By Victor Senthinathan
Honourable Mention, Writing Competition 2017

Prompt 2: Tell us about an encounter with a patient that has significantly shaped your understanding of medical practice or changed your worldview.

I always thought of hospitals as unpleasant places. It was a place where sick and dying people congregated, where white walls stretched out aimlessly and there was the ever-present promise of a registrar quizzing me on something I had just forgotten.

On this day however, my hospital seemed idyllic. It was the type of day where sunlight didn’t just stream into rooms, but cascaded off walls, golden glitter veiling the room. It was the type of day where every ward held smiling patients with easily identifiable differential diagnoses. It was the type of the day where your clinically appropriate shoes can’t help but skip into a room to find a patient for your case report. This is where I met Mary. I would be amiss as a medical student to not mention that the patient has been de-identified to maintain patient confidentiality.

Mary was 70 years old and had a demeanour akin to those stereotypically smiling Hollywood grandmas who always seemed to have biscuits crackling in the oven. Her grey hair was suspended on the nape of her neck in a sophisticated French twist, and her voice sparkled with vivacity. I asked for her name and age and occupation like a traditional medical student, and then asked what had brought her to hospital. Mary had just-diagnosed Stage IV Breast cancer which had metastasised to her lungs and was not expected to survive the year.

* * *

It’s strange how as a medical student, one is not forced to confront the idea of death. Isn’t medicine after all the study of existence, the study of what affects it and how it occurs? Medicine is about life, and death is an important part of life. The conclusion to a story is arguably the most important part after all.

But then again, medicine is all about preserving life and stretching it out. Medicine is all about denying the concept of death.  In medical school, we never really learn about palliative care, or are forced to dwell on conditions which result inevitably in death. And to be fair, I would not want to learn about conditions where I could not do anything. However, as a result, death is only broached shallowly. As a result, death is an intangible concept only expressed in 5-year survival rates and in knowing that palliative care existed when doctors failed.

My only brushes with death to this point had been the death of my grandparents, solemn affairs where I didn’t understand anything that was happening apart from the fact my parents seemed indescribably sad and everyone was draped in black. As a teenager who underwent a thankfully un-photographed emo phase, death was more a fashion accessory than a fear, something to hold around you without ever truly pondering.

In the first year of medicine, I was forced to confront death in one of many interminable legal lectures. I learnt that from an Australian medico-legal perspective (which is the most relevant as a medical student), death is described as the irreversible cessation of either the circulation of blood or of all function of the brain, which can be determined in numerous ways such as checking for brainstem reflexes. This seemed a perfectly reasonable way to think about death, and so I went on, uncaring of philosophical concepts which were dimmed by seeming irrelevance.

* * *

For those who’ve never talked with terminally ill patients, it can be uncomfortable. It can be incredibly awkward when a patient starts talking to you about their impending death. For me, this situation seemed more like a devilish OSCE station than real life. I had no idea what to do and how to approach this situation. I did not know where to look, looking at my shoes seemed incredibly disrespectful but looking at her face would remind me that this was a lady that was going to die and of the predicament I had found myself in. Should I keep my hands by my sides, should they be behind me? Can you say it’ll be alright to someone with a death sentence? What meaningful words of comfort can you offer someone who is about to die? All I could do was listen in silence which seemed painfully inadequate.

Yet what struck me was how she spoke about death. I didn’t know how would I approach my death, but I knew it would not be with serenity. Most likely I’d be hiding under the bed, pinching myself and crying out for my mom. Yet Mary seemed strangely peaceful. She talked about her life and how everything had to come to an end. She talked about how death had offered her a chance to be closer to loved ones, both in the heavens and down on Earth. It was a chance to heal old wounds and to take note of what was truly important to her. Death was an opportunity to make sure she had done everything she had wanted to do and to leave in everlasting grace.

For me, the concept of death seemed almost horrific in its permanence. The idea of being stilled forever, of not being able to speak for eternity was terrifying. Eternity was a long time after all. Mary seemed to embrace the permanence of death and the chance to discover if anything lay after it. For her eternity did not seem a long time at all.

* * *

When I left Mary, I was confused. The definition of death which floated in my head as a grim remnant of my Year 1 experience did not come close to capturing Mary’s view on death.

What was death then? From a dictionary’s perspective, death is the absence of life. Life is defined similarly as the condition that distinguishes organic material from inorganic. This definition too seemed insufficient. Was the only thing relevant about life the Krebs cycle?

Everyone has a different definition of life, and no personalised definition is wrong. For me, life is potential, it is the capacity to dream, the ability to love and be loved, to express yourself in cheesy sentiments. Death from this viewpoint is not when one’s brain ceases to work and the blood ceases to run, but when one is no longer truly loved.

Don’t we all carry loved ones around with us? When I’m about to do something bad I can hear my parents scolding me. When I do something wrong I can hear my sister mocking me. If my friend was to die, would I still not feel their compassion when I was sad? If I can still feel them around me, if they can still change my life, aren’t they still alive in a sense? If I remembered Mary every time I thought of what it meant to be alive, wasn’t she still alive in a way?

It is easy to be scared by death, especially when you never come face to face with it. I still really haven’t. I hope when I do, I remember how Mary embraced death not as something to be feared, but as a chance to remember what is important and to leave with grace.