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by Meredith Yang

Today is the fourth anniversary of my grandmother's death. She died of pancreatic cancer.

She started dying on the stretcher, as it pulled away from the house toward the ambulance parked alongside the curb. You see, she didn't want to die in my aunt's home. It was “bad luck to die in someone else's home,” she would say—”It would curse Auntie's home forever.” I knew she had held out until the very end.

My Dad called me on the phone with the news, and I cried out in disbelief. We all knew this was going to happen, but I will never forget the knot that twisted tighter and tighter in my stomach, a fleeting sense that I was up against an irreversible, obdurate fact. He asked if I wanted to talk to her one last time. I felt the swell of my emotions well up in my throat. Isn't she dead though? I remember thinking I didn't have time for rational thought. It was futile and I didn't care. I needed to tell her I loved her, that I would love her forever, even if my voice reverberated from a plastic phone speaker, while she lay dying on an EMS stretcher, in the middle of our street in the Dallas suburbs.

A few days later, I stood in front of her casket, touching her cold, hardened skin. We showered her casket with different colored petals from a fresh batch of flowers. My Grandpa insisted that she wear an old pair of worn Nike sneakers that he had personally patched up for her. My family and I all thought her final resting attire looked a bit strange but, in a bittersweet moment, quietly agreed. She was dead after all, I remember thinking.

Moments later, I found myself in a verbal altercation with the receptionist of the funeral home. “You spelled her name wrong. It's P-e-n-g Ruifang. How could you make this mistake?” My Dad ushered me away. I was fighting for something that could not be won. She was dead, and so in a sense, a misspelled name didn't matter.

She was dead, and so nothing mattered.

She was dead, and so everything mattered.

Two truths.

Years later, I found myself struggling on my hematology–oncology clerkship. Time and time again, we rounded on patients with cancer who were hospitalized with diarrhea, leukopenia, shortness of breath, or yet another GI obstruction. These patients were, no doubt, dying. I struggled with the meaning of it all, shuffling from room to room. At the end of a 3-hour long session of rounds, a fellow team member repeated the oft-recited observation that “It's a bit like rearranging deck chairs on the Titanic, isn't it?” I furrowed my eyebrows in disbelief and anger. I was shocked by its boldness and angered at how quickly a sly joke shattered any sense of purpose I had had—if it was so futile, then why are we here?

One morning while prerounding, I discovered a patient crying, her eyes frantically darting back and forth: “Someone just came in and told me that I'm going to die.” I sat next to her, in silence as she wept, running through responses in my head as I recalled her grim radiology report. Leptomeningeal carcinomatosis I had read. What do I say to someone who is about to die?

I ran through responses in my head. It's going to be okay—a bald-faced lie. You're a strong woman—probably irrelevant at this point. Your daughters love you—true, but this was always true. We'll take care of you—we will, but not in a way that would change what is to come.

Nothing seemed adequate. I wrapped my arms around her and just gave her a hug. “No one knows the future,” I said quietly. I berated myself for having equated the medical futility of her case to the futility of my actions. The absolutism of life and death that medical training so often demanded of me—pulse or no pulse, systole or asystole, breaths or no breaths—suddenly felt irrelevant. In medical school we're taught everything—pharmacology, clinical management, preventative screening—all in the hopes of prolonging life. You can recite what you have learned with such fluency, know it like the back of your hand—and yet the bulk of our training teaches us nearly nothing about what to say when a life to be lived is no longer part of the equation. I felt embarrassed—I had nothing. The futility (certainty of her impending death and the uselessness of my training?) was not lost on me, but I knew deep down that the last thing I wanted to do was leave.

Months later in the Emergency Department, I rush to prepare for CPR of an incoming patient. As the paramedics roll into the room, the attending declares, “99-year-old with unknown medical history, found to be pulseless, apneic—family wants everything done.” We position ourselves and begin CPR immediately. She is thin and frail. Her eyes are wide open—I notice her dilated pupils. She has these beautiful, brown eyes, encircled with a light blue–gray.

I overlay my hands on her chest and pump. We cycle through CPR, shocking her, feeling for pulses, communicating with each other. We feel a weak femoral pulse. We keep going. “Norepi given!” someone shouts. I switch out with a nurse so that we can maintain high-quality CPR. With every compression, I watch as her arms flail in the air. Did they say 99-years-old? My mind flitted back and forth, again judging the futility of it all. What is wrong with me? I scan the faces of my team members in the room, failing to detect a single ounce of self-doubt.

Finally, it stopped. We had worked for 20 minutes. We close our eyes for a moment of silence. I close her eyes. I slowly place her arms back into a natural, resting position. And in that moment, I realized that I had been asking the wrong questions. Yes, we all die. Some of us are closer to it than others. But futility and the inevitability of our end does not take away from what we do in medicine—it can't. Futility doesn't mean that we just leave.

What matters is that we believe that our actions have purpose, whether it be medical or symbolic—because that is the only way to operate. What matters is recognizing that death doesn't detract meaning and purpose from our actions—it adds to it in an infinite and unquantifiable way. “The secret,” as Paul Kalanithi writes, “is to know that the deck is stacked, that you will lose… but you can believe in an asymptote toward which you are ceaselessly striving” (1).

Time and time again, my thoughts go back to death, its futility, and the meaning that it imparts. I grieve, knowing that it is an unshakable truth that my grandmother is dead. But at the same time, her death has given me more meaning as a doctor in training who will wrestle with death. Every decision I make, every interaction I have with my patients—in life and in death, beyond death—matters. I can't just stop with futility. I must remember to not let futility direct my actions, but let it inform them—that there is always more to the end than meets the eye, that I can bear witness to, accompany, and respect.

My grandmother was dead, and so everything mattered.

I think back to the things that I did, in the face of death, in spite of its futility: telling her I loved her over the phone as she lay without a heartbeat, dressing her with an old pair of Nikes at her funeral, fighting for her misspelled name—it matters. It has to.

The author thanks Dr. Orlov and Dr. Cifu for their unwavering support and guidance.

Reference

1. Kalanithi P. When Breath Becomes Air. Random House; 2016.

Back to the July 2023 issue of ACP IMpact