Boris Veysman
New Jersey, Piscataway, United States

This story “Teaching Death” by Boris D. Veysman was originally published in Academic Medicine, 2005 Mar; Volume80(3):290.© 2005 Association of the American Medical Colleges Publication.

“God! You chose me to watch over the life and death of your creatures. I now turn to my calling.”
—The Maimonides Prayer¹

Another day as an ICU intern: endure hours of rounds, complete dozens of daily tasks, and watch another patient die. The patient’s systems were failing in sequence as they were probably designed to do. We had done everything the family wished. Today, it was not sufficient.

While writing notes, I overheard that he was “bradying down.” Although swamped with work on other patients, I wanted to witness this because the attending had predicted that his heart rate would start slowing down just this morning. On the way to the bedside, I overheard the new medical student saying to her patient’s family, “This is how we monitor the kidneys.” I motioned her over, “You should see this.”

She looked puzzled, as what could be more interesting than convoluted tubules and their effect on creatinine. “Mr. Holmes is not doing well,” I said.

“You mean, dying?” her voice shaking a bit. “He is on maximal pressors, yet the blood pressure is dropping,” I said. “Previously, when his heart rate was higher, the cardiac output was adequate for perfusion, but now that it is dropping, the patient is experiencing decompensated shock.” She was jogging along next to me and nodding intently. I remembered doing the same thing only a year ago and feeling completely clueless. Before I could elaborate and help her understand the situation, we reached the bedside, watching the patient fall apart in real time.

I looked at him; he was filled with tubes. I then looked up at the monitor; with numbers falling, his EKG was irregular and slow. The beeps were painfully infrequent in the backdrop of several wailing alarms. The nurse pressed a button, introducing a dreary silence, which was only broken by the sound of the ventilator and my own heart beating. My initial anxiety rapidly dissolved into knowing anticipation. By now, I knew there was a rhythm to this process, a pattern, and it was calming. I looked at the nurse, the attending, and the residents; they were a team running a familiar play. I was unnecessary. Then, I saw the medical student and at once knew my purpose. She was pale and anxiously scanning the room. I asked how she was doing. “I am okay. But what now?” she asked.

The heart rate was 56. Blood Pressure 60/30. Carefully choosing my words and speaking quietly and calmly, I began with a brief history and recent complications. Rate 48, Pressure 55/25. Then all organs failed in turn as the shock worsened and the heart’s rhythm decreased in time. I explained that at this stage all resuscitation efforts would be of no avail. Vital signs continued to drop. Rate 32, Pressure 49/25. I explained to her the incredible importance of the advanced directives. We were not doing more than we should.

Asystole. I paused. We stood quietly as the monitor was disconnected and the ventilator was turned off. The body became peacefully still as the eyes stared vacantly ahead.

“Are you okay?” I asked, knowing that she wasn’t. “Yeah, thanks,” she said weakly. “Should we close the eyes?” she finally asked, and I nodded in agreement, wondering why I didn’t think of it. Slowly she shut the patient’s eyes, and the eyes stayed closed—as they do in the movies but not always in real death.

Later we talked, and she thanked me for walking her through the death of a patient. That day was unlike any other since I had begun in this profession. I did what I wish had been done for me when I was “growing up” as a doctor. See one, do one, teach one.

Reference

1. Rosner F. The medical legacy of Moses Maimonides. Hoboken, NJ: KTAV Publishing House; 1998.