What we learn from the dying

He lived to see morning, and beyond, but over the next 3 weeks, he never smiled again in my presence. The misery that had settled around him deepened as his blood counts dropped, and even the most trivial infections swept over him like brush fires. By the end of his third week, he was unrecognizable: gaunt, with crusted lips and a look in his eyes. Hollow, haunted, certainly, but also sullen, as if he resented us and everything we'd done in the name of curing his disease. We should have warned him, I thought his eyes might say. We should have told him just how bad it would be. But by that time he had stopped speaking to anybody.

He wasn't that sick, understand, not until the very end. What stopped him from speaking wasn't anything physical. I think it was the knowledge that had started growing in him that first night, that all of this could unravel. That everything he had taken for granted — his health, his body, his life — could all turn out to be so fragile that a wayward sneeze could blow it away. In the face of that knowledge, what is there to say?

'Let him go'
Another case: A nice enough guy in his mid 40s came to the E.R. complaining of chest pain. Changes in his EKG and the results of blood work showed that his heart had been damaged. I managed to meet the patient for about 5 minutes before they wheeled him off to the cath lab. A nice enough guy, a little giddy from the morphine, not really able to take any of it in.

He came out to the CCU a few hours later, still groggy, surrounded by a forest of IV poles running all of the latest anticoagulants. A few hours after that, a nurse paged me to say she couldn't wake him up. He was answering questions in a sleepy, fretful voice. His answers just weren't making sense. When I arrived at his room, I pulled up his eyelids: His pupils were tiny black dots, and they were pointing in different directions. We had him in the scanner 12 minutes later.

I put the CT frames up on the view box and they showed a big white blot in the middle of the patient's brain. The blot was blood: an artery had ruptured. The neurosurgery resident on call was looking over my shoulder.

"We can't touch it," he said.

And that was it. Over the next several hours I was going to watch this patient die. In fact, he was already dead. The process is well described in the literature, inexorable and orderly in its progression. A classic. I'd seen it a dozen times in textbooks, but I'd never watched it happen in real life.

The blood collecting in his skull was starting to build up, pressing on his brain. Soon his brain would have only one place to go: down a very tight opening in the membrane that supports the brain within the skull. There it would squeeze off its own blood supply and die. And a little while later, it would bear down on the brain stem and squeeze off the nerve centers that kept him breathing.

I called my attending and gave him the story. When I was done, he said, "Just keep him comfortable. And let him go." And then the attending said, "Have you seen this before?"

I told him I hadn't.

"Go examine him periodically. Check his retinas. Watch the posture change. Everyone should see this once."

Every half hour or so, in between trying to keep others alive in the ICU that night, I went into the room and peeled back the man's eyelids. I don't remember, really, what I felt as I watched the retinas bulge out as the pressure in his skull increased. I memorized the way it looked, because sometimes you will see this in, say, a case of meningitis, and it's important not to miss it.

The last time I came into the room, the man's eyes were open. They were blank as a pair of billiard balls. He was panting, his pulse was 42, and his pressure was dropping. The end was near. I thought to look one more time at his retinas. But as I leaned over him, in both of his open eyes I saw my own reflection hovering, a figure robed in white, immense, hazy, and distorted.

In my fourth year of medical school, I spent a month in the neurology consult service. Many of the cases we were consulted on were sad: a teenager in the eighth day of an epileptic seizure; a man who had come in because of a twitching thumb — and left with a diagnosis of Lou Gehrig's disease; a 52-year-old who couldn't remember anything since a car accident on Christmas Eve in 1964 and kept asking where his parents were. But the worst times were when the admitting team wanted us to decide if its patient was brain dead. This is a dismal question, and the request is usually prompted by a family struggling to accept what has happened. We averaged one of these each week. The first that month was a 22-year-old housepainter who had set an aluminum ladder against a high-voltage power line. He lay in a bed in the burn unit, surrounded by a dozen relatives who followed our every move.

The brain-death determination involves some startlingly crude maneuvers, one of which is a test for "withdrawal from noxious stimuli." This means hurting someone to elicit a reaction. I stood and watched as the attending demonstrated this. As he worked, a murmur arose from the relatives lining the wall. When the attending rolled the patient's head from side to side, yanked on the endotracheal tube, and poured ice water in both ears, the murmuring grew louder. When we left the room, I was sure the expressions that followed us were reproachful.

My last brain-death evaluation that month involved a 32-year-old man who had been found unconscious on a stifling hot July day. When brought to the E.R., his core temperature had registered 107.8°F. The man had shown no sign of mental activity in 4 days, and the ICU team was starting to worry.

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