This is the third time I have written a post featuring a work by Jacqueline Woodson. She is a celebrated contemporary author, and her work continues to resonate with me. In her short novel Another Brooklyn, protagonist and narrator August tells her coming of age story and attempts to come to terms with her mother’s suicide that occurred when she was a child. As a grown anthropologist looking back on her life, August weaves her memories with observations of various cultures’ views and practices around death and dying. From India, Korea and Mongolia to Mauritania, Uganda and Bali to the Philippines, Indonesia and Fiji and even to an enslaved Ibo tribe off the coast of South Carolina, she notes a wide array of responses to human suffering and loss.
August describes the first day of her college career at Brown when she tells the professor,
"I’m here because even when I was a kid, I wanted a deeper understanding of death and dying,” (159).
Her observations stirred a memory of my own time at Brown when I designed a project for a comparative literature course called Literature in Medicine. I had spent the semester studying depictions in literature of humanistic side to medical treatment, including reading Dr. Eric J. Cassel’s admonishment that damage and suffering contain “features that must be defined in terms of a specific person at a specific time” (from “The Nature of Suffering and the Goals of Medicine”). I decided I wanted to take a stab at noting the definitions myself, and after emailing several physicians at a local hospital I found one who would let me interview his inpatients.
Cassel instructed doctors to note a patient’s “comfort zone”, to understand how a patient is feeling and what the patient understands so he or she can know how to treat the patient, how much information to offer and how s/he can extend compassion. This humanistic outlook, Cassel argued, would assist the physician in fulfilling the twin obligations to relieve suffering and cure disease. Keeping this in mind, I designed a set of questions also based on Dr. William J Donnelly’s ideas in his article “Right the Medical Record: Transforming Chronicle into Story” in which he stresses the importance of the documentation of patients’ feelings and knowledge of their situations. I asked the patients what they knew and felt about their situations, what kind of pain was involved, whether they could describe the situation using a metaphor, how the illness affected their lives, whether they thought their situations unique from others dealing with the same illness, how the illness changed or confirmed their outlooks on life, what they learned from the experience and what, if any, beliefs helped them through it all. Each of the interviews was unique and revealed a patient’s particular needs and feelings about his or her illness and treatment. I never received a complete set of answers to my questions from any one patient, and each conversation took a different turn.
I would have loved feedback from my professor, but since I was an underclassman in the course, I was assigned to a T.A. who met me at a sandwich shop to give his feedback on the interviews.
“Have you ever considered going into anthropology?” he asked.
“Oh, no,” I admitted, surprised. “I hadn’t thought about it.”
“I think this is a great start to a study in anthropology,” he continued, “You should think about it. I really enjoyed your paper.”
I smiled, relishing the compliments.
“What are you going into?”
“Medicine,” I stated, as if it were the most obvious choice. I loved literature, but the course was Literature in Medicine. It was a good excuse to read about the field I hoped to be passionate about.
The patients I interviewed for my project weren’t near death, so my compilation of observations differed from Woodson’s character. Later, during an internship in internal medicine and surgery following medical school, I continued to gather stories from patients about what they thought of their illnesses and plenty more about what they thought of their doctors, but unfortunately, I also had more than my share of experience with death and dying.
Over the course of my one-year internship I lost twenty, mainly elderly, patients in my care. During my one month rotation in the ICU I pronounced two patients each time I was on call (every fourth night). I felt like the Grim Reaper. My fellow interns and residents sympathized with me. They reassured me it wasn’t due to anything other than being handed patients who were truly ill. Sometimes the patients had orders not to resuscitate. Sometimes we found out about their wishes after having already started the resuscitation process at which time we withdrew interventions. Other times we did all we could. I assisted with the positioning of lines to administer life-supporting medications. I felt a woman’s ribs crack under my palms as I performed CPR.
At the end, when it was time to declare them gone, I used my stethoscope to assess for a heartbeat and breath sounds. When the heart and lungs were quiet, I would look at the clock and announce the time of death.
However, I discovered that sometimes the organs would seemingly continue to function beyond when we would accept the person as gone. On one occasion, with close family at the ICU bedside of their loved one who had clearly passed on, I detected delayed electrical charges as the patient’s heart squeezed out one beat more. With the nurse glaring at me to call time already, I felt stuck between my obligations to make sure his heart was truly still and to give the waiting family some release. In another ICU case, after I had already called time of death, the patient’s chest heaved two last agonal breaths. I placed my hand on the dead man’s arm and willed myself to speak words of reassurance to his twenty-year-old son who had witnessed them.
“This is normal. The muscles can contract after a person dies to give the impression that they are taking a last breath.”
The son was terrified, but then again, having lost his mother to cancer the year prior and then to observe his father struggling in the ICU at his end, well, it would be too much for anyone.
You can guess how this affected me. How sometimes I would be alone in a room with the deceased and fear them coming back to life, grabbing my arm, shaking me that I had made a terrible and incompetent mistake. Of course each death was upsetting. And the effect snowballed.
I remember one woman in a regular hospital room who, not having been sick enough to require the ICU earlier in the day, began struggling to breath overnight while I was on call. She had a DNR order. Perhaps she also had a “Do not transfer to the ICU” order as well. I don’t remember, but that would make sense looking back on this. She wasn’t one of my patients, only one I was covering for the night. I had a vague understanding that her family was aware of her situation, although she was alone that evening. I can’t remember any details of her case, only that she must have had some underlying lung disease -- cancer or otherwise -- and as her oxygen demand increased that evening, the decision in front of me and the rest of the team was to give her morphine and make her comfortable while she passed away.
I ordered an ABG -- an arterial blood gas. It’s a painful blood draw from an artery that can give insight how much her lungs were struggling to exchange oxygen for carbon dioxide.
“Who ordered this ABG?” I heard a nurse exclaim from across the workstation where I was sitting. “Why put her through this?”
“I ordered it,” I spoke up. I knew the nurse hadn’t expected anyone to answer. She just wanted to share her exasperation with the nurses around her.
“But she’s dying,” the nurse laid into me.
“I know,” I retorted. “But I’m the one who is going to let her go, and I need to know that there was nothing else I could do.” Our patient wasn’t going to make it through the night, I was fairly sure, but I also needed to be able to live with my decision. I didn’t want to call time of death before it was really time.
I think she passed away just after change of shift in the morning, after the rest of the team arrived, because I don’t remember pronouncing her, although it’s possible that I blocked it out.
This past fall, as my husband and I struggled through treatment and end of life decisions for our English golden retriever, I realized it was the first time I was deciding to actively end a life. I had seen death and dying so many times in the past, in expected and unexpected situations, but this was the first time I was choosing to end suffering through euthanasia.
I made the phone call to schedule a vet to come to our house while my husband and I were out to breakfast during a vacation that we would cut short in order to spend three precious last days with our pet. It was the hardest phone call I have ever made. I cried openly in the middle of the restaurant where I forced myself to hold it together enough to ask my questions and take notes on the vet’s name, the time of the appointment and the procedure involved.
The appointed day came too quickly, and wouldn’t you know that after an entire morning of sitting with our dog and staring at the clock, counting the minutes we had left with her, the vet ended up running late. And then we started to worry that we wouldn’t be finished before needing to get the kids at school. The situation felt absurd. But at least Sanibel was at home, we decided.
I greeted the vet in our driveway, and she immediately gave her condolences along with a warm hug. I shrugged off her medical interpretations of the Lyme disease and the attempted treatment plans. Knowing we were short on time but being all too aware that this was the last time I would introduce someone to my dog, I tried to put a face on things and remember what joy our dog had brought so many who had met her.
“Come on inside,” I waved her along behind me as I climbed the back steps, “There’s someone I want you to meet.” My voice cracked at the last word as I considered how many people would never get the privilege.
I wanted this last experience to go well for our dog who was usually extremely shy of strangers, so I slipped into the voice I used to use when she was a puppy, a higher-pitched voice usually reserved for puppies and babies. As we entered the living room where she lay in her spot next to the sofa, I announced cheerfully,
“Sanibel, there’s someone here to see you!”
Unexpectedly, Sanibel raised her head and wagged her tail (two movements that had become an extreme effort for her) and in a last burst of joy greeted this stranger. The vet offered a warm smile and immediately sat Indian style on the floor close to our dog, letting her sniff her hands before petting her.
“She’s here to help, Saniel. She’s here to help,” I continued to try to soothe her as she lay her head down again between her paws.
“Oh, she is so sweet!” The vet flashed a tragic smile, and my heart broke as she continued more slowly, “but you can tell she’s not feeling that great.”
True, her breathing was haggard, her lips hung from her mouth from the protein loss, and her legs were edematous from the fluid accumulation. She barely had the energy to move. My husband had been carrying her outside to pee where she would walk only a step or two.
She was dying, but for some reason it took me until that moment to see it.
After the vet administered a sedative, Sanibel seemed to breathe easier. My husband commented that it was the calmest he had seen her in weeks. She was peaceful.
After the vet administered the second medication to let her pass, my husband continued to stroke her side and I clung to her ears. I kissed her then and picked up my stethoscope which I had placed next to me earlier that day. I checked for a heartbeat, and there was silence. No stray electrical activity. Nothing. There was no doubt that she was gone.
For the first time in a situation like this, I didn’t look at a clock. It was sometime after one in the afternoon. I knew we had to go pick up the kids soon from school. But I don’t know what time she passed away.
We had stopped her medications a few days before she passed. She had been refusing them anyway. She had been refusing to eat. From the time she had come home from a two day hospitalization the week before she had been signaling that it was time.
I had wanted her to pass on her own. I didn’t want to carry this burden of deciding the time of her death. In stopping her medications, we let her disease advance. She was suffering, and I have to remember that letting her go was an act of compassion.
A week later I opened multiple letters and cards of condolences from the three veterinary teams who treated her at the end. Each attempted to reassure me that I had done all I could to help her.
Sanibel was terrified of thunderstorms. She would come and find us for comfort even before the first rumble -- she could sense when a storm was on its way. There have been three thunderstorms since she passed away. I have cried each time she failed to appear at our sides. I have longed for a chance to reassure her that it is okay.
As the protagonist of Woodson’s story notes rituals and attitudes surrounding death in different cultures, one common theme surfaces. Many of the groups of people try in some way to preserve their family -- either by keeping the dead in the house long after they pass or by killing the rest of the family in order to be buried with the deceased or by exhuming the deceased sometime later to wash and perform rituals over the body. Many of these examples unsettled me. Yet, while I can’t say I accept the practices themselves, I instinctively understood the sentiment behind them. As my husband carried our expired puppy out to the vet’s waiting car, I found myself desperately wanting to save some part of her. I wanted her to be with me always. If we could have buried her in the backyard, I would have wanted that at least. Instead, I clung to her head, now limp over my husband’s elbow, and kissed her goodbye.
And perhaps as I move through the stages of grief, I will one day cease to relive the steps of the process and come to accept this as true, that she was loved and we did all we could for her. When I think back on the patients I knew during my time in medicine, I have come to peace with their passings, just as, fictional as she was, Woodson’s protagonist marched towards acceptance of her own story. We may act on it in different ways, but the process of letting go is one we all must march through on this side of eternity.
Here you will find a catalog of my writing and reflections.