Watching death

Not so clear-cut

The patient’s monitor showed that his heart stayed in sinus rhythm, but the rate continued to slow and then abruptly switched to the flat line we all see on television. I checked his pulse and respirations, confirmed that they were absent, and noted that this was consistent with his flaccid muscles and the way the colour had drained from his face. I told the family that the moment had come and that he was deceased. Then I paused for half a minute, as it just seemed like the right thing to do.

Suddenly the monitor started back into a sinus bradycardia. I must confess that my first emotional reaction was annoyance. Did this corpse not realize how foolish it was making me look? Then, to add insult to injury, he took a single breath. Other than that he looked as dead as before. His colour was still ... dead ... and I confirmed that he still had no pulse.

Maybe I was oversensitive, but I felt a need to explain to the family why the man I had just declared dead was now breathing again, and why the monitor that we could all see looked the same as it had when I said he was alive. In the setting of septic shock, acute renal failure, severe hyperkalemia, and recent asystole, developing pulseless electrical activity does not constitute a positive prognostic sign. I explained to the family that his body still had some live bits that were making a few last gasps, but that the important point was that he was past the point of no return. He would not come back to life. Two minutes later, his pulseless electrical activity rhythm drifted back to asystole, and my moment of embarrassment passed.

Now I had to fill out the death certificate. But what was the patient’s precise time of death? Usually I have no trouble defining this; either the nurse or family members tell me a specific time, or I use the time of the moment when I say “stop resuscitation.” In each case the time of death is within a minute so I can record it accurately. Now I was less certain. Was death the first asystole or the second?

But surely real death is cellular death. In that case some of his cells were still alive even as I was filling out the death certificate. Or maybe real death is more specifically brain cell death. That is not so satisfactory either. One of the reasons his family was so stoic was that his brain had not functioned well for a long time. In that sense most of “him” had been dead for years. If Mr X. were only Mr X.’s mind, then he had been mostly dead before I even met him and I did not really watch his death at all. In that case my whole encounter with him was a sort of last gasp. Maybe that is why it seemed so calm. In the end, of course, my choice of what to record as the last digit in his time of death for his death certificate was of no real consequence, so I picked one.

Gradual process

For many of you the idea that death is a gradual process rather than a specific moment probably seems like a no-brainer (if you will excuse the expression). And deep down I had known it all along. But I thank Mr X. and his family for reminding me that life is not an on-off switch. Life occurs along a continuum, sometimes for years. That in turn serves me as a reminder to live life to the fullest—right now.