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The alarm clock sounds, a painful reminder that it’s my week to cover the intensive care unit. I take off my favorite sweatshirt, stripping away its warmth and comfort. I jump into and out of the scalding shower, racing to get ready. Making my way toward the kitchen, I roll my eyes at my teenage daughter who is eating ice cream and waffles for breakfast. Her ride waits out front, but before she escapes I get a rare hug, her wet hair cool as it brushes against my cheek.

I spy her melting, unfinished breakfast and shovel what’s left into my mouth. The cold vanilla ice cream and maple syrup drips down my chin. Wiping away the evidence of my indiscretion, I get into my jeep with the top down. The 20-minute ride is a guilty pleasure, with the spring air cool across my face. The coffee in my hand warms me from the inside out as I make my way to work.

Mrs. Valentine’s family waits for me in the ICU. The overnight nurse has already filled me in on the evening’s events. The family has come to a unified decision, and they have called friends and loved ones from near and far. Their mom has been on a ventilator for six days and continues to get worse. Her pneumonia and kidneys are the most urgent problems, leaving her dependent on a ventilator and dialysis. But underneath the surface, her lung cancer is the real culprit. What started as a time-limited trial to see if her lung infection could get better had now run its course. The family knows we are no longer helping her to live; we are prolonging her death. This is not what she wanted.


With her family at her bedside, intravenous drips of morphine and lorazepam are adjusted, until her breathing is relaxed and unlabored. The restraints on her wrists that had prevented her from pulling out IVs and tubes are removed and the monitor is turned off, no beeps or flashing numbers to distract. The guardrails are pulled down and her hands are held by her tearful but resolute family, all at her bedside. The breathing tube is removed and exchanged for gentle humidified oxygen over her nose and mouth.

Her nurses continue their vigil, focusing now on her breathing, assuring that it’s easy and peaceful. They watch her face, monitoring for tension in her brow or any other subtle signs of stress. Family friends drop in to offer support. The chaplain is nearby. And three hours later, as the time between breaths grows long, she takes her last breath.


She’s gone, peacefully and quietly.

In my ICU, this is a “good” death. Without shocks, chest compressions, or drama. Her family at her bedside throughout.

Yet we failed her. We could have done better. We should have done better.

We failed her in medical school. We spend countless hours in the anatomy lab but barely a few hours learning communication skills and palliative care. We read books on diseases and their cures, but only a few handouts on how to provide comfort. Eager and enthusiastic future doctors are well-prepared to treat sickness but ill-equipped to face the challenges of managing death.

We failed her when too many residency programs did not actively introduce, teach, and model talking about goals of care. We teach residents how to engage patients with pointed queries on the presence or absence of signs and symptoms, but leave them unprepared to deal with the wide open responses to open-ended questions about the dreams, goals, and fears of patients facing their own mortality. We fail residents by not acknowledging the shame we feel when we cannot cure, and the distance that can create between us and our patients. But when we cannot cure, we can comfort. And we miss showing residents that when we feel most helpless, we can still affect our patients in powerful and meaningful ways as they move towards death.

We failed her by not having mandatory palliative care consults concurrent with her cancer diagnosis. Studies have shown that palliative care does not necessarily hasten death, but often prolongs life with better quality.

We failed her when doctors did not stand up to the medical industrial complex. It is human nature to believe that more of something is better than nothing. And big industry is more than happy to encourage more testing, imaging, and treatments. It distorts marginal benefits while minimizing toxicities and side effects, monetizing patients’ optimism and hope for the benefit of stockholders and CEOs.

We failed her as a society by avoiding difficult conversations. End-of-life discussions are the exception rather than the norm. Sports and politics, along with our smartphones, dominate dinnertime, making it easy to ignore issues of our mortality. By avoiding talking about death, we fail to discover what it means to live.

We failed her as her doctors. Had she and her family been armed with more information and more choices, she might have chosen a path quite different.

Maybe, just maybe, she would have opted to be cared for in the comfort of her home, instead of in a cold, sterile intensive care unit. She could have been in her own bed, wearing her own sweatshirt, soft and warm, enjoying waffles and ice cream, with syrup dripping down her chin. Enjoying a hug from her daughter, with her wet hair brushing against her cheek. Feeling a spring breeze from the open window on her face as she takes her last breath.

Jeremy Topin, MD, is a pulmonary and critical care physician at Northwest Pulmonary Associates in Chicago. This article originally appeared on his blog, Balance.

  • But people also need time to process death. And no one should be judged nor pressured as to how they handle their own death nor their loved ones dying.
    My sister has ALS and went into hospital with pneumonia. They wanted to jyst send her to a nursing home to die without the ventilation, non invasive. Her carbon dioxide would raise and she would become very scared and panicked when she couldn’t breathe. A bipap is also comfort care. But under hospice it isn’t alliwed. Hospice was more honest than the dr and acknowledged without it she wouldn’t live more than 2 weeks at the most.
    She wanted it. She had the right to medical care.
    The dr did agree and took her off hospice and wrote a letter that part of her treatment was to include the bipap.
    Yet the last nurse was very nasty and threatening to her that she shouldn’t be using the ventilation.
    She is stabilized now in acute care and being moved to long term care. She could still live 6 months or longer.
    No one should decide for someone else much less pressure them to die faster than they are ready to.
    It has also been a help to our family to be able to begin to face that we will lose her soon.
    In an effoet to reduce suffering, medical profession can cause a lot of unnecessary suffering by not honoring each individual’s right to make their own decisions especially about dying.
    The medical profession is Not God and doesn’t have the right to look down on people because they want to live, that is not compassion.
    If I person doesn’t want additional treatment that is up to them, but ut also should be both ways and not about saving money if something provides them with comfort care even if it may extend their lives a bit longer.
    People should not be forced to give up if they are not ready to. Especially when their dying is a surprise to them and family and they really need that adjustment period of facing death.

    • We appreciated the doctor’s compassion and caring, the willingness to let my sister decide about hospice and make sure that she would be allowed to continue on the bipap.

      Death is a sacred journey, as uniquely individual as is each person.
      Each person has the right to travel that final stage of life at their own pace, in their own way.

      The article mentions dying at home.
      Unfortunately many people live in retirement or assisted living, but when they need regular assistance for basics, they no longer are allowed to continue to live at their retirement home/assisted living.
      Only the very rich can afford round the clock care.

      Which leaves nursing homes as the only option available as many enter their final life stage.

  • Thanks for this lovely piece. I was at my mother’s side when she died in August 2016. I wrote a poem about it here:

    What the poem doesn’t talk about is the cold, discompassionate conduct of the nursing “home” staff. Your intensive care unit sounds like heaven on earth in comparison. At least you and your colleagues care. Thanks for that.

    Also, your post reminded me very much of Atul Gawande’s book “Being Mortal;” you must read it if you haven’t already.

  • I recently retired after almost 50 yrs in nursing. My last job was end of life care. I totally am committed to doing what I can to get people to face the taboo which is death.
    The difference between the families that had faced up and discussed what they wanted at the end of life and those that had not was so obvious.
    It was so good to be able to be in control and be giving a positive experience to both patient and family and so often it was possible to leave the relatives with such a quality and inspirational experience to remember them by.
    It is the most wonderful thing to give the ones who you care about and also yourself.
    Just consider finding ways to face up to life and take the taboo out of death it will be so worth it.

    • Death Is not a taboo, it is a sacred journey, as uniquely individual as is each person.
      Each person has the right to travel that final stage of life at their own pace, no one should be judged nor rushed.

  • Its really really sad how we don’t know how to handle or what to do when your loved one is dying may be we don’t want to know he is going you just don’t want to believe. I have gone through this situation when I lost my brother few months back .Just felt very helpless and guilty that was unable to help him

  • Amen to that. Never knew a fellow ICU/CCU nurse who wanted to die in the hospital ICU. We promised that if one of us were brought in dying that we would take them downstairs to the little atrium garden outside to die in peace outside under a tree.

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