A Pronouncement | Stories | Notre Dame Magazine

The shadow of an IV pole elongates across my computer monitor as the autumnal sun recedes on the western side of the Hudson River. For a moment, the sterile cardiac intensive care unit (CCU) is burnt orange, light and shadow wrestling on the faces of its occupants before the sun’s glow ultimately succumbs to the unnatural LED lights. My co-resident turns to me, the dark rings under his gentle eyes made more visible by the neon-yellow mask obscuring the bottom half of his face. “Is there anything else you need help with?” he asks. I shake my head, dismissing him for the day, knowing that with his departure, I will be the only senior resident in the unit for the next twelve hours. “I hope you have a quiet night,” he says, his voice colored with cautious hope as he throws his backpack over his shoulder.

I motion the first-year resident on call with me to sit at the computer next to mine. “It’s just you and me against the world, Sharon,” I say in a half-hearted attempt to keep the mood light. Mask around her chin, she flashes me a nervous smile as she pulls her wavy black hair into a bun. No stranger to the CCU’s 27-hour call shifts, Sharon eases into the rhythm of the night’s tasks on our to-do list. Stretching along the hospital’s westernmost wall, the resident-run CCU has seven patient rooms on one side and seven on the other, with the physician and nursing workstation as an island in the middle. I scroll through the list of patients. All 14 are critically ill, but Josefa, a 73-year-old Dominican woman with pancreatic cancer, stands out. She had arrived early that morning from a nursing home in septic shock. After conversations between her family and last night’s on-call resident, the family had decided to make the patient “comfort care.”

When the end is inevitable and the patient or their family consents, we may withdraw aggressive life-sustaining therapies, but we never withdraw care at the end of life. Yet, for all our good intentions, once a patient’s chart says, “comfort care,” and the medical team knows they’ll never leave the hospital alive, we often mentally triage tasks for that patient to the bottom of our list. I had yet to meet Josefa or her family, having spent all day taking care of urgent tasks for the unit’s 13 other patients. I glance up from my computer screen towards Josefa’s room. Through glass doors, I see seven family members surrounding the patient’s bed, their downturned faces veiled in shadow. As I rise out of my chair to meet them, the cardiology fellow waves me over to look at another patient’s monitor.

Through the discordant array of beeping machines, one alarms louder than the rest. Samuel, the cardiology fellow, a tall man with clear-framed glasses, directs my attention to a patient’s oxygen levels. “He needs an arterial line. Right now.” The patient in question is Tom, a 40-something man with an end-stage autoimmune lung disease and a blood clot in his pulmonary arteries. Despite having a machine rapidly pump oxygen into his nose, his blood oxygen percentage plunges intermittently before my eyes. Tom needed a lung transplant, but at that moment, our only option was to place a catheter in an artery to monitor his blood oxygen more closely. Our terse exchange over, I quell my unease at having not met Josefa or her family yet, now focused on gathering supplies for Tom’s procedure.

After discussing the risks and benefits of the procedure with Tom, Sharon and I get to work. With confidence born of practice, Sharon uses an ultrasound machine to locate Tom’s right radial artery and slides the catheter home. An anguished wail cuts through the steady din of the unit. I look up from Tom’s wrist, the arterial line in place but needing to be sutured down, and swear under my breath as I see a nurse directing me to Josefa’s room. “Sharon, can you wrap this up alone?” She nods her affirmative, and I step out of my sterile gown, grab my stethoscope and stride across the unit to Josefa’s room.

Sliding open the door reveals a scene of piercing grief. A woman lies prostrate across the patient, sobbing into the white sheets that cover her. Six other family members meet my gaze, all with tears streaming down their faces. I glance up at the patient’s vital sign monitor, noting that the heart rate now says “0.” “Lo siento mucho por su pérdida,” I say. I am so sorry for your loss. I wrap my arm around an older woman’s shoulder, her head leaning easily onto me as she sobs silently. We stand there for a brief, enormous moment. Seven loving family members and I, a stranger, all gaze down upon Josefa, whose peaceful face I had never known in life. I signal towards my stethoscope. “Con su permiso.” With your permission.

The death exam is never routine, but I’ve grown accustomed to performing it over the past two years of my internal medicine residency. There’s a checklist of tasks, which boils down to evaluating for any heart, lung or brain activity. The nuance lies in performing the exam in a way that enhances the dignity of the examinee and does not interfere with the present family members’ ability to grieve.

After donning blue nitrile gloves, I lay my stethoscope on her chest, take a deep breath, close my eyes, and listen for over a minute. No heart or breath sounds. While I do this, I gently press two fingers on the carotid artery in the patient’s neck. No pulsation. Finally, I assess for pupillary and corneal reflexes to check for remaining brain activity. I hold Josefa’s face in my hands and lift her left eyelid, followed by her right, quickly flashing my pen light over both, noting that the pupils are dilated and do not react to light. No pupillary light reflexes. I then take cotton gauze and lightly brush the edge of the colored part of her dark eyes, noting that she does not blink. No corneal reflexes. With the exam completed, I stand up straight, glance down at the cheap fitness tracker on my wrist, and pronounce the time of death. “Falleció a las siete y cuarenta. Lo siento mucho.” She passed away at 7:40 p.m. I am so sorry. “Cualquier cosa que necesiten, estoy disponible.” Whatever you need, I am available. After meeting eyes with each family member, I nod solemnly and slip out of Josefa’s room, sliding the door shut behind me.

13 patient monitors continue to beep periodically. After a time, Josefa’s family files out of the room, allowing her nurse to prepare the body for the morgue. I stand to say goodbye, and the grey-haired woman who had rested her head on me grabs my hand in a wordless expression of gratitude. Sharon’s work phone buzzes, alerting us to a new patient in the Emergency Department needing Josefa’s soon-to-be-vacated room. Mercifully, a nurse dims the overhead LED lights as the CCU’s patients and staff settle in for the night.

In my short medical career, each patient encounter has been an opportunity to live out the question that should guide all physician-patient relationships: How will I uphold this person’s dignity? When I am presented with the opportunity to help pen the final chapter of a life, my solemn obligation is placing all other tasks aside to focus on relieving suffering and gently ushering in death. Medicine’s idyllic vision of accompanying a patient until the end often succumbs to other demands, other patients. So, when the 27-hour shift ends, I step into the city streets and allow my thoughts to turn inward. The mid-morning sun warms my tired body and spirit. Even if I failed to guide her to the other side, I am hopeful that my last encounter with Josefa filled her final moments with dignity and peace.

Erik Carlson’s essay was one of five honorable mentions in this magazine’s 12th annual Young Alumni Essay Contest. Carlson is an internal medicine resident in New York City and is pursuing a career in palliative care.