On the first day of medical school, we were told that over the next few years we were going to be trained to treat illnesses, to help patients live well, and to also help them to die in comfort. And we were told to never lose sight of the patient. ‘Always palpate the patient’s abdomen’ said our professor (our anatomy lecturer, a surgeon who would retire that same year). This was his lifetime advice – advice that many years later would go on to be described as patient-centred care. ‘Always palpate the abdomen.’ The same surgeon that told us to be humble enough to accept that some of the things we were going to learn may be outdated even by the time we finished medical school, to never stop learning and to accept that what we once held as the truth may change. And to say sorry. Those words have come back to me many times over the years.
The consultant
In the third year of medical school I was loitering around the nurses’ station, trying to look useful, when I overheard the ward sister on the telephone.
She was calling the porters’ lodge. Porters are constantly requested throughout the day and night. They are summoned to move trolleys and people, and machinery. They weave and whistle through hospital corridors with requests for X-ray films and blood results, and nervous patients. But this telephone call was different. This request was quiet and unhurried.
‘I have a package for Rose Cottage,’ the nurse told them.
I didn’t understand at first. Was Rose Cottage one of the administration buildings? Was it part of Estates? Was it some building in the distant corner of the hospital grounds, where secretaries typed and filed all the patients away? If so, why were we sending a package there, and why was it spoken about so quietly?
To me at the time, and to those passing by the nurses’ station and anyone else who might be listening in, it meant nothing, but to the nurses and to the porters it was a code. It meant that a patient had died.
The package for Rose Cottage is a body for the mortuary.
As a junior doctor, the first job I was ever asked to do was to certify a patient’s death. I arrived at the hospital on my very first day, still warm from medical school. I was fresh and unblemished, as yet undamaged by exhaustion and a sense of hopelessness. Still fuelled by a vision of the kind of doctor I wanted to be. My bleep went off within minutes of arriving, and I answered it with the wide-eyed innocence of a child.
‘This is Dr Cannon,’ I said, still testing out the shape of the words.
‘Could you come to the ward and certify a death,’ said the voice on the other end of the telephone.
It was a rubbish first job. I could think of many more jobs I would rather have been given, but I presumed it would be fine. My training, after all, had prepared me.
At medical school, we are taught very little about death. We learn many things about the dying process, we read textbooks about the mechanics that lie behind our final breath and the pathology of the diseases that will eventually kill us all, but we speak very little about death itself. There is a space. A space between an illness claiming its victory and the correct way to fill out a death certificate. A space that contains relatives and upset, chaos and reflection. A space that very often contains pieces of our own self-doubt.
Up until that first day as a junior doctor, I had never met death outside of my own family, other than in the detached, leathered cadavers of the dissection room and in the neat rituals of a post-mortem. As a medic, I had never found myself face-to-face with the end of someone’s life, at least not one that didn’t rest quietly upon a stainless steel table, but still I went to the ward on that day to fulfil my first task as a junior doctor feeling more than prepared for the experience.
And I did know how to feel for a pulse and how to look for signs of respiratory effort. I did know how to check for the presence of a pacemaker and fill out the death certificate. I had been taught all of this, and I could deal with it.
But what I couldn’t deal with, and what I didn’t know, was how I would feel walking into a room at the end of someone’s life and seeing all the small details around that room that told me who this person was. The small details that told me this person’s story. The bag of knitting and the get-well cards, the half-eaten packet of Polo mints and the puzzle books. It was the paperback on the bedside table that stayed with me more than anything else. Closed shut, its bookmark resting for evermore halfway through a story. I took the sight of that paperback and kept it with me. It joined other small details I collected on the wards as I went through my days, not realising that it was the weight of these details that would eventually break me.
When I arrived on the ward to certify the death, I collected a pair of latex gloves from a box on the wall, and the rest of the bay watched as I disappeared behind the curtains that were drawn around the patient’s bed.
I didn’t know the patient. I had never spoken to her or been involved in her care, I just happened to be the doctor on call that day, and I just happened to be the one who was summoned when she passed away. As I worked, I could hear the sound of the rest of the ward, as it played out just beyond the paper-thin curtain. It seemed uncomfortable, brutal almost, that ninety-two years of life could finish to a soundtrack of meal trolleys and floor cleaners, and the whirr and click of visitor conversation. When I’d finished everything I had to do, I removed my gloves and I paused. I looked around the cubicle for something else, another task, but everything had been done. Still, I waited for a moment. As a doctor, my duties had been fulfilled, but as a human being I felt as though the end of someone’s life needed to be observed in some way. It felt impossible to turn on my heels and just go, and throwing my gloves into the nearest bin and getting on with my shift seemed strangely dismissive of the long life that had just ended right in front of me.
When I finally left the cubicle, the eyes of the ward remained upon me. I glanced around as I drew the curtains closed again. Most of the patients had visitors and they were curious, but not distressed. The woman in the next bed, though, was visibly upset. She held a tissue in her hand, but she didn’t use it for the tears that fell from her eyes, she just folded it and unfolded it, over and over, as I watched. I sat in the empty chair next to her bed and waited.
After a few minutes, she looked at me.
‘I shouted at her,’ she said. ‘In the night, I shouted at her to shut up. Now she’s dead.’
‘You had no way of knowing that, though,’ I said.
‘She was making so much noise,’ said the woman. ‘Moaning and groaning.’
I reached out for her hand, and the folding and unfolding stopped.
‘You wouldn’t shout at people, would you, if you knew they were going to die? I’m not sure how I’ll ever forgive myself.’
When the porters arrive to remove a body, the curtains around the other cubicles are pulled to and the double doors to the bays are closed. The body is disappeared, out of sight, conjured away and through the unmarked door in the basement of the hospital, where it becomes absorbed into the rituals of the mortuary. It becomes a package for Rose Cottage. When the rest of the ward reappeared, shocked and curious, it felt as if those ninety-two years had never existed in the first place.
We do not speak of death. In an age where we swagger at the thought of our own openness, death remains silent, hidden away behind curtains and codes and acronyms. For us as human beings, death reminds us of an inevitability; as doctors, it highlights the fallacy of a perceived weakness. We spend years learning how to mend people, and we line up our armoury of drugs and drips, and machinery, and we rage and fight and argue with death until the very end, as if it acts as some kind of a barometer of our usefulness. Unlike clinicians of years gone-by, society refuses to speak of the end of life as a natural progression, because to do so would threaten our own identity.
Our stubbornness comes with a price. We have rehearsed conversations with patients about dying:
In the event of a cardiac arrest, would you like us to attempt to resuscitate you?
Yes, they cry, yes! YES! Of course they do. Anything else is unthinkable. The gaps in difficult conversations are filled with new treatments and drug trials, and hope. Death has become an adversary, dying has become a battleground. Patients make treatment choices based on these conversations, and our failure to speak openly and honestly means there is a danger of harming the very people we are trying to help. There are no soap opera deaths. Countless times have I chased around a hospital looking for a consultant to sign a Do Not Attempt Resuscitation form, because a patient has deteriorated, and there were no plans put in place. Death can be loud and messy and chaotic, and the nursing staff are, once again, left to pick up the pieces. Department of Health research tells us that 70 per cent of people say they feel comfortable talking about death, yet only a handful have discussed their wishes with family, and while most patients state they would prefer to die at home, due to the medicalisation of dying, very few manage to achieve this.
If we are lucky, we will experience the quiet wisdom of the palliative care team. We will be allowed to die at home, or be given a side room. We will have had honest, open discussions where ‘end of life care’ is said with a sense of choice and empowerment, not an air of defeat. Until we learn how to have these conversations, until we stop talking in codes and acronyms, there will always be patients whose requests are never heard, and there will always be a package for Rose Cottage.
Ninety-two years of life deserves more than the scraping of plates on a meal trolley behind a paper-thin curtain. It deserves more than a corner of a ward surrounded by strangers. It deserves a choice. It deserves some dignity. As medicine becomes more sophisticated, as drugs and treatments become more skilled at keeping us alive for longer, caring for our emotional health as well as our physical health is even more important. A good innings is so very much more than a number.