Respects

Mr. S died last night. I had never gotten to know him and was just vaguely aware of his name being on the white board, mostly because there was a disagreement about how to pronounce it. It didn't seem right or fair to Mr. S that I should be the only one there when he died. It seemed like somebody who knew him should have been with him. But that wasn't how it went.

I picked Mr. S up at 3:00, from Claire. (3:00 is kind of a quasi-change-of-shift--a lot of nurses work the whole 7A-7P, but there's a bit of a shift in the staffing ratio, and so some go home at 3:00, and the remaining nurses take over their patients.) Claire is in her early twenties and just started on Wright 10 a couple of months before I did. She's petite, with dark hair and porcelain skin, and truly does look a bit like Audrey Hepburn--an effect accentuated by her habit of wearing black shirts and these scarf headbands that look vaguely 1958.

She said Mr. S was Comfort Measures Only, which interestingly rarely gets abbreviated by the nurses to CMO, and the words are even spoken in a slightly low tone. It seems to be about respect for the life that's ending, since if they're on our unit, rapidly approaching death would be the only reason they'd be so designated. (In most cases, patients for whom there is no further oncologic treatment available but still have a while are discharged to home on hospice. There are some patients who are "DNR/DNI" who come to us, but it's generally for some kind of palliative treatment, which might even include chemo or radiation, to make life better or more comfortable.)

Claire walked me through what you do for a patient who's Comfort Measures Only. You don't do vital signs (which feels really strange--otherwise everyone gets vitals done at least every 4 hours). You keep him clean, turn him every two hours, and make sure his IV morphine is sufficient--that he doesn't seem like he's having any pain or air hunger. Mr. S was unresponsive, and his urine output was down to something like 50cc per shift, indicating that his kidneys were shutting down. When I went in, though, he didn't seem to be suffering. Claire had turned his morphine up to 4 mg/hour because she thought he'd been struggling to breathe on 2 mg. During her shift, she'd also noticed that he felt really hot and so had taken his temperature (104.3) and given him a Tylenol suppository, figuring that fevers can make you uncomfortable, too. Mr. S had the raspy breathing that comes at the end (the "death rattle," to be 19th century about it), and didn't open his eyes or move in any way when spoken to. Someone had set his television to some kind of internal channel that was quietly playing church choral music and displaying a stained glass window.

Although I no longer have an actual preceptor for a shift, I do have a "resource nurse" assigned to me to go to in cases where I'm at a loss, and so Carol walked me through the tasks. She told me that mouth care was important (he was mouth-breathing, and his tongue was all dry and coated and nasty), and pointed out that his scrotum was incredibly edematous, and showed me how to arrange things so he wouldn't be uncomfortable. She called in two other nurses to help turn him and boost him up in bed (he was a big guy) and orchestrated changing the linen on the assumption that he'd sweated when his fever came down from the Tylenol.

At her suggestion, I changed his central line dressing, since it was due. I did his mouth care and hung another bag of normal saline. I asked whether we should give him more Tylenol. We measured his temperature at 105.1 axillary. Carol said sure, we might as well, and so she and a PCA turned him, and I got to give my first suppository since nursing school.

I went out for a moment to chart, and then it occurred to me to ask Carol--should I change the caps on his central line also? It seemed kind of silly, since that's mostly to prevent infection and make sure the lines stay patent, which in his case seemed like not much of a priority. Carol hesitated. Well, she said, technically, yes. It only takes a few minutes, and I miraculously wasn't much behind, and it just seemed--I don't know--respectful to give him all the care he had coming to him. I'd even already brought the supplies in to do it, so I decided to go ahead.

I went in, and for the first time that I'd seen, Mr. S opened his eyes. It almost seemed as though he were looking at me, so I talked to him. I asked him if he had any pain, and if having the TV on was okay. But the moment of awareness seemed to have passed, though his eyes remained open.

I went ahead and changed the first cap. It's a task I've done enough times that I know how, but not so many times that I can think about anything else while I'm doing it. I have to focus entirely on what the next step is. (Get a saline flush ready, open the cap package, screw the flush onto the cap while it's still partway in the package to maintain cleanliness if not sterility, prime the cap, take off the old cap, clean the line's end with an alcohol wipe...) That finished, saline and then heparin flushes instilled to keep the line patent, I looked up at Mr. S and realized that he wasn't breathing. What's more, it suddenly seemed to me that I hadn't heard him breathing for a couple of minutes. I'd been so absorbed in trying to change the cap properly that it hadn't risen to the surface of my consciousness.

I took the blue disposable stethoscope down from where it was hanging and listened to Mr. S's chest in several different spots. Not fully trusting myself, I then took his wrist to try to find a pulse. The thing is, I kind of knew just from looking at his face. This is only the second time I've ever been with someone when they died (the first time was years ago, before nursing school, when I was a hospice volunteer), but there really is something that happens to the face. I had known Joseph, the hospice client, reasonably well, but Mr. S I knew not at all. I had never even seen him before his final four hours. But in both cases, although fully unconscious, the dying person was palpably present in his face. Once dead, though, the face pretty much immediately became an inanimate thing. The person was just gone. I guess it's probably partly a circulation/color thing, and maybe something to do with the facial muscles losing tone? I don't know. But it's very distinct. And somehow, I find that reassuring. We as humans have an importance and a presence just being alive. There is an identifiable flame of human life, however small and dim. And its existence is proved by how clearly absent it is when it goes out.

I went out into the hall, and Jill, a young-ish but still relatively experienced nurse, was standing there charting. Um, I said, I think Mr. S just died. So Jill came in with me to check. She took one look at his face and said, "oh, yeah--looks like it's even been a little while." I said that no, it had to be pretty recent because he was moving and opening his eyes not too long before. She said we should go get a house officer (intern or resident) to pronounce him, and then she would walk me through what else needed to be done.

We found Seth the intern sitting at a computer in the nurse's station, just a few steps from the door of Mr. S's room. Jill told him Mr. S has died, and we need you to pronounce him. Seth said that he'd never done that before, but after a moment he got up and headed into the room. Jill and I took a quick detour to grab a shroud kit out of the clean utility room, and then stood in the anteroom (Mr. S was in an isolation room), and she explained it to me. She said we'd have to wait until we found out whether the girlfriend would be coming in to view the body. If not, she described to me how we would bind the hands and feet into position and get the body into the (white plastic) shroud. She showed me the tags we would stamp up with Mr. S's hospital card--one for the toe, one for the outside of the shroud, and one for the bag(s) of his belongings. She showed me the straps used to bind the chin shut, but she said they gave her the willies, and she never used them. The funeral home wires the jaw shut, anyway, she said.

In the next room, despite not having done it before, Seth seemed to know the drill. He shouted Mr. S's name, tried to rouse him, then grabbed a stethoscope and listened to the chest (I think the rule is a full minute). He checked the pupils, and maybe did another thing or two I didn't see. To the empty room, he announced, "Time of death, 7:06."

Since it was so late, Jill assured me that it truly would be okay for me to leave the rest to the night nurse coming on. We couldn't do anything until the intern had made all the necessary calls to the family, anyway. Then there was just the preparation of the body (cleaning it up, taking out the tubes, as well as binding and be-shrouding), followed by getting the morgue key from security, followed by taking the body to the morgue. So I charted what I needed to, signed out to the nurse getting my remaining patient (my third had been discharged a bit earlier), and finally, after establishing that Seth was still in the middle of making phone calls, checked in with Jen, the travel nurse who was supposed to be getting Mr. S. She said it was fine, and I could go put my daughter to bed.

I rode the elevator down alone. I think I was waiting to find out what I felt about the whole thing, since I'd been kind of carefully in efficient-professional mode while I was on the floor. But all there was was quiet, with maybe a distant pressure or weight that was almost sadness. And I got outside, and the rain had stopped, but the air was still unseasonably mild, and I walked to the subway.