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When the diagnosis is death



We were in the midst of preparing for rounds, hustling through progress notes and examining patients in that familiar race to 9am. I was well past the halfway mark of my Internal Medicine clerkship, but I still felt like a novice in comparison to our seasoned intern, Jess*. I watched her skate up and down the halls, visiting nearly every patient on the floor. She fielded phone calls, checked labs, documented her findings, read through consult notes and still found time to help me prepare for the one patient I was responsible for presenting on.  

We had just received an early admission — a complicated transfer from the ICU — so Jess was knee-deep in piecing together the complex hospital course. 

Around 8:40am, an unfamiliar voice interrupted the typical keyboard clamor. 

“Are any of you looking after Ms. Camparo?” She asked. 

“Oh that’s me,” Jess said, not looking up from her screen. 

“I’m the nurse from Hope Hospice,” the woman replied, “I think the patient is uncomfortable.” 


I turned around to see the woman speaking. She had gray hair pulled back neatly in a bun. She was wearing a skirt and blouse, which in the sea of scrubs, gave her a certain sense of misplaced authority, like a math teacher who had wandered away from the classroom. 

I checked our patient list to see who she was talking about — Ms. Camparo, 77. I didn’t recognize the name. We had never discussed her on rounds. Even less familiar were the three words next to her name: “Comfort Measures Only (CMO)” Of course I was familiar with the term. It meant we should refrain from any unnecessary poking or prodding that typically comes with medical intervention and instead focus on making the patient as comfortable as possible. But those three letters, like Ms. Camparo herself, were outliers in the hospital. I realized we had not discussed Ms. Camparo on rounds because there was “nothing to do” from a medical perspective. 

“I think we should remove the oxygen and up her morphine,” Math Teacher Nurse added, “Her legs are mottled. Did you see her this morning?” 

“Yes, she looked ok when I examined her,” Jess replied, still hunched over her screen, having not yet made eye contact with our new friend. 

“They’re definitely mottled.” Math Teacher Nurse said, scanning the backs of our team for someone to recognize the significance of what she had said. 

I remember when my uncle was dying and my mom was on the phone with her sister. “His toes are turning blue,” I could hear my aunt saying. “His eyes are closed.” My mom nodded. Each day, a new sign of his body giving in. Mottled skin, glassy eyes. This is the code we use for death when we cannot bring ourselves to say the word. It is the physical exam no doctor wants to do. 

“Ok I’ll change that order,” Jess chirped, back still turned, “Thanks so much for letting me know.” 

And with that, Math Teacher Nurse walked away, kitten heels clicking on the cold hospital floor until being swallowed by all the other sounds — the beep beep beeps and drip drip drips — that tell us our patients are still alive. 


By 11am, we were in the middle of rounds and predictably behind schedule. It didn’t help that I was one of three medical students on the service, which meant that half of the presentations were at least double the length of a resident’s. My attending, more patient than most, sat through each of our lengthy discussions without interrupting or hurrying along our deeply unnecessary recitations of labs and imaging findings from over a year ago. 

Suddenly, Math Teacher Nurse appeared again. She stood behind our circle of chairs, waiting for her presence to become known. I looked up and saw she was looking down. 

“I’m … so sorry to interrupt,” she said to the floor, “But it seems the patient has passed.” 

The air felt thinner. 

Jess rose from her seat. 

“Have you done this before?” Our senior resident asked.

“Yes” Jess replied, checking her watch to make note of the time. 

I turned back to our attending, anticipating a digression to discuss the patient's death. Instead, she signaled to my classmate that he could resume presenting, and we continued to barrel through the list. 

When Jess returned, she looked smaller. Her jaw, clenched. 

She sat down and fumbled on the keyboard, trying to pull up her next patient to discuss. Her hand was shaking.

“I can finish talking about your patients,” our senior offered. 

“Ok yes, sorry. I just have to. I just … have to fill out this death packet and haven’t done that part before.” 

“All good,” our senior added, “We’ll finish up rounds, do what you have to do.” 

I looked up to see Jess filling out the death certificate on the computer. I had never considered it was just another intern task. I thought about my father’s death certificate, tucked away in my mother’s armoire. How strange it must have been to walk into a hospital with the love of her life and leave with a slip of paper instead. I wonder if the intern who wrote his ever thought about us.

I sank into my chair and thought about the beep beep beeping of Ms. Camparo’s monitor signaling her final breath. I thought about who would be receiving the news of her death and how their day would unfold. Where would they gather? What would they eat? 

I watched the team continue to discuss patient plans and problem lists and found myself floating farther and farther away. I floated back to when the hospice nurse came and told us Ms. Camparo’s legs were beginning to mottle. This time, I followed her back to the room and I sat by the bed. I held Ms. Camparo’s hand and stroked her hair and said it’s going to be ok. I waited for her family to arrive so she never had to be alone.

That is what I would’ve wanted the intern rounding on my dad to do. I would’ve wanted her to laugh with him, and cry with him. I would’ve wanted her to call my mom to tell her it’s time to say goodbye. I would’ve wanted to say goodbye myself. I would’ve wanted so many things. 


*All names changed for privacy 

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