“Want to learn how to certify a death?” asks James, one of the junior doctors on the general medical ward I am attached to. “Yes please,” I respond, remembering the tick box in my medical school log book next to “certification of death and writing a death certificate”.
I feel guilty, but although I’m sad somebody’s loved one has gone, all medical students know to take offers of teaching whenever they appear and an education in the rituals surrounding a patient’s death is no different.
James leads me down the ward and into a side room. The lights are off, the room dimly lit by the dull morning sky. As I look down at an elderly woman dressed in her hospital gown, there is a stillness around us that I’ve never felt before. The radio on the bedside TV is still on: “It’s 10.30am and we’ve got more great tunes coming your way, plus another chance to win …” This station’s mood dial is set to upbeat happiness, and its presence now is utterly bizarre.
“What do you think we have to do?” asks James.
“I know we need to listen to her chest,” I reply.
“Yes, that’s right, and there’s more too”.
James walks me through everything, step by step. First, he gently touches a rolled-up piece of tissue to the woman’s cornea, the outer layer of the eye. “That would make me or you blink” James says, before shining a pen-torch in each of her eyes. Her pupils are still. The last reflex he tries is to apply pressure in the bony grooves above the eyes. Nothing. “Now you can listen to her chest.”
I unwrap the stethoscope from my neck, and as I approach I really look at the woman in front of me for the first time. I am 22 and have seen death in many forms: the passing of a middle-aged father who couldn’t be resuscitated after more than an hour of chest compressions, the gory autopsy of an overweight man in the basement mortuary and the plasticised, formaldehyde-covered body parts on the tables of the dissection room. But this is different. She is dressed and positioned in bed like all the other patients. But at some point this morning, her body overcome with disease, she stopped.
I pause, place my stethoscope on her chest, and listen. “Who will be in this week’s big top 40? Tune in to find …”. James steps round to the other side of the bed and turns the radio off.
I listen again and hear noises. Confused, I realise that my hand is trembling and that this is generating interference that I hear in my stethoscope. I steady myself, and there is nothing. Stethoscope anchored on her chest, where my ears are used to the rushing in and out of whooshing air and the rhythmic lub-dub, lub-dub of the heart, the silence is deep and unsettling. To confirm death, doctors must listen to the chest for four minutes, and as I listen I briefly wonder who this woman was, where she called home and where she used to run around and play as a child.
The time passes slowly, but it ticks by and I am done. James listens and then we carefully pull the sheet up to her neck, as though tucking her into bed, and exit the room.
We emerge into the hustle and bustle of the main ward. James tells me she died of heart failure and pneumonia. The confirmation of death is documented in the patient’s notes, and then James is off, cracking on with the usual mountain of jobs. At the end of a long life, death needn’t be a defeat for doctors, more a natural result of medicine’s limitations and the inevitable march of disease.
As I take out my log book, I reflect on how much more difficult confirming death might be if the patient were younger, or had died under different circumstances. This time I hadn’t met the patient in life, but doctors are required to confirm death for patients they’ve cared for over weeks or months or years.
I tuck the log book back into my pocket. Learning to acknowledge death is going to take more than a tick-box.
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