The oncology fellow--a tall, wiry Navy doctor--was speaking to my patient's sons. Dr. Clark was strangely aloof, his eyes meeting everything but the eyes of the men before him, his gaze shifting constantly to avoid the uncomfortable topic that their presence represented. He tossed his weight from leg to leg and his looming stature slouched, leeching confidence by the second. Both of the distinguished, white-haired gentlemen had a myriad of different emotions playing through their eyes, but one I could see a mile away and blindfolded--fear.
And I had no question as to why. I had just come from their father's room after checking the PCA rate with the day shift LPN. What little I had seen at bedside coupled with my knowledge of the patient from a few shifts prior directly contradicted what the oncology fellow was telling my patient's sons. Their father was actively dying.
Two days prior, Mr. M was sitting up in bed and attempting to get up to the bathroom on his own. He was pleasantly confused as to his location and the date, but at least he was oriented to himself and knew his family. Today, he lay motionless, slumped over in bed, his respirations slipping from labored to agonal, and his low platelet count evidenced in the blood that was beginning to leak from his IV, his eyes, and his nose. Mr. M was himself a retired Navy officer of considerable rank. His confused rantings of, "My cover's been blown!" and "I've made a terrible error--we have to get out of here!" was proof of much more than a man who had perhaps spent considerable time watching daytime TV and reading crime novels. It reminded us that the retired Captain was at one point a very capable, distinguished officer, a far cry from the shell of a man who lay dying in bed.
Mr. M's sons were not impressed with Dr. Clark. Rob was the oldest and the spokesman for the family. He was a tall, gentle-voiced yet straightforward man with glasses who seemed to be a younger version of his father. He redirected a question to Dr. Clark. "It's just that Dad's been so much quieter today. Do you think my mother should go home tonight or should we make arrangements to stay--?"
"Oh, I think you'd be safe to go home tonight." Dr. Clark nodded, interrupting Rob as he awkwardly interjected his opinion. "Like I said, I really can't see him going tonight."
At that moment, Rob caught my eye from in front of the station. I took the opportunity to join the conversation, approaching the group and introducing myself at the same time. "Good evening, gentlemen. I am Lieutenant Soldiernurse. I will be Mr. M's nurse tonight."
Rob clearly recognized me from a previous shift when he had come to the nurse's station looking for his father's nurse, who had been on break. I had assisted him in finding what he needed and gone on my way. Now, his eyes settled on me. "Ah, Soldiernurse. Very nice to meet you again. Now tell me, we're trying to figure out what to do with Mom tonight. She isn't sure whether or not to stay or go, and we all want to be here when Dad passes." Rob paused as if to swallow back grief before he spoke again. "Do you think we should stay?"
I quickly found myself deferring judgement until Dr. Clark was no longer around. "Well, I haven't had a chance to assess your father yet." I said, waiting to deliver what was going to be a striking contradiction to the doctor's prediction until I was alone with the family. "Let me go take a look and I'll let you know what I think." I said.
Dr. Clark excused himself clumsily, retreating to the physicians' room just off the ward. I headed into Mr. M's room, meeting Mrs. M at her husband's bedside. It didn't take but a few seconds in the room for me to get that tingling feeling. I completed my assessment, but it was hardly needed for me to form an opinion of how the night would go. Already, the voice in my head was talking. Don't let them leave tonight.
"What do you think, Soldiernurse?" Mrs. M asked as I put my stethoscope back around my neck. Her petite form hoovered near her husband, her eyes dark with pain and worry.
I shook my head. "I can't tell the future, Mrs. M." I said gently. She nodded, tears in her eyes. "And I can't make any promises, but if I were you, I wouldn't go anywhere tonight. From what I understand, he was talking to you all this morning. He seems to be declining quickly. I'm going to keep him out of pain and as comfortable as possible. And it wouldn't surprise me if he went tonight."
Mrs. M nodded, her face twisting at my words. "Thank you. I think we'll stay." She said.
A few minutes later, I found some blankets and a pillow as well as a rare cardiac chair that would serve as the recliner that Mrs. M had asked for. I brought them into the room and met up with the whole family, together at the bedside. From the expressions on her son's faces, it was clear that she had told them my prediction. They thanked me profusely for the sheets and chair as well as my honesty. I explained to them the plan for the night: hourly checks on Mr. M's respirations, an increase in his basal morphine PCA if his respirations indicated he was in pain or uncomfortable, and ativan to boot every hour if warranted. The four of us agreed on this plan and the routine began.
The contrast between the nurses' station, which rang with Christmas music and conversation as I caught up with a few nurses I hadn't seen in a few months, and Mr. M's room, which was filled with the solemn voices that recalled a life soon to end, was stark and proved a difficult transition. Before I entered the room, I took a few minutes each time to quiet myself, gather my composure and remember what I was walking into. Before I came back to the desk, I did the same in reverse. It was a whiplash-inducing seesaw between two vastly different sets of emotions, but through the night, I kept up the pace and my face, tending to Mr. M's hourly pain needs and answering questions for the family.
Most of the time, I'd enter the room and Rob would tell me what his father's respirations were. I'd count to confirm and note that Mr. M's son was usually right on the nose. Throughout most of the night, Mr. M's respirations were consistently in the high 30's to low 40's. The morphine PCA went up, the ativan went in, and hour after hour, Mr. M still showed no sign of relief from his pain.
On one check, I found that Mr. M required a full linens change and a clean up. I called in reinforements, his family went for a walk, and we turned Mr. M from side to side as carefully as we could while we cleaned him and his bed. It was the only time I was able to get a reaction of any kind out of the lethargic man.
My coworkers, their jobs complete, left the room. I pulled the blankets over Mr. M and waited with him. I smoothed the silvery halo that graced his head, wondering when he'd chose to slip away.
After a few minutes, his family returned. I placed a new gauze pad under his nose to catch the blood before I left. As I did so, a voice behind me spoke up.
"How long will he go on like this?" Rob asked me, his face gripped in grief.
I shook my head. "It depends. Some people will hang on for days." I admitted to him honestly.
"For days?" The younger brother, a shorter man by the name of Alan, asked.
I nodded. "Sometimes, yes. But you can help him. Many people will hang on because they don't think their loved ones will be able to handle it when they go. Tell him that it's all right for him to go when he's ready. Tell him you love him, but it's all right. Sometimes that's all people need to hear." I said, remembering a patient whose wife had given him permission to pass. After laboring through his final two days of life, he died two hours after she had whispered her consent in his ear.
"Really?" Rob asked. "We'll do that, then."
"Good." I smiled. "I have seen that help more than once. And I have to tell you all, if you fall asleep or get up and go for a coffee and come back and he's gone, please don't think that you somehow failed him. Many times, people won't die in front of the people they love. It seems like they'll wait for you to fall asleep or step out for a few minutes and then they'll slip away. But that doesn't mean they died alone. It wouldn't mean he didn't know that you were here."
Everyone nodded slowly, clearly taking time to think about what I had just said. I asked if they needed anything and excused myself once again from the bedside.
A few minutes later, however, Rob and Alan emerged from the room. Their cell phones were dying and they wanted to know if anyone at the nurses' station had chargers that might give their phones the extra boost they'd need. For twenty minutes, I scrounged amongst my coworkers for chargers until I found one that fit Alan's phone. As I sat next to the computer where it charged, Rob came of his father's room again and sat down across from me.
"Soldiernurse, I have a quick question for you." He said.
I nodded. "Sure."
"Dad wanted to have a limited autopsy performed after he died and I wanted to make sure the paperwork went through the right channels." Rob said. "You see, kidney failure has been killing the men in our family for generations, and no one knows why. Dad wanted this autopsy to be his final gift to me and Alan--so maybe the two of us don't have to go through what he did."
I nodded. "I admit, I haven't seen any of the paperwork, but it's likely in his chart or with the physicians. If he does go tonight, I will make sure to tell the morgue and the docs. They should be able to ensure that the paperwork gets through and they can contact you if there are any issues." I said, making myself a note.
Rob smiled, thanked me, and disappeared back into his father's room. I entered a note in Mr. M's chart regarding the conversation and went back to chatting with my coworkers.
Before I knew it, another hour was up. I made my rounds, increased the PCA once more, and gave another dose of ativan. His sons and wife slept in chairs and on the couch near his bed. It was 0208.
Upon exiting the patient's room, I found myself volunteered to count narcs with another nurse--a dreaded and despised task that falls on a certain night of every week. As we counted, my mind wandered. Christmas carols continued to caress the early morning silence. How is it fair that at a time of year when we so vehemently celebrate birth, a family should have to mourn a death? I wondered as the click of the Pyxis echoed through my thoughts.
"Soldiernurse." My friend and coworker, CPT Donn, stood in the doorway.
"Yeah?" I asked.
"It's Mr. M's family. I think he's..." She squinched up her face.
"Oh." I stood up from my hunched position over the narcs. Ms. Amelia, the other nurse who was counting with me, paused the count.
"I'll take your spot. Go and see." Donn said, trading places with me.
"Thanks, lady." I said. I took a deep breath and emerged into the dim light of the front station. Rob stood at the desk, tears in his eyes.
"Lieutenant, I think he's gone." Rob told me.
"I'll be right in." I said, following Rob toward his father's room. I paused a little ways down the hall to wash my hands and let the alcohol rub dry. I closed my eyes outside of the view of the family and braced myself. I'm not ready to do this tonight. I don't want to go in there.
We'll go together. A firm, gentle voice replied.
And with that, I stepped into the room. Rob, Alan and their mother stood at bedside, each of them with tears running freely. A look at my patient and I already knew what I was about to confirm with a minute of listening for what I surely wouldn't hear. I slid my stethoscope off my neck, placed the cold bell on Mr. M's still chest and held my breath.
That minute of listening for the apical pulse of a deceased patient is the longest minute I've ever known. It is a time of intense stillness when sixty tenuous moments tick by like glass about to shatter. Ten seconds.
I waited and listened above the deafening anticipation that clattered and clamored silently around me. Twenty seconds.
The eyes of the family focused intensely upon me, watching my expression and the patient's chest. Thirty seconds.
Mr. M was still warm, but no effort rose from the quiet body. Forty seconds.
I took a deep breath, bracing myself for what I was going to have to tell the family. There was no escaping it now. I had known before the watch began and I was moments away from confirming their fears. Fifty seconds.
Oh, if only ten seconds would last longer. If only it could be extended to put off the terrible reality they would soon be facing. But nothing lasts forever. And ten seconds were soon gone.
I pulled the stethoscope from my ears and shook my head. "He's gone."
The three family members collapsed on each other. I waited only briefly before exiting the room to give them privacy. They had each other and didn't need a stranger in their space. At the desk, my coworkers waited.
"Is he gone?" CPT Donn asked.
"Yeah. He's gone." I confirmed.
We paged all the right numbers, talked to the doctors, alerted the chaplain and spoke with the morgue. All the wheels were rolling and as everyone called back, I documented in the chart that everything had been done correctly. I pulled out the body bag, labeled the tags and prepared towels the towels and wipes. The nurses' station suddenly came alive with a solemn sense of duty as the last rites were said and the family ushered out of the room.
Rob, Alan and their mother met me at the front desk. Words of thanks were whispered that I'll never forget. I embraced Mrs. M, Alan, and finally, Rob, who nearly lost me in a bear hug. "Thank you." He whispered. "If it hadn't been for you, we would've gone home and missed it. This wasn't how we imagined him dying, but it's so much better than it could have been. We sat in the room, talked to him and remembered our lives with him, and he just slipped away. Thank you."
We said our goodbyes, a strangely familiar farewell spoken from three family members to a nurse who had been merely another face on the ward a few hours prior. I turned back into the nurses' station and wondered how the family would handle Christmas without Mr. M. How would they get through the season of birth after such as loss?
A moment passed, and I wondered at the silence of the voice in my head that so often answers questions such as that. But it wasn't long that my question went unanswered.
And the radio stopped me in melodic reply.
"Mild he lays his glory by
Born that man no more may die
Born to raise the sons of earth
Born to give them second birth
Hark! the herald angels sing
Glory to the newborn King!"