He demonstrated his indomitable will to live in many ways. When the initial staging tests revealed the cancer was much more widespread than originally expected, his response was, “Well, we’ll just have to work a bit harder to get rid of it, that’s all.” When his first chemotherapy cocktail failed miserably he moved on to the next line of treatment without so much as a backward glance. Plan B was followed by plans C, D, E… . One day the cancer disappeared. Extensive testing failed to show any trace of malignancy within his body. Rick was in remission. He was thrilled, but he wasn’t surprised – he had fully expected to conquer his foe.

A year later the cancer recurred. At first Rick was despondent, but before long his unflagging optimism returned. Conventional chemotherapy proved to be completely ineffective this time, so he signed up for oncology trials involving experimental drugs. If he was quoted a mere five percent chance of success for a given regimen he’d say, “That’s all right – I’m going to be in the lucky five percent.” When the drug proved to be a failure he’d shrug and say, “Let’s hope the information they got from studying me will help the next guy beat his cancer.”

Once in a while a treatment regimen would look promising in the early stages – Rick’s tumours would shrink, his blood counts would improve and he’d start to feel better. He would predict with unshakeable confidence that it wouldn’t be long before he was rid of his disease. Within a few months, though, the cancer would invariably regroup and resurge, stronger and more resilient than ever. Eventually it became apparent to everyone but Rick that he was not going to win the war.

The attendants hit the door running. “He was awake and talking the whole way here, but when we pulled into the ambulance bay he slumped over and became unresponsive!”

Rick looked sepulchral. He was propped up in the stretcher and leaning heavily to the left. His eyes were vacant and he was barely breathing. I put two fingers to his neck. His carotid pulse was weak. I cupped my hand to his ear and said, “Rick, can you hear me?” He didn’t respond. I put my hand in his. “Rick, squeeze my fingers.” His hand remained limp. I was reaching for the blood pressure cuff when I noticed his left eye glistening. I stood transfixed as a solitary tear broke free and tracked down his cheek. A tear from a dying man. Endgame. I felt someone walk over my grave. Turning to one of the attendants, I whispered, “What’s his code status?”

“I’m not sure, but you can ask his wife – she’s right next door in the triage room.”

Tammy was distraught. I explained that Rick was moribund and asked if he had ever given any indication as to whether he wanted aggressive interventions in the event his heart stopped beating. She said he had requested no heroic measures be undertaken. We went back to the treatment room together. His blood pressure was hovering around 60 systolic and he was nearly unconscious. It didn’t look as though he was going to last long. She held his hand and stroked his thinning hair. The rest of us stood by and waited.

Impossibly, several minutes later he opened his eyes and looked around. He was too weak to talk, but he seemed to recognize Tammy. He obviously wasn’t yet ready to relinquish his fragile hold on life. I sequestered his family in the triage room for an impromptu conference and asked if they were in favour of giving him a rapid infusion of intravenous fluids in an attempt to boost his blood pressure. I explained any improvement would likely only be temporary, but that it might give him a few more hours of consciousness. After deliberating for a short time they decided to give it a try.

Halfway through the third litre of saline he arose like Lazarus, asked for a drink of water, and held court with his family. When I asked him what his wishes were regarding end-of-life care, he confirmed he didn’t want CPR, defibrillation, intubation or mechanical ventilation. Intravenous fluids were fine, though; he was hoping to keep body and soul together long enough to participate in an exciting new chemo trial scheduled to commence in a couple of weeks.

“You do your job, and I’ll do mine,” he said to me with a mischievous twinkle in his eye.

Over the course of the next two hours Rick slipped in and out of consciousness. During lucid intervals he would reminisce with his family about happier times. Sometimes he spoke wistfully about up-and-coming treatments he had read about. Not once did he speak of death. Shortly after midnight he lapsed into a coma. I wrote admission orders and transferred him to the medical floor for palliative care. By 3:00 a.m. the emergency department’s waiting room was empty. I hung up my lab coat and drove home.

Three hours later my telephone rang. It was a nurse from the medical floor.

“Sorry to wake you, Dr. Gray, but Rick just died.”

“I’ll be there in a few minutes.”

I got out of bed, dressed and returned to the hospital.

Pronouncing someone dead is a strange ritual. It’s equal parts medicine, religion and magic. Like falling snowflakes, no two pronouncements are ever the same. Sometimes the body is alone in the room; shrouded in darkness, isolated and abandoned. Other times the room is well lit and packed with family members and friends. Sometimes the dominant mood is sadness. Other times it’s relief. No matter how many mourners are present, though, a palpable stillness descends when I enter the room. I become a shaman. My gift is closure.

On this occasion there were seven people clustered around the bed. When I walked in, they all turned towards me expectantly. My fingers gripped the stethoscope in my pocket. For a moment it felt like a string of rosary beads. I approached Tammy and squeezed her shoulder in sympathy.

“Thank you for looking after him earlier,” she said.

“You’re very welcome,” I replied. “I only wish we could have done more. Was he in any pain at the end?”

“No, he looked like he was comfortable.”

“Did he ever regain consciousness after he left the emergency department?”

“Yes, a few times. The last time was about half an hour ago. He opened his eyes and spoke to me. I think he must have realized he was about to die.”

“What did he say?”

“ The fire’s gone out.”

Rick was recumbent on the bed with his eyes closed. Although it was clear that his life-thread had finally been severed, I could sense his family needed me to confirm it. I lifted his cooling wrist and felt for a radial pulse. There was none. I assessed his carotids. Nothing. I placed the diaphragm of my stethoscope directly in front of his bluish lips and listened for breath sounds. Silence. I auscultated his chest for a heartbeat. Once again there was no sign of life. The last thing I usually do is check for a pupillary reflex. I put my right thumb on his left eyelid and gently opened his eye. A solitary tear broke free and tracked down his cheek.

Parenting 101

My next three patients are a young family with mild gastro symptoms. While I obtain a history from the parents their toddler Billy pokes around the room, happy as a clam. I examine the father. I examine the mother. Now it’s Billy’s turn.

I ask his parents to put him on the stretcher. When his mother leans over to pick him up, Billy goes bonkers. He windmills his arms and screeches, “No!” He then runs behind the stretcher and stares up at us defiantly.

“I don’t think he’s going to let you look at him,” his mother concludes.

“How old is Billy?” I ask.

“He just turned two.”

“I think we’re in charge here, don’t you? Please put him up on the stretcher so I can check him.”

She approaches Billy cautiously. He bares his teeth at her like he’s some kind of rabid ferret. When she lifts him up, he arches his back, kicks his feet and uncorks a blood-curdling, “No! No! No! NOOOOOO!!!!” Damned if she doesn’t put him back down.