“Do you have time for a poem?”
The poet-patient walks into my clinic for a follow-up appointment after a hospitalization, where he almost died. He coded twice, required CPR, and after a prolonged hospital course, he miraculously walked out of the hospital. There is no sign that death had knocked on his door so recently and so fervently. This elderly yet jolly gentleman answers our unending questions about his physical health, but it is his question to us that makes me pause. Do I have time for a poem? This busy clinic day, I stop reflecting on why his heart stopped beating and instead what motivates his heart to beat in the first place.
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Death is universal, yet remains a mystery. In the patient-physician relationship, physicians are outsiders to death and to the patient experiencing it. The physician’s role is still crucial: we serve as witnesses to their life, their existence. When patients pass in the hospital, I pronounce their death, listening with my stethoscope for the heart that stopped beating. Each time I listen, I ask myself, what is my role as a physician in caring for patients while they experience the inevitable? What is my role in caring for patients who perhaps were less interested in the number of years lived and who were more interested in the significance of those years? As I pronounce patients, I am witnessing their death, but there is deep meaning in witnessing their life. This act of witness is the cornerstone of preparing patients, and ourselves, for death.
I learned to embrace this further when taking care of my Hindi-speaking Fijian patient in the intensive care unit. I felt paralyzed when I watched this patient choke on a cup of chai, thinking, was this it? As I collected supplies to support him, his coughing fit tamed itself. At that point, he had been in the hospital for a few weeks with a severe case of pneumonia, worsened by his history of end-stage lung disease. We had just returned from a family meeting, concluding that we did not have to restrict what he eats or drinks anymore to prevent choking. He valued his daily chai over our attempt to prolong his life. In our preparation for his death, we prioritized his quality of life and comfort. As I stood by his bedside, relieved his breathing returned to normal, we delved into a conversation about his legacy — he was a deeply respected Hindu priest in the Fijian community, as evidenced by the daily throng of visitors in his room. He started to chant a few prayers and told me a story about the god of death, a story I heard many times in my childhood.
Hindu mythology captures death as a god: Yama. As the ancient story from the Katha Upanishad goes, a young, curious boy named Nachiketa is scolded by his father, who sends him off to Yama’s home. Nachiketa knocks at Yama’s door, but there is no response, so he waits. After three days of waiting, Nachiketa finally meets Yama. Yama is impressed with Nachiketa’s patience and gives him three boons. Nachiketa asks first for peace for his father. He then asks how to perform the sacred fire ritual for his second boon. Finally, he asks Yama: what comes after death? Yama is hesitant to answer this question, saying it is a mystery, even to the gods. Yama suggests instead to ask for gold or a mansion, trying to divert Nachiketa — but Nachiketa knows that material wealth is temporary. After Nachiketa’s insisting, Yama finally concedes and explains a cornerstone of Hindu philosophy: the body is temporary, but the soul is immortal. He goes on to explain Hindu metaphysics, and Nachiketa gains this knowledge and becomes realized — the ultimate aim of a Hindu seeker.
I found it incredible that my patient, on the brink of death, was teaching me about the god of death, as I tried to prepare him for his own death. The story he related to me came from a sacred wisdom that evokes secular insights. Perhaps a moral of the story is not only Lord Yama’s intricate explanation of Hindu metaphysics to Nachiketa, but also the fact that Nachiketa had the courage to face the god of death in the first place. As I meet patients at the end of their life, I constantly battle the paradox of prolonging life while honoring it — of fostering courage to face death. Can we, like Nachiketa, patiently await death’s arrival? Can we allow ourselves to be the guest of death? Nachiketa could have run away from Yama, treating death as an enemy. However, the grace with which he, and my patient, encountered death honors life in the most genuine way.
How we face death is how we prepare for death — and preparation for death is mutually healing for patients and physicians. There are several advances in medicine for end of life care, including medications to control pain and even to relieve existential suffering. However, in my relationships with patients at the end of their life, controlling these symptoms is the tip of the iceberg. What I, and I hope my patients, have found most meaningful is the listening I do before I listen to the cessation of their heartbeat with my stethoscope. My witness of their life can be healing and also foster the courage in my patients, as well as myself, to face their death with grace.
Poet David Whyte describes witness as the ultimate show of friendship:
But no matter the medicinal virtues of being a true friend or sustaining a long close relationship with another, the ultimate touchstone of friendship is not improvement, neither of the other nor of the self, the ultimate touchstone is witness, the privilege of having been seen by someone and the equal privilege of being granted the sight of the essence of another, to have walked with them and to have believed in them, and sometimes just to have accompanied them for however brief a span, on a journey impossible to accomplish alone.
Similarly, physicians certainly do aim to improve a patient’s clinical outcome, but one of the most meaningful aspects of the patient-physician relationship is the empathy that blossoms from bearing witness to life. Notably, as Yama expounds his philosophy to Nachiketa, he says, “Those who see themselves in all and all in them help others…” Here, he describes empathy at its height, and I believe listening to patients with attentive compassion is the foundation of the empathy required at the end of life. The most profound privilege of being a physician is to witness the wisdom, stories and vulnerabilities of strangers, and in doing so to create an intimate connection. This connection is only possible through the physician’s impetus to be present with the patient; a recently published humanistic initiative defines presence as “a purposeful practice of awareness, focus and attention with the intent to understand and connect with patients.” When we listen to the patient, we bear witness to her life; we help validate her existence, her life. This, I believe, is the greatest preparation for death: to help honor another’s life by validating her existence.
Reconstructing the physician’s duty in this way reconciles the moral tension that arises between the dual aims of prolonging life and preparing for death. The greatest role of a physician is to compassionately witness a patient’s life, preparing a patient to knock on death’s door.
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“Yes, I absolutely have time for a poem,” I say, as a witness to my patient’s life.
Author’s note: Dr. Shankar is supported by a VA Office of Academic Affairs Advanced Fellowship in Health Services Research. The views expressed herein are those of the author and do not reflect the views of the Department of Veterans Affairs.
Image credit: clouds by Dean Hochman is licensed under CC BY 2.0.
Fellow Physician Contributing Writer
Stanford University School of Medicine
Megha Shankar is a health services research fellow at the Palo Alto VA and CHP/PCOR at Stanford University. She completed her undergraduate degree in anthropology and biology at the University of Chicago, medical school at the University of Illinois at Chicago College of Medicine, and internal medicine residency at the University of Washington.