Friday, April 6, 2012

I now pronounce you.

"Work is love made visible."  ~ Kahlil Gibran

This day was a regular day at Grady for the most part. Regular in that I had the regular things on my agenda like rounding with my team and signing the charts and looking things up that I didn't know or couldn't remember. I was sitting at the nurses' station reviewing data on the computer. Sitting in a place that is really a "nurse only" place but that the nurses graciously allowed me to occupy. They knew I was just killing some time.

I stared at the computer monitor and mindlessly scrolled through the lab values. Kidney function: abysmal. Sodium: the highest I'd ever seen. I wiped my hand over my face and then looked over toward her room. I pictured a phlebotomist fastening a tourniquet around her swollen arm and plunging a needle deep into the crook of it to get that blood. For what? These results would not change our plans or alter the outcome.

"Why did we get labs on Mrs. Cafferty this morning?" I'd asked on rounds earlier that morning.

"She's a full code, Dr. M," my resident responded while making careful eye contact with me. I liked the way she spoke up before her intern could get uncomfortable about my direct query.

"I know she's a full code," I replied, "but there is not a single lab test we can order or respond to that will change what is happening." Our eyes were still locked.

"But Dr. Manning she's still our patient. She is here on our service and under our care. Shouldn't we still be doing the same things for her as the rest of our patients?"

I moved my eyes from my resident to the rest of the team. They were shifting nervously from the chutzpah of the senior resident's responses.

I asked myself that same question:  Shouldn't we still be doing the same things for her as the rest of our patients?

But she wasn't "the rest of our patients." She wasn't at all.

This was different--and difficult because we had grown to deeply care for Mrs. Cafferty. She'd been admitted to our team three separate times that month, all for complications of her severe refractory leukemia. Entering her eighth decade, her body had run out of fight. Four full rounds of hell-atious chemotherapy with nothing but nausea, horrid exhaustion and frighteningly awful anemia to show for it.

And yes, at the time of that discussion she was still a "full code." This meant that her family wanted every single heroic thing done on her behalf, despite her dismal prognosis.

But still. Even if she was indeed a "full code" that didn't change the unfortunate reality. Mrs. Cafferty was dying. Especially on this, the worst of all of her admissions to date, there was no disputing it.

"Mrs. Cafferty is dying."

 I stated the facts and left it at that. In silence, it set in. I could see their wheels turning. Imagining those same things that I was thinking like, Why are we sticking her with needles and pricking her fingers for blood sugars when those things hurt? Why are we not focusing on keeping her as comfortable as possible? What are we doing?

We entered her room that morning and I stood by as my resident eloquently discussed all of these things with the family. By this point, Mrs. Cafferty was lapsing in and out of consciousness, so this conversation took place with her children. And no, this was not the first time that the subject of end-of-life care had been brought up with them, but it was the first time they were ready to accept what was happening.

"Let her go in peace," the eldest daughter finally said. "This is our decision. Mama would not want us to keep her alive this way. Please just keep her comfortable." The rest of the family nodded in somber agreement.

It was a big family, too. Big and close and keeping close vigil at their beloved matriarch's bedside. So there was a big crowd there when that decision was made. People sitting on chairs and leaning against walls. Teenaged grandchildren nestled tightly into bedside chairs together and even one sitting right beside Mrs. Cafferty in the bed.

By the time I was sitting at the nurses' station scanning those futile lab results, it was early evening. Our interns had finished up and were gone for the day and the resident was probably on her way home after clinic.

And me? I was just sitting in that nurses' station waiting. Waiting for Mrs. Cafferty to die.

Around lunch time she had crossed into a different physical state. That state with agonal respirations and deep, gurgling sounds representing entry into the home stretch. Like thunderous hooves of horses at the end of a race; I'd been doing this long enough to know that it was only a matter of time before she crossed the finish line.

More and more family arrived. They must have heard those hooves, too. Galloping hard, fast, closer and closer. They all wanted to be there to lay the blanket of roses at the very end.

"Dr. Manning? I think. . . .I'm pretty sure she's gone."

That's what that elder daughter came out of the room to tell me. Her eyes were red and tired. She made no attempt to wipe the tears from her cheeks. Her lip quivered when she said that last word: "gone."

I looked up from that screen and froze on her face for a minute. Next, I abruptly stood and came around to face Mrs. Cafferty's daughter.

"It was peaceful," she said with her lip still trembling. "She's. . .she's gone. . .gone home." And with that word "home" she began to cry full on. Hard and sorrowful cries but still restrained.

Instinctively, I hugged her. Tight and hard, pressing my fingertips into her back without saying a single word. I'm so sorry, I was thinking. Do you know? It was an honor to care for your mother. This is what I wanted that hug to convey. I hope it did.

The next part is that part I've never liked. Pronouncing the patient dead. Ever since I was an intern, this has always filled me with angst. Particularly when it has to be done with family watching. The finality of it all; it has always been different than a conversation about the theoretical or even inevitable end of life. Pronouncing someone dead is concrete and unwavering; it's never open to interpretation or with even the finest trace of hope for something miraculous to change it.

Yet this? This is what I signed up for. And I had a relationship with this family so I knew it would be best for them all if I stayed in that seat at the nurses' station until the moment came. I didn't want it to be a stranger or the cross cover intern on call. At least if I could help it.

When I entered the room, it was like coming into a wake. Confluent weeping and sniffling created the ambient noise with the exception of one big, grown man crying a muffled, guttural sound into the fold of his elbow.

"I'm sorry for your loss," I spoke quietly. After pausing for a moment, I approached Mrs. Cafferty. She looked like she was sleeping more than anything. Like Sleeping Beauty, peacefully and quietly sleeping.

I placed my fingertips on her carotid pulse and waited for what I knew I would not feel. After feeling no pulse, I flashed a penlight quickly into her pupils to look for a light reflex. None. It was official. Mrs. Cafferty had expired.

Glancing at my watch, I noted the time--6:23 PM. Though it should have been the furthest thing from my mind, I immediately thought of how happy I was that this was a Tuesday. Had it not been, I would have already been gone to get the kids. Tuesday is the day that my sister, Deanna, picks up the boys so I put thanking her for that on a mental post it note for later.

"Dr. Manning, we appreciate what y'all did for Mama." This was what one of the younger ones in the room said. He looked to be in his late twenties or early thirties, but I really couldn't tell if he was a son or a grandson. I nodded in return.

Next, that same elder daughter extended her hands outward at her side which I quickly learned was a signal that the entire family recognized. They all formed a giant horseshoe around Mrs. Cafferty's bed that became a circle once the two people on each side of the head of it each placed hands on their sweet loved one's respective shoulders. Before I could even react, each of my hands were already tightly encircled by family members--one was a teenager that I'd seen earlier and the other was that same spokesperson daughter who had now become the new matriarch.

"Every head is bowed, every eye is closed," she instructed, "Let us pray."

And that is exactly what she did. Or rather what we did. We touched and agreed and acknowledged the life of someone I had known for only three weeks, but whose life unfolded before me with every word. Having my eyes closed helped me to see it all the more clearly. . . . what love can do when applied consistently.

We said "Amen" and then someone began to sing. Soft at first but then stronger and stronger. A gospel song that I didn't recognize, but one that must have been one of  Mrs. Cafferty's favorites from the response it garnered. Hands raised toward the heavens, more weeping, tight hugs gripping with grief.

Then, it was all over. People began spilling from the room with arms slung over shoulders. Nurses offering condolences and hugs. And me sitting at the nurses' station again, this time writing a death note.

I finished up, drove home and told every single member of my family how much I love them. And I also thanked my sister.

And yes. This? This was just a regular day at Grady. Regular in the sense that it was perfect and meaningful and full of grace.

Happy Good Friday.


  1. You have at add another option to your like buttons... how about "no dry eyes here" or "please don't let this be an ugly cry" ?

    Here I am sitting in public and getting stares... it looks like my computer just broke up with me, thanks Grady Doctor! But a beautiful and touching post, as always.

  2. At least I'm home alone with the tears down my cheeks. I hope my end is as complete.

  3. We had to make a similar decision for my mother-in-law about a year ago. The care and caring of all the staff in her ICU (Hollywood Presbyterian, thank you forever!) was a blessing especially through those last three days.

  4. She never warns me about reading these posts while I'm at work... sheesh.

    That was beautiful, Sister.

    I love you.

  5. An undergraduate thesis project on death and dying. Volunteer time with Hospice. Books read by Kubler-Ross and Dr. Bernie Siegal. And now a strong desire to become either a Hospitalist or an Oncologist.

    Thank you for the beautiful and touching reminder that doing this at this stage of my life is right for me.

  6. And so it will be for all of us.
    Let us go in peace.

  7. How perfectly beautiful. You've made me cry, quietly but rightly. Thank you.

  8. I am one of your silent readers, I don't even remember how I found your blog. I'm a second career seminary student and I'm praying that I get a chaplaincy internship rotation at Grady. I read because I want to learn, but I also read because of the ministry of medicine that you so gracefully practice. Thank you for sharing your work, your soul and your self with the rest of us. Blessings.

  9. Last year our bass player and tenor in our band died on our basketball court at church on Saturday before the first private Sunday after we opened our new church building. The week before we held the public opening. The service that Sunday was a private tribute to Les, whom we all loved. I termed it the family funeral. The public funeral happened the in the following week, but the family funeral was the most meaningful. We had this for my mother. The hospice worker was at her house and two of my sisters and my younger brother were there as we were being praised by the hospice worker for the care we were giving her. The children were in the back yard playing. I was watching her breathe and noticed as he was talking that she gave my hand one final squeeze and stopped the labored breathing. I was the one who said that I thought she was gone. My mother and I didn't have a strong positive relationship. She yinged when I yanged. It has been such a comfort over the years that she acknowledged that I stayed with her and was there for her. I think the family funeral is the most important closure. Everything else is just tradition. I wish I'd been available for my father's.

  10. How does your giant heart fit inside your body?

    You writing is beautiful, eloquent and true. You are a gem in this world, and I'm so thankful I found your blog, because you give me hope and perspective.

    Your patients are lucky to have an angel like you to care for them, to bear witness to their lives, and to honor them in your writing.

  11. Spice Girl -- Ha ha ha! That's a funny suggestion. Perhaps I will add an "bordering on ugly cry" button. You are so sweet! :)

    Kristin -- Oh, sister Kristin. Thank you so much. I hope mine is also as complete.

    Cathy -- ICU staff are amazing. I am glad your mom-in-law had good people there caring.

    BumbleBee (little sis) -- I love you more.

    Path201x -- Yes, sister. This is the right time for you!

    Sister Moon -- Yes and yes. Wish you had been there with me. You would have appreciated it.

    Elizabeth -- You are wonderful. Just got back from Florida and am about to catch up with your blog!

    Jill -- I hope you get your internship there, too.

    Angella -- You should know grace when you see it. You are one of the most grace-filled people I know.

    Lisa -- Thank you for those beautiful words.

    Mel -- Thank you. And trust me, I am the lucky one.

  12. Thank you for posting such a beautiful life story. You captured the moment so eloquently.

  13. This is an important topic because it demonstrates the change from we must prolong life to we should avoid prolonging death. Once death is inevitable, it should be made as comfortable and comforting as possible. Unnecessary suffering must be avoided, surely?

  14. Fantastic post. Very moving. Thank you for sharing.


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

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