Have you ever seen somebody die?
In my first year of medical school, this subject has yet to be broached in a meaningful way. As medical students, we are preparing to work in a field of literal life and death, but how do you handle death if you’ve never seen it? Life is easier for us, we have all seen it, experienced it at least to a degree. But death is elusive. It’s shrouded in mystery. It’s painted in novels and movies and TV shows as difficult and beautiful. It’s talked about in hushed, reverent tones of inevitability and acceptance. Even when it’s messy or unfair, the character at the end has some realization that there was good in it.
Have we been unconsciously trained to expect this from our patients? Do we expect them to accept, to transcend into their greatest selves right at the moment of their hardest struggle? Do we anticipate this from our patients’ families—to understand, to cope, to adjust, to acknowledge the loss and yet make logical decisions on their loved one’s behalf? How are we, as medical students, to be trained to console and best direct our patients and their loved ones through the course of dying if we ourselves have never experienced it?
I have found that watching someone die is an experience unlike any other; it changes you in ways you both appreciate and hate. Though, almost a right of passage on the path to becoming a “real” doctor, it seems clinicians rarely speak about their first and very visceral experience with death. It creates anticipation, fear, and maybe a tinge of excitement imagining what it might be like when you are the one there in the room when a person’s soul departs—when they draw their last breath. It becomes this mystical realm of someday-but-not-yet. What happens when that day comes?
I have seen someone die
I have seen someone die and here is the truth of that experience for me. I watched both of my grandparents decompose this past year; transition from vibrant, warm, exuberant people to barely more than carcasses—similar to what I spent the last six months hacking into in the anatomy lab.
In March of 2013, I found out my grandfather (Papa) had salivary gland cancer. This was a blow delivered awkwardly by my parents one afternoon. I was in shock. My Grandma and Papa had raised me. They were often more like my parents than my real ones. They were two of the most important people in my life.
Somewhere in the back of my mind, I had always known this day would come. Death is a natural process that everyone encounters. But I couldn’t believe it was now. I saw my Papa that week. I drove over to their house and, as usual, he was in his garden, kneeling on the ground in dark pants and a button-up shirt, dirt caking his knees. Surrounding him were a trove of tools and he was wrenching some part (I cannot even name off) of his sprinkler system. “Hello Lauren,” he rumbled. How could this incredibly active seemingly healthy man be dying?
Two and a half years later after countless bouts of chemo and radiation, it was undeniable. His liver gave out and his organs began to shut down. Within two weeks, he went from presiding over his Mason’s club to lying in a hospital bed unable to talk or even open his eyes.
I remember my Papa’s last day. The morning had been horrible. I had gone by myself to their house and found my grandma in hysterics. I ran in to find him spewing bile, gasping for air. I stood there utterly helpless.
Fast forward a few hours and my parents, aunt, and I sat in the family room where his hospital bed lay. It was May 13th and a beautiful day. The screen door was open and there was a soft breeze that floated in mixing with the increasingly evident smell of death.
He couldn’t open his eyes anymore. They fluttered constantly but never focused. He could no longer speak, but moaned every so often, stridor with every inhalation. His breath was rotten and his mouth looked like a black hole. I remember standing over him noticing how few teeth he had left. We were looking at old family photos—pulling album after album down from the shelves, sifting through years of memories just for something to do.
My grandma stared at him. She couldn’t look away. She didn’t say anything, just wrung her hands and stared at him as his breath became more labored and less frequent. And then, I was sprinting to the next room, urging my dad off his work call, “this is it, this is it,“ I said, “you need to come now“. We all sat there and waited. Occasionally, someone would walk up, hold his hand, tell him he was loved. My grandma went up and told him quietly he could go. And that was it. He breathed in deeply and out, and his body was still.
What do I remember after? I remember my dad, who doesn’t express emotions, pacing the beer garden outside. Just walking the path, hands clasped behind his back, eyes up to the sky. I remember my grandma’s eyes losing focus, her body crumpling into me, almost as if she had had a stroke. I remember making a joke to lighten the mood. I remember the tears that ran down my aunt’s face silently. I remember driving home that night turning up the heat in my car as high as it would go, sunroof open to the stars, sobbing. I remember thinking how incredibly ugly death is.
In the recent months with newly acquired vocabulary, I have poured over articles trying to pinpoint down exactly what was affected in my Papa. The parotid gland where the cancer began. His recurrent laryngeal nerve that made him unable to speak much of the time from diagnosis to death. His liver shutting down—the bilirubin turning him yellow. His teeth falling out because of chemo. I can break it down into science now, but it doesn’t really matter. That wasn’t my Papa.
My Papa was the man who built me a sandbox on his back porch. The person who took me to feed ducks every Wednesday in preschool. We used to go deer tracking throughout my childhood—we would wind along a path in their giant backyard, cross a creek, following prints and droppings for what felt like miles. He built me a swing, fashioned it off a tree, and my sister and I would fly out over the creek as he pushed us. He drove carpool to school. He learned my friends’ favorite sodas and snacks and would bring a cooler with him when he picked us up.
He was partially deaf so you would have to speak a little louder whenever you talked to him on the phone. He had a beer every night at 5pm—only one, and a bowl of chips to go with it. He kept Neccos in his pocket—the candy apparently everyone but me abhors—and would fish them out when I asked. He taught me how to use power tools—to build bird feeders, and boxes, and a stool. He taught me how to play the piano. He attended every performance I ever did. He collected articles “disproving” global warming that he would send to me. I would fire back, pointing out all the article’s flaws, and I remember his slow smile when he got his desired rise from me. When I told him I was switching to medicine, he fished out his old chemistry book from 1949 and handed it to me, commenting that perhaps the science was a little outdated. This was my Papa.
Part two of “the year that would never end”
Move forward a few more months and still reeling from the loss of my grandpa, we learned in October that my grandma’s melanoma, which she had ignored while my Papa was dying, had metastasized. We were more prepared this time. We knew what it was like. They gave her six months. It took her four.
At her end, I sat by her hospital bed, and the scene replayed. But she, unlike Papa, wanted to die. She had made that well known. Her mind was going because of Alzheimer’s or depression, both of which had been greatly exacerbated by my Papa’s death. But there had been a few months before the diagnosis, where she had come back out of her shell a little. She talked of wanting to go again to Hawaii. She had made friends at her retirement community. We took her out to coffee and dinner. Her incredible sense of humor came back.
As she became weaker, though, she returned to the shell that had clouded her since my Papa’s diagnosis. She was weak, and tired, and had had enough. The night she vehemently expressed this to my father, she had a stroke. Upon hearing this, I waited one week to complete an exam and jetted across the country back to California.
American Airlines offered free movies, and as I clicked through, I found The King and I. My grandma and my favorite movie to watch together. I sat in the dark somewhere over Indiana, tears running down my cheeks as Anna waltzed with the King, feeling like I was running a race against time. By some cruel miracle, she lived 17 days after her stroke. Her advanced directive firmly stated no assistance and yet her body didn’t seem to grasp the concept that it needed food and water. I arrived on the evening of day 15.
I sat with her the next two days. She looked eerily like my Papa. Eyes fluttering, mouth open all of the time, gasping and moaning. Her mouth too was rotting and black. It’s a strange thing to notice but it was so unlike her—always clean, always healthy. I remember thinking that I would rather die immediately than have someone watch me like that. I asked her if she wanted to listen to my lecture capture, and because she didn’t moan, I took it as a yes. When I told my dad as much, he remarked, “Well, if three hours of that didn’t kill her nothing will.” As I said, we got better with the death thing the second time around.
We took turns being with her—never leaving her alone except at night. I was alone with her when there were a few false alarms. I watched as twenty seconds occurred before the next breath. My heart began to race as I thought, this is it, and I’m alone. Part of me was terrified—was I adult enough and capable enough to handle it? Part of me, I’m embarrassed to say, wanted it to be just me and her when she went. A voice I tried to hush kept nudging how perfect it would be—just me, her, and the special connection we had shared my whole life. But I don’t think she wanted any of us to see her last breath and so she went at 5 AM when only her caregiver, Puyon, was by her side.
Again, it was horrible. Again, it was unfair; a healthy person wasted away in front of me until she wasn’t that person that I knew.
My grandma was everything kind and good
My grandma was everything kind and good. I think it was impossible not to like her. Every single person I have met has commented on how sweet and funny and special she was. This was a woman who had the amazing knack of making friends immediately and easy. She was vivacious, unpretentious, and chatty, and it instantly drew people to her.
Even as a child, I knew she was something incredibly special. Someone to emulate. When I was about 3, I decided I wanted to be just like her. We had matching jackets and a matching haircut as well because I wanted to look like her. She was fiercely independent and she would tell me stories of her many adventures—how she traveled to Hawaii and Alaska before they were states and how she ventured to the south alone before the civil rights movement.
She loved going to the city and to coffee and to the movies and we did each as frequently as the two of us could. My Papa and she visited almost every country in the world and she loved different cultures and the thrill of the unknown. She loved reading, watching the stock markets on TV, and dancing. She was one of my best friends, my confidant, and my role model, we would talk for hours on the phone each week when I was across the country in college and grad school.
I gave eulogies at both of their funerals. I found it very difficult to put into words what they were to me. How do you describe someone who was your world in a few measly sentences? How to do you explain that when they died, part of you did too?
After my Papa passed, my mom said he had given me an incredible gift. The very thought still makes me furious. She was implying that witnessing death in such an intimate way before beginning medical school would make me a better doctor. Well, it was not a gift I wanted. I did not want to watch the strongest man I knew collapse. I did not want him to become a walking skeleton. I didn’t want to see him fight so incredibly hard for life that was eluding him. I did not want to see her so fragile, so hopeless. I didn’t want to see her rot in front of me. I didn’t want any of that. I would happily exchange being a second rate doctor if I could have my grandparents back.
March 2015 to March 2016 have held both my happiest and saddest memories. Amidst celebrating my engagement and a new career journey, I said goodbye to two of my best friends, my second parents. I said goodbye to a part of me.
Even my hurried wedding—shoved in the day before Christmas so my grandma could attend before she died—held mixed emotions. The same lady who had traipsed the hills of San Francisco with me barely five months earlier could no longer walk—trailing oxygen machine behind her, a walker in front as she shuffled her way slowly up the aisle of the church, mumbling “My baby. My baby is getting married today.” I sobbed that night in my new husband’s arms, unsure whether I was crying because I hadn’t had time to process the marriage before we did it, because the fantasy of the wedding had not occurred, or because my grandma was dying.
I sometimes close my eyes and I can picture everything as it was perfectly. I can feel the soft brown carpet of their house on my cheek. I can smell the juicy chicken my grandma is roasting. I can taste the foam of the beer my grandpa has given me. I can hear their voices ringing in my ears. I can feel how incredibly loved I was.
Why am I sharing this? Because I want to you see my Grandma when you experience your first code. I want you to notice the auburn hair that she’s dyed since she was 20. I want you to see the gentle upturn of her lips. I want you to look into her eyes that are mirror images of mine, freckles and all. I want you to see my Papa when you pronounce time of death at 3:28 pm. I want you to carefully remove his gold-rimmed glasses, sliding them off his strong German nose. I want you to smile at the combed over bald spot. I want you to see the person he was.
Our patients are people, alive or not. Human beings with strong back stories, memories of adventures, of love, of loss of struggle, of joy, of shame. The dying patient is that same person who once lived. The dead are not the relics they appear.
Let us learn to treat them with that respect. Let us help their soul on to something more peaceful.
It is our privilege.
Maybe my mom was right after all, calling it a gift.