I’m making rounds at nursing stations, soliciting priorities for my day, when a nurse flags me down.
“My patient Randy has end-stage pulmonary fibrosis. His daughter is supposed to arrive around noon for a goals of care conference. But Randy’s O2 sats are dropping steadily, even though he’s on the maximum oxygen we can give him. He’s really anxious—can you put him on your list?”
I promise to return as soon as I finish checking in with my other units. After doing so, I review his chart and learn, among other things, that Randy is a retired logger in his 60s, that his code status is DNAR (Do Not Attempt Resuscitation), and that he has refused intubation. I head to his room and encounter a respiratory therapist struggling to adjust his mask and air flow.
“Randy, the chaplain is here—do you want to see him?” she asks. Randy nods vigorously.
“Hi, Randy, it’s Chaplain Greg. I’m here for you any way I can be. Your daughter Brittany is on her way, but I’m happy to stay with you until she arrives.” He extends his hand and engulfs mine within it.
The therapist looks worriedly at his oxygen levels. “This isn’t working—I’m calling a rapid response.” Soon the room is flooded with doctors and nurses. The lead ICU nurse tells me to stay where I am and barks out, “What’s his code status?” I reply, “He’s DNAR,” which they quickly verify.
Amid the hubbub I see Randy close his eyes, and I say, “Randy, hang in there. Give me a good squeeze if you can.” I feel my knuckles roll painfully and as I squeeze back I say aloud, “Randy, you’re a damn strong man. Good squeeze. Let’s keep it going.”
Just then Dr. Jonas, our palliative care doctor, arrives. The others stand back, but Dr. Jonas tells me to stay put and moves to the opposite side of the bed.
“Randy, we’re now at that point we’ve talked about before, where we can’t do anything more to treat your illness, we can only try to make you comfortable. Do you understand?” Randy nods. “Are you ready to proceed with comfort care?” Randy nods again. “OK, then.”
With that, the rapid response team departs, leaving only the palliative care team, his nurse, and me. Dr. Jonas looks at Randy’s chart, discontinues most existing orders, and issues new orders for meds to relieve pain, anxiety, and air hunger. The beeping monitors tracking his heartbeat, blood pressure, and oxygen levels are turned off, and the room is suddenly peaceful.
I feel Randy’s hand relax and I ask how he’s doing. He smiles faintly and gives me another good squeeze. “You’re a brave man, Randy. You’re doing great. Brittany should be here any minute now.”
Maria, a nurse with a voice like an angel, arrives with Randy’s comfort meds, and as she prepares them for injection into Randy’s IV line, she begins singing softly.
I see skies of blue and clouds of white
The bright blessed days, the dark sacred nights
Recognizing the melody and lyrics, I join with a trembling voice.
And I think to myself
What a wonderful world
Randy smiles through his mask and gives my hand another squeeze. The others in the room see this and join Maria and me in softly singing the remainder of the song.[1] Randy relaxes further as the meds kick in.
Soon Brittany arrives, takes Randy’s hand opposite me, and gets briefed on his status. She, too, asks me to remain where I am. She expresses her love for him, her support for his decision to end treatment, and her gratitude for all he has given her, including supporting her in becoming the first person in the family to graduate from college. Finally, she takes a deep breath and nods to Dr. Jonas.
“OK, Randy, we’re ready to take off that oxygen mask. Are you ready?” Randy, now deeply relaxed, gives a nod, and gently squeezes my hand and Brittany’s.
Dr. Jonas takes off the mask and Randy seems relieved to be free of it. He breathes on his own, but his breathing slows steadily and soon he no longer responds to my squeeze. Dr. Jonas steps in to confirm that he has died.
◊
I have long struggled with the sentiment expressed by Dylan Thomas in his famous poem, “Do not go gentle into that good night,”[2] especially when he urges,
Old age should burn and rave at close of day
Rage, rage against the dying of the light
It’s not that I believe we should never rage at our mortality, or at the diseases and debilities that ravage our bodies as we near end of life. On the contrary, our desire to remain alive and well is primal, and rage is often an appropriate response to anything threatening that desire. It is certainly an emotion I felt toward a nasty prostate tumor I was diagnosed with a few years ago. Rage can serve to mobilize our energies for battles we can and should fight, and to express our despair when we feel powerless.
But just as there is a time for rage, I believe there is also a time for acceptance, especially “at close of day.” I don’t view acceptance as surrender or as a lack of courage to keep up the fight, but rather, in the words of the Serenity Prayer, as the wisdom to know the difference between what we can change and what we cannot—and the inevitability of death is something we cannot change.
I have no doubt Randy, a burly logger from rural Washington, had his moments of rage at the disease that took his life before his biblical allotment of three score and ten. But “at close of day” he had the wisdom to know the difference, and the courage to walk bravely and steadily “into that good night.” My colleagues and I, to say nothing of his daughter Brittany, were grateful for the opportunity to accompany him that day, to be able to offer him comfort, and to witness his powerful example in facing death.
[1] “What a Wonderful World” sung by Louis Armstrong
[2] “Do not go gentle into that good night” by Dylan Thomas
