of the day.

I returned at the end of the day, to find Beth at her mother’s side reading a book, and was informed that Julie and Ben were again staying at a hotel, and that Beth’s two brothers had returned home.  The nursing staff had set up a cot for Beth, and I noted dark circles under her eyes and a tall cup of coffee next to her.  After some conversation, I headed home for the evening.

Again, I arrived in the morning to find Ms. Shank still in her room, motionless except for her breathing, and with Beth, Julie, and Ben at her side, while Ben played on his hand-held game system.

“At first I didn’t want her to be gone so quickly,” Beth noted, “But now, I hate to see her hold on like this.”

“Beth, I can see it in your eyes, and hear it in your voice…you have every right to be exhausted beyond words.”

Beth nodded slowly, and Julie’s eyes widened in confirmation that yes, her mother was quickly wearing down.

“My mom won’t leave Grandma’s side,” Julie explained. “She hasn’t left the hospital once since we arrived.”

“What is your fear, Beth?” I asked.

“I don’t want her to die alone.  What if I leave, and I come back, and she’s just gone?”

I nodded an understanding.  “Beth, what if I sat in for you?  I have a long day of surgical cases, but after my day of work, all I have left on my agenda is studying.  How would you feel if I took my books in with me, and promised not to leave your mother’s side for a couple hours?  Would you feel comfortable leaving?”

Julie’s eyes lit up in hope that her mother would agree to it. “Mom, you really need to get some proper dinner, and a shower.  You can’t process things if you never leave the hospital!”

Beth nodded slowly.

“Tell you what,” I said, “I am going to head to the O.R., and after work am going to go home and grab some dinner and my study material, and then come check back in around 6.  I can stay until 10 tonight, and if you feel comfortable, I would suggest you leave the hospital for a little while.  I will promise to call you the moment anything changes.”

I left the room and went about my day as normal, and when I returned to Ms. Shank’s room that evening, I found Julie and Beth with their stuff in their laps, ready to head out the door.

I smiled.  “Good!”

“Are you sure this is okay with you?” Beth asked.

“I am absolutely sure.  Sometimes the best thing that we can do for our patient is support the family.  All I am doing this evening is studying, and I can do that anywhere!  I promise I will call if anything changes.  See you back around 10 or so?”

Julie smiled. “We are going to get her some proper dinner, and have her soak in the hotel’s hot tub for a while.  We will see you this evening.  Thank you so, so much!”

As they left, I settled in beside the patient.  The room seemed much less eerie now, with some of the family’s belongings around, and now understanding a bit more about who the patient was.  Ms. Shank rested comfortably beside me, and I started in on my studies.

Beth and Julie returned a few hours later, Beth visibly rejuvenated. “Thank you SO much!  I needed that more than I realized.”

“Not a problem at all!  Not a thing changed since you left!”  I smiled.  “Hey, I remember you telling me that you had a sister.  Was she going to try and make it to town?”

Beth took a deep breath.  “My brothers have both made it, but my sister is incarcerated.  We have been making calls, and I believe she is going to be able to make an escorted stop by the room tomorrow.  I do wonder if that is why my mother is holding on.”

“I’m glad she may be able to make it; that’s great!”  And with a few short exchanges, I excused myself for the evening.

The next morning, it was again the same, with the family there excited to greet me by first name; I listened to her heart and lungs, and exchanged a short bit of chit chat about my surgical cases for the day, before I took off to the OR.  I returned at lunch to find both Beth and Julie seated around the bed.  Ben was in another room watching TV.

“My sister made it this morning!” Beth exclaimed.  “That’s the last family my mom was close to!  We figured she is hanging on this morning still, waiting for you to come by one last time.”

I smiled, relieved the entire family had now made it.  “She will let go when she is ready.  But you have done an amazing job of supporting her.”

“We have just been sitting here, exchanging favorite memories of her from ages ago, as well as reflecting on things we think have been the greatest blessing to her in more recent days.  We both agree that you have been an extraordinary gift to my mother in her final days here.” Beth remarked.  Julie nodded in agreement.

I shared a few warm sentiments with the two, remarking that it was a gift to me to be allowed involvement in their mother’s life.  I explained that I would be back after a large surgical case I was about to walk into.

Upon finishing the case in the O.R., I logged into the computer to look at another patient’s lab results, and noticed that Ms. Shank’s name was no longer in my list of patients.  I frantically scrolled through the list, thinking that I must have missed her name somehow.  Not seeing it, I scooped my stuff up, and half-ran, half-walked down to the Med/Surg unit.  I had just caught sight of the inside of her room, when a nurse came running up to me.

“There you are!” The nurse said. “The family asked that I page you, but I couldn’t figure out how to get in touch with you.” I was only half hearing the nurse, as my eyes fixed on the now neatly made and empty bed in the center of the room. “Ms. Shank passed away minutes after you left her room earlier.  The family wanted to wait around for you, but I encouraged them to leave.  They left you their phone number, should you wish to call.”

I thanked the nurse, took the number, and turned away.  I didn’t want her to see the embarrassing emotion threatening to overtake.

It was a good thing!  She had lived a good life, she had spent her final days with her family, and she was now completely free of pain.  I should be relieved…and I was.  But then what was the sudden lump in my throat?

I walked in a daze to the piano in the foyer just outside of the med/surg unit.  I sat down at the bench, removed my stethoscope from my neck and placed it into my white coat pocket, and for a few moments just stared at the keys emptily.  But then I closed my eyes.  “Father,” I prayed, “I do not even understand my own emotions, much less the depths of your plans or the depths of the lives of your children.  But I ask for comfort for those who love and grieve, and praise you for the gift of life.  Thank you, dear father, for gifting me with a peek into the intimate life of your daughter, as you welcome her into your precious and loving arms.”

And with that prayer, my fingers began to dance upon the ivory keys beneath them.  And as my fingers played a song they had never played before, the tears streamed down my face.

A few minutes later, a friendly squeeze on my shoulder had me turn.  A woman just leaving from visiting another patient took me into her arms, and held me tightly in her embrace.  “Thank you,” she whispered, “Thank you for your service to your patients, and your evident heart for them.  May the Lord bless and keep you in what he has set out for you.”

I wept in her arms.  I did not understand the depth of the pain I was feeling, or why it was there.  But this woman was exactly right.  The Lord himself had chosen this path for me as an avenue to care for His children, and without doubt would equip me with the courage and love to continue on.  And what an extraordinary gift to be chosen for such a work!

When I turned back to the piano, I took a deep breath, set my shoulders back, and allowed my fingers to dance once again.  As my fingers set free, so did my heart.  Ms. Shank was free of her pain and free of her limitations.  And I was free to continue to love and care for God’s children as He calls.    

And what a blessed daughter of God I am, for it to be so!