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Becoming a PA

The beauty of death

Vaglio, Rebecca MMS, PA-C

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Journal of the American Academy of Physician Assistants: December 2016 - Volume 29 - Issue 12 - p 1-2
doi: 10.1097/01.JAA.0000508214.27213.75
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Flashback to May 2012. It was the first day of my clinical experience as a certified nursing assistant, and I arrived at the nursing home at 7 a.m. with no idea what to expect but an open mind. My first patient was an older man, and I walked to his bedside to inspect his condition. His mouth was permanently perched open to the point that his oral mucosa was dry and cracked. His eyes were closed and so sunken that his bony structures protruded. His frail and emaciated body was rigid as he lay in a deflated bed in a cold room. I stepped closer to him, placed my hand on his arm, and introduced myself. His skin was frigid. He was motionless. All I could hear were his sparse and erratic respirations whistling through his patent mouth.

At this point in my training I didn't know much, but I knew this wasn't right. This man was dying right before my eyes. There was no family in the room. There were no friends. There was just me, a nurse, and this man's imminent death. In my mind I was terrified. Was I supposed to do something? Was I supposed to just let him die? As I stood in the background while the nurse waited to call his eventual time of death, I took the time to be silent. To be still, and to hope that he would find his own peace. In that moment, there was nothing I could say, nothing I could do to change the outcome. As he hovered between life and death, I questioned if my presence was necessary? No, not really, I concluded. But the thought of him dying alone, unwitnessed, in a cold, empty room was not acceptable. In his last moments, he took several deep breaths and then the breathing halted. His once tense body now completely relaxed.

It was then that I realized I had looked at his final moments with selfish eyes. I wanted to help him. I wanted to be his calming presence. I didn't want him to be all alone or to be forgotten. I wanted to do something. I wanted it all to have meaning and purpose—for myself. But his death wasn't about me at all. This wasn't my story. Instead, it was about a man who suffered in a body that was beyond repair, and his death was his release. He was no longer suffering. No longer agonizing. He was set free in mind and in body. As he transitioned from one phase to the next, whatever and wherever that may have been, it was certainly away from the broken shell that remained on the bed.

Flash forward to October 2015. I am now a PA student in my general surgery rotation. I haven't seen a patient die since that very first patient encounter several years ago. But I am not thinking about death today; instead, I am preparing for my first aortobifemoral bypass, on a 60-year-old woman. From her chart, I know her risk factors are extensive, including high cholesterol, heart disease, age, obesity, high BP, and an extensive smoking history. After conservative measures have failed, this surgery is now her only hope. The surgical team and I await her arrival, and she finally rolls through the OR doors. She is propped up in her stretcher, and her robust abdomen shakes as she glides along the floor. Her hair is brittle, and the smell of smoke exudes from her pores. Even though she promised all her doctors she would stop smoking, her fingertips are still stained with nicotine. She is a sweet woman, though, and is in the best of moods. She lies on the table with a smile on her face and is ready for whatever may come of this surgery, as she knows her body is unable to fight her extensive disease by itself.

Hours into the surgery, she begins to code. Her abdomen is wide open, and we quickly remove medical tools from her open cavity. Surgeons are yelling, tension is high, and everyone is scrambling. No one speaks to me, but a piercing look from the fellow tells me I must get out of the way. I step back from the table as the surgeons begin CPR.

In that moment, I recall the very first patient I saw die, and the same thoughts cross my mind. Is this it for her? Am I supposed to do something? I am more educated and more experienced than I was several years ago, but I still have no ability to help the dying patient in front of me. So, again, I stay quiet, in a cold room, with no family or friends of the patient to be seen. The patient continues to code, and eventually she dies. The surgeon is angry and blames herself for not being able to save her patient. But as I stand silently among the chaos, I remember again that this is not about me or the success of the surgeon. This is about a woman in a body she could not escape. At this moment, I can see what no one else appears to have noticed. She is free. Sometimes, being trapped in a failing body or mind is worse than death. Unfortunately for this patient, her body had entrapped her, and when medicine could not provide a cure, her only remaining chance of release was death.

For me, these experiences were transcendent. I was able to witness not just death but the beauty of death. This beauty isn't always tangible or visible, but it's there, whispering through the societal and medical constructs that say death is always a bad outcome. And in her whispers, death shows her beauty by liberating a body that no longer functions.

Maintaining patients' quality of life and constantly deciphering the right diagnosis, treatment, and cure are valued above anything else in medicine, but where does that leave those patients who are preparing for death? Every moment of life should be treated with the utmost care and respect—from beginning to end. The beginning of life is often described as beautiful and a miracle—the opposite of death. Yet death might be the final remedy that allows a patient to finally get the comfort he or she has been seeking for so many years.

Too often, as clinicians or as caregivers, we become selfish in what we want for our loved ones or patients who are reaching the end of their journey here on earth. We want what fits our needs, what can give us the best closure and serenity. We ascribe immense importance to the meaning of life, but often the sacredness of death is lost. Yes, life should always be valued. But we also should have a greater acceptance for death and take the time to realize the majesty of its grasp.

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