My patient had traveled from Kenya to Cape Town to seek a second opinion. The doctors back home condemned his condition as “too advanced.” The doctors in Cape Town said nothing new.
He was in end-stage multiple organ failure and our goal was simply to support him as much as possible. Over the course of a few days, he deteriorated–and with that decline, delirium took hold. He slipped in and out of awareness so frequently that even his brief lucid moments were confused, spent trying to establish how much time had been lost, and what had happened while he had been gone. His delirium was also a warning shot of sorts, and so in the moments when he was present he was terrified–we all knew, he most of all, that these were the last days of his life.
Sometimes when I was there, it felt as if he were trying to claw his way out of limbo. I, being the only person in his immediate surroundings, was what he reached for to anchor him to the real world. Once when he was momentarily lucid, he asked me for my help. I tried to elicit what the matter was–Did he need something? Was he short of breath? Was he in pain?–but all that was wrong was that he was scared of what was to come. The matter, then, was that he was finite. But there’s no medication we can give for that. Over a thousand days of medical training behind me, hundreds of thousands of words and phrases committed to memory, and yet I stood there unable to summon even a single word that would help him. In that moment I remember being potently aware of my youth: I was on the upward slope of the trajectory of my years; he was on the sharp descent of his. I was speechless, but in any case to provide him with comforting words sourced from my minimal life experience would have been absurd. Twenty-two year olds do not help sixty-eight year olds to come to terms with difficult existential truths. They help them to open jars when their hands have become arthritic, or to fix the computer when it breaks.
Perhaps these conversations come more easily to those who believe in life after death. Every religion has a bank of helpful phrases which seem to be applicable to infinitely many situations. I would love to loan from that bank, but when I have it has always sounded contrived, and it feels dishonest too to borrow from a faith I do not follow. But being somebody who understands death as being a full-stop and not a comma, I feel that anything that I say earnestly about dying will bring no solace to people who believe in– or at least hope for– a life after this one. And so I thought my efforts were best expended simply providing my patient with basic kindness. Of course, I hoped that he would accept the nature of his journey and arrive at the terminal peacefully, but that outcome was not one to be achieved through medical intervention. So, in the end, I simply sat with him for a while, and squeezed his hand when he looked frightened, and that seemed to calm him. Then I stood up and made a note in his folder, and went off to my tutorials and lectures, and after that I went home for the weekend.
When I came back on Monday, he had gone.
To be honest, I felt grateful–and then ashamed for that–that I had not been there to see him off. He was the first patient I had known who had died, and I think seeing him go would have broken me. As if to make up for my absence on that occasion, I found myself present at many other deaths over the next few weeks, and I was struck by the harsh reality that Death does not always announce itself. Often, especially in a setting as busy as ours, it slips people away while your back is turned, sometimes quite literally. One evening in the chaotic emergency centre, I was asked to take a blood sample from a patient for a culture. These procedures are arduous for untrained, fumbling hands, and in the hubbub of the emergency centre it is necessary to turn on tunnel vision, and to put the din on mute, in order to focus solely on the assignment at hand. It is as if the entire world ceases to exist for the duration of the task. When I swung around triumphant, the culture bottle pregnant with blood, it was to find that my world had come back into existence with one less person in it. The patient in the adjacent bed, between that bottle’s being empty and then being full, had died. Somewhere between naught milliliters and several, an entire life had vanished.
A few months later, my father phoned to deliver some bad news: My Oma, his mother, had passed away in her sleep. If life were cricket, you could say that she had had a good innings: she left us at one day shy of ninety-six years. In the following weeks, I often found myself thinking back to a day when we had visited my Oma and I had noticed her staring at my feet. After a while, she had turned to my dad and told him to tell me that she thought that my shoes were cool. (My dad acted as a translator–my Oma had not wanted to move to South Africa from Germany, so as a form of passive protest she committed herself to never learning a word of English. Looking at myself, I sometimes wonder if stubbornness has a hereditary component to it.) The next time I saw her, she didn’t say a word about it, but she was wearing a pair of those shoes¬–brand new. I looked at them and smiled. She saw. She smiled back. It is one of those memories so pure and wholesome it makes you feel swollen with happiness just thinking of it. Thankfully, it seems as though she had as good a death as any of us could hope for, and I appreciate that my experiences with patients’ deaths had left me somewhat prepared for it.

* * *

As I sat at the bedside of my Kenyan patient earlier this year, the only tools in my Imminent Death medical kit were hand-holding and kindness, and now I have a little experience too. Patients, in some sense, seem to see healthcare workers as the gatekeepers of demise, and in our holding that position it is assumed that we must have some understanding of what lies on the other side. But patients who pass over do not return to give us feedback, and we had no prior knowledge that qualified us for the position. It appears that my medical kit will never contain some vial of enlightenment–I will remain as ignorant in matters of finitude as the people I will treat.
I have a theory that when I have a few decades’ experience, my first line treatment for disquiet in the face of impending death will be unchanged–take a moment to sit, peel off your gloves, hold your patient’s hand, and just hope that when they hit the comma or the full-stop or whatever it is, they are at ease with letting go.