back to just normal dying.

CW: death, obviously

Cassie here again (and I’ve prescheduled some posts and L’Erin’s on vacation soon, so the next few will likely be from me, too.)

Had my first real interaction with a family under non-covid circumstances yesterday.

They were only allowed to visit because their loved one was dying, and our visitation procedures are still really hard core…but eventually there were four strangers in the room with me, along with their loved one.

It’s been so very, very long since I’ve seen a ‘normal’ death, that I’d almost forgotten what to do.

When covid patients died…you didn’t get a choice. They were on that freaking train, and it was coming into station. Things always felt fast, even when they weren’t, with very few exceptions.

But this was a death of a more leisurely sort. The kind where you get the chance to hang up a morphine drip and titrate it even.

I used to be very good at this sort of thing.

Back before covid, people still died, you know? And given the specialties my hospital has, we saw more than our fair share of elderly people who’d come in and who definitely were not going out again. I had my schpiel down — here’s what we’re gonna do, here’s what it’s gonna look like, here’s what you can do as it happens.

All of that was out of the window yesterday though. I felt like some kind of cave troll emerging into the sunlight, having to interact with strangers face to face.

I wanted to provide them with that Quality Death Experience (tm), and we didn’t start off that way, but we got there.

So here’s what happens when people die at the hospital, in normal times.

(First off, we try to send people home via hospice if that’s an option. It’s almost always better, especially when our visitation rules are still draconian.)

After that, we’re all about ‘comfort care’.

We kept this patient there because we were going to ‘compassionately extubate’ them, by which we mean pull out their breathing tube, see what happens, and go from there. (Oftentimes, patients wouldn’t last long enough for hospice to be involved, they’d die pretty quickly, depending on baseline lung function.)

At that same time, we turn off any other element of ‘life support’ that’s on going. (You can see my prior post about what that usually means.) Any supplemental oxygen, any blood pressure medication, fluids, insulin — we turn all those things off, because the goal’s no longer keeping the person alive.

The goal’s just to help them die cleanly.

Which is what I was having such a hard time explaining yesterday. I mean, I can’t just come out and say, “Yeah, the goal here is that they’re gonna die.” Except that…that’s the true-truth, right? I explained all the emphasis on them being ‘comfortable’ — we don’t want people to look like they’re uncomfortable or air hungry — so in an optimal world, in the best (ICU, not home, alas) situation, it’d just look like your relative was asleep until their heart stopped.

I think a lot of the time, people think about death as a switch, and I may have mentioned that here before, forgive me if I have. The family feels like they’ve come to this great momentous decision and they’re all ready to yank life away from their relative like a dinner magician with a tablecloth, but no — the actuality of being there is usually much, much slower. It can take days, even. It just is what it is.

The patient got a little rough yesterday — sometimes people drool, and it gives them death rattles, and no one wants to hear that — so you give them medication to dry the spit up and additional sedation to gently decrease their respiratory drive.

And while I’m giving it, one of the relatives in the room with me asks, “So, why don’t you just give him a lot of that stuff?”

And I was all, “Well, I don’t want to overshoot, you know?”

But of course he doesn’t know (nor do you, heh) and neither does anyone else, really.

I said something flippant about killing someone once (because even in the before times I’ve always been a morbid bitch) and a doctor friend came out of the woodwork to correct me. “That’s not what you’re doing. You’re just taking them up to the ledge. You’re not pushing them over.”

What I didn’t say then though, that I couldn’t even really conceive of saying until much later, afterwards, after many more times it’d happened, was, “But you’re not even on the ledge with me at all! You write the orders and then walk away! You’re not there, touching the medications or the patient! Everything’s an abstraction for you!!! So how dare you tell me what it feels like to be giving medication that is invariably going to be killing someone no matter how slowly it happens. Back the eff off.”

(I may still be angry about this, in my heart.)

I thought about explaining the difference between euthanasia and whatever-the-hell-comfort-care-is-supposed-to-be-doing to the family yesterday but opted not too. They didn’t need that, even if it would’ve felt good for me to get it off my chest.

(Because I’ve been in some deaths where slamming 40mg of morphine into someone very rapidly whose clearly in agony was entirely appropriate and done so that their loved ones didn’t want the horror of that memory in their mind. Air hungry people — it’s just not right. No one wants to close their eyes and see that later.)

I did remember one of my old canards: “Just like how babies are born on their own schedules, people die at their own times, too,” which seemed to relieve the family some, since it was taking so long.

But that’s the goal really. To do this perfect three point landing, where you get someone to glide, feather-gracefully, out of this world and into the next. Where families have had enough time to say good-bye and hopefully circle around to the story-telling part of things, laughing about memories and sharing photos.

Where it’s not about the dying person in there anymore — it becomes about knitting together who will be left behind.

God, every time I hear someone laughing in a comfort care room, it’s such a burden off of my shoulders — I know I have done my part right.

The last death I had visitors around for was my super traumatic (for everyone involved) death I referenced in this post: covid, Fox News, America, and me. So it’s been awhile, you know?

And that one, like all covid deaths, was just a trainwreck. Just because it was covid, and it didn’t have to happen like that.

What killed me though was a few weeks ago our palliative care doctor came by to say that that family had called her, and they were still wondering if we’d done everything we could.

A death after which I had blisters on my fingertips from bagging that patient for so long.

She was just talking with me to talk, because she knows me well now, but I had this visceral reaction — I wanted to defend myself and cry. How dare they doubt me. I had literally given my all and done my everything….

But it wasn’t about me, you know? (This is the refrain I tell myself all the time, when I want to kick back and cuss and scream: “is this really about me?” and “is this interaction actually therapeutic to have?”)

They were just at home, alone, brewing. Festering, probably. They hadn’t gotten to have story time. Nobody’d gotten to laugh. That death was abrupt and unexpected and awful.

(And I expect there’s going to be quite a lot of this second-guessing everything in the covid after-times. Everyone got covid from someone else, you know? And not all of them were from mail carriers or at the grocery….)

Anyhow.

The hard part right now is our visitation rules are still wonky. My patient was still alive at the end of my shift, and I had their family hidden in there with the curtain. Technically, I should’ve kicked them out hours before. But I’m not an asshole, and if you don’t ask questions like ‘when should they leave?’ then no one can get mad at you if they don’t, voila!

(I even smuggled up delivery food for them, although I told them it couldn’t be a pizza, seeing as we’re not allowed to get pizzas anymore, because god forbid we indulge in a potluck now that we’ve all got our shots, heh.)

And then my shift was over, and I handed off the narcotics to the next nurse, who I introduced, and it was me alone in the room with them again.

I felt the need to make some sort of closing statement, because I don’t know why, I did, so I launched off with, “I hope —” and then I paused, and then I just was honest. “I actually don’t know what I hope.”

Because I didn’t — what the fuck do I know to be hoping? That things go faster, or slower, or for them to be able to hide in there all night?

“I’m just glad you get to be here.”

Which was the God’s honest truth.

— Cassie