The other night I was making myself a cup of ginger tea in a vain attempt to ensure myself happy dreams. The teabag had one of those little tags attached to its string with a comforting saying. I look forward to reading comforting teabag sayings sort of like I read my horoscope occasionally, hoping it will tell me that everything is going to be okay and I am about to come into a surprisingly vast sum of money.
My teabag saying was this: When fear is forcing you to give up, call upon your heart’s courage to continue. I stirred the teabag disappointedly about in the hot water. I had been kind of hoping my teabag would tell me someone else’s heart courage could be called upon for me to continue. To be thrown back on my own resources by my teabag was deflating. Plus that night I had my usual crappy dreams. That’s the last time I’m relying on ginger tea.
I have been thinking lately though about the resources I draw on for strength to continue. It’s not that I have such a terrible life. In the grand scheme of terrible lives, I have it really good. Also, it’s not a competition. So some mornings as I drive around between my nineteen dying patients, I feel quite sorry for myself and my stress load seems temporarily unbearable and I cast about to see what sources I can draw on to make myself feel better.
In the absence of teabag comfort, there’s always Deepak Chopra’s Infinite Potential podcast, which I have been tuning into lately. Deepak describes this as a metahuman miniseries about what makes us conscious beings and why it matters that we are. The main thing I love about this podcast is his introductory ad honoring his sponsor, LinkedIn. It affords me endless joy to listen to him extol in his impeccable Indian accent the virtues of mindful hiring. It is little wonder, he intones earnestly, that someone is hired every eight seconds using LinkedIn. Even though I don’t actually run a business, it just makes me want to rush out and hire someone.
After he has glorified mindful hiring for a bit, he goes on to interview some of the great minds of our time: Dr. Oz, Don Hoffman and, well, those are the only two great minds I have heard him interview so far. But just listening to him riffing with Mehmet Oz about the heart as I drove to work the other day set me completely on fire. Oz told a story about a mentor of his who pioneered a method of open heart surgery on kids in the 1950s whereby he hooked the mother up to the kid so when the surgery was underway, the mother’s blood was coursing through her child’s veins while their heart was temporarily stopped for the procedure, and her lungs were oxygenating her child’s blood.
This idea just made me start leaking tears on my drive up the 9G towards the Kingston Rhinecliff Bridge. Then Oz talked about how he lamented to this mentor that his open heart surgeries had a 25% fail rate. So one in four times, he would lose a child and have to go out and break the news to the waiting parents. His mentor said well my fail rate could potentially be two hundred percent, because I could lose both child and mother.
Now I was crying in such a way that I could barely see the road. Nothing appeals to the hospice nurse sensibilities like a potential two hundred percent surgery fail rate.
But the two of them also talked about how the heartbeat continues from the moment in utero when fetal heartbeat is first detectable (and here they played a recording of that rapid fetal heartbeat I recalled so vividly from my first pregnancy ultrasound) to the moment it flatlines at death (cue recording of an ICU monitor going from intermittent to continuous beep).
The essence of hospice care is that death occurs outside of the ICU, ideally in the home environment. There’s no hookup to machines, no flashing lights, no beeps. Often the moment of death goes unrecorded. Family members find the person dead in their bed, or the death occurs at some difficult to determine moment while loved ones are in and out of the room. Sometimes the dying wait to be alone. Sometimes they wait for a specific person to be present. At least, that’s what we like to think. In reality, there’s no saying exactly why a person dies the moment they die except that their heart just stops beating.
And yet, that moment is a profound one. I have laid my stethoscope against the chest of a recently deceased patient many times, and each time I feel again the weight of what has occurred. I am struck by the absence of sound. Where moments ago there was the familiar lub-dup of a heartbeat, no matter how faint or irregular, now there is silence. If it’s a patient I am familiar with, I will have listened to their heartbeat many times and be familiar with its peculiarities. And now I’m putting my steth against their left chest wall, and there’s nothing.
When a patient dies on hospice, a nurse usually makes a visit we call a pronouncement. It sounds like we declaim something from the rooftops, but in reality it is usually an extremely quiet moment. Families can decline this visit, but mostly they want a nurse to come and support them at the time of death. Some families actually rely on the nurse to convince them that the death has actually occurred. I have been called to homes where a patient was so clearly dead there was no way anyone could dispute it. And yet the family need me to tell them, sometimes they need me to go through the motions of listening for a heartbeat with my stethoscope. I have to do this, and then turn to them and say something like your mom is gone, or he has left us for them to begin their process of grieving. It can be a curiously formal and final moment.
For me, it is sometimes a heavy responsibility, and sometimes a moment of black comedy. I have pronounced patients who were so clearly dead it felt sort of ludicrous to apply my stethoscope to their cold chests. And yet, that can sometimes be what the family needs, and that is what you do.
Aside from my life of pronouncing people dead, I do like to listen to instructive podcasts, enlivening music, and to read the odd horoscope. Just now for example, a random online search of my daily horoscope told me that responsibilities at home and upsets in my circles of friends could distract and stress me. Make an effort to balance it all, instructed my online psychic confidently and yet completely unhelpfully, and you’ll make it through the day. It’s 9:26pm. Maybe I’ll just go on LinkedIn and see if its mindful hiring practices will get me through the last two and a half hours.
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