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The Next Step

My wife recently asked me “How do you deal with death on a daily basis?” I tried to answer this question as best as I could, but ended up stumbling over my thoughts. I wanted to convey my feelings about the personal effect death can have on anyone who is exposed to it routinely. Working in an Emergency Department, the tendency is to push the thought of death to a far corner of your mind and leave it there. It may be common for a Nurse, or Doctor to think “Oh, I’ve seen that before, that is too bad, but it is busy, and this is just part of my job.” I would guess that on a deeper level, amidst the everyday flux of life and hectic work in the Emergency Department, the people we see in the last stages of life effect us in ways we cannot comprehend. After working in Medicine, and in the Emergency Department specifically, I think death has the potential of metamorphosizing itself within the human psyche: from a grim notion tucked into a dark corner, to an absolute gift that has the ability to change us immensely during life. I believe those who find themselves accustomed to death are given a unique opportunity to embrace this gift. I have found myself being cognizant of the way people die.

Sometimes death is sudden. Trauma and experiencing the sudden death of a patient is one of the hardest, gut wrenching experiences I have endured as an Emergency Department Resident. The familiarity of trying to save someone who has endured a life ending traumatic injury and being unsuccessful makes death that much more palpable. These are people like you and I who moments earlier were living life: working, biking, swimming, surfing, driving, and skiing. They were someone’s husband, wife, father, daughter, girlfriend, boyfriend, or boss. They are dressed like you or I-in sweats, biking gear, a suit, a dress. You catch a glimpse of their belongings: a purse with a cell phone, a hair scrunchy, a backpack with books, a bottle of water. Reminders of things that were. There is a flurry of activity around them-you hear the Paramedics report, you assess the injuries, you do everything you can. The finality can be a short, quick ending. Other times the struggle is prolonged, mostly by us. All that is left is an empty shell. Now they are gone.

Sometimes patients die alone. They come into the emergency department and seemingly have no one. No relatives to call, no contact information, we may not even know their name. Sometimes they are elderly, from a nursing home, and the closest family is a plane ride away. Sometimes they are found on the street. Sometimes they live alone- did anyone know they existed? It is hard for me to imagine that we will be the last comfort they may have. How can you be given such a charge? You try everything to save them, but when it becomes apparent you cannot-how do you help someone with the transition from life to death? I have seen nurses hold their hand, or stroke their hair. I have seen Doctors become teary. I pray we did not let them pass alone.

Sometimes patients are ready to die. Patients with cancer or other terminal illnesses may come to the Emergency Department if their condition has suddenly worsened. Having worked as a Family Practice Resident prior to working in the Emergency Room, I had become familiar with helping patients with terminal illness and families transition towards dying. In many cases all efforts are made to treat the illness. When efforts fail, institutions like Hospice provide invaluable care for patients and families making this transition.

I recently met a patient named John. He was 45 years old and was diagnosed 6 months ago with metastatic Melanoma-a rapidly spreading form of skin cancer. He had been receiving treatment for his cancer for 3 months, and his condition had worsened. He was brought to the Emergency Department because he was having tremendous difficulty breathing (the cancer had spread to his lungs). I remember asking him “John, what can we do for you.” He replied with a glimmer in his eye and a small smile, forcing what little energy he had left, just to speak: “Nothing man, I’m ready for the next step.” He passed 5 minutes later.

These words stuck with me, “I’m ready for the next step.” I cannot imagine being truly ready for the next step-not yet anyway. So back to the question: How do I deal with dying? I live everyday to the fullest, stirred by the people we have tried to help in the Emergency Department. They are with us on some level every day. You have to pull them from the far corners, and realize they could be anyone of us at anytime. Life is so precious, we have to respect it, this is their charge: We are alive: the woman on her bike that I pass on the way to work, the elderly woman in the grocery store, the homeless man on the street, my wife and son laughing on the couch. We cannot take life for granted.

I would love to hear your thoughts or personal experiences about death, or the passing of a loved one-your experiences can help us all embrace life.

Sean Donahue
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.