When Death Becomes Personal
It was a straightforward case, one that even a fourth-year medical student like myself could piece together. A 53-year-old woman with prior breast cancer treatment has unremitting back pain for a month. Pain medicine was ineffective, and her pain and disability were growing worse with time.
I picked up the ringing telephone; it was the radiologist, confirming my fears. A mammogram had revealed a grapefruit-size tumor in her remaining breast. In truth, the news should not have come as such a surprise. There were clues: the previous breast cancer surgery, unremitting back pain and being two years overdue for a mammogram. A bone scan showed that nearly all her bones were riddled with cancer. Simple diagnosis: metastatic breast cancer.
Her daily suffering and progressive disability were apparent despite her attempts to conceal them. Stabbing rib pains made each breath and every movement a lesson in courage and stoicism. Soon she began to limp. Then she had to use a walker. Not once did she utter a complaint.
Merciless cancer cells had chewed away her hip joint, making a hip replacement necessary. Still, she did not complain. This courageous woman’s course of illness would prove to be slow and painful, difficult for any medical student to watch. Maybe death is easier, I thought as this woman’s disease progressed. Perhaps it is the desirable alternative to suffering? My years of doctor training only affirmed my early impressions.
I would learn that death in the hospital was often algorithmic and dispassionate, and perhaps easy. Monotonous chants for medication or defibrillation paddles echoed across the room: ‘One amp of Epi! An amp of Atropine! Charge the paddles and shock ‘em!’ These chants were familiar to the mass of people in white coats and green scrubs who methodically performed their tasks. One person pumped air into deflated lungs. Another person pressed vigorously on a motionless chest, filling in for a failed heart.
Often, this was the last stop for the patient. An open hand waved up high signaled the end. Wrappers scattered on the bed and floor were swept up. Traces of blood were washed away to prepare the body for transfer to the morgue. A cool body finally seemed to be at peace. Workers returned to their routines.
These experiences taught me about the many faces of death. The end could come slowly and painfully, or could be quick and numbing. Death often seemed natural and almost welcome in the elderly, but unnatural and tragic in a child. Suffering gave to death a calming, friendly countenance. Grief, however, turned the gentle kiss of death into a crushing bite. For it was the shrieks and cries of loved ones that reminded me death is never easy.
As a senior resident in the coronary care unit, I treated a wonderful woman, a teacher, who had suffered another in a series of heart attacks.
The woman, whom I’ll call Mrs. Paulsen, was only 49 years old, but her heart could no longer pump enough blood through her rotund body. We had long conversations about my road to becoming a doctor, and she shared with me her teaching successes and disappointments.
For weeks, doctors tried to clear fluid from her lungs and get her home to her family. Every day, it seemed, another setback made that goal more elusive.
One quiet night in the coronary-care unit lounge, Mr. Paulsen sat down beside me as I watched a football game. We cheered during the game and discussed our favorites to win the Super Bowl.
Then he turned to me with a serious look on his face and asked: “Do you think my wife will get home for the holidays?”
“We see some improvement each day,” I lied.
The next morning, Mrs. Paulsen’s weary heart finally gave out. There were more medication chants and chest compressions as we tried to reignite a stalled heart. When it was all over, doctors walked off to write notes, nurses helped clean the body. The wrappers were swept up, and I headed to the lab to check test results for other patients.
The elevator door opened, and Mr. Paulsen stepped out with a hopeful smile on his face.
“How’s my wife?” he asked in his burly voice.
I could not escape from this uncomfortable task. Part of me wanted to rush off to the next task. Now I, not his family doctor, would have to break the news of his wife’s death.
How do you tell a man he will never again speak to his beloved wife of 30 years? High school sweethearts, they had gone to the prom together and been inseparable ever since. They raised four children. And they battled Mrs. Paulsen’s illness together.
Mr. Paulsen read my eyes and realized what had happened. He struggled to hold back tears. I told him some details about her last moments of life.
Just one day earlier the two of us spoke of football and hope. That moment we would speak of lost dreams and despair. Mrs. Paulsen had hoped for 10 grandchildren--and now would not even see her first. No matter how I told him, no matter what words I used, it seemed like everything I said was wrong.
As I stared into Mr. Paulsen’s eyes, I thought back to the phone call I had received from that radiologist a few years earlier. While I listened to his report on the 53 year-old woman’s mammogram result, my legs became weak and wobbly.
“A grapefruit-sized tumor in the left breast,” the radiologist reported.
I collapsed against the wall and cried, “My mother is going to die.”
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Dr. Joel Cohen practices urgent care medicine in New York City. He can be reached by e-mail at jcdv@rcn.com.
