While shouting the most mundane of sentences, I came to understand silence. Deafening silence – that kind that feels new and mumbled and wrong – meant absence. But this absence was unlike the lack of oxygen in outer space; rather, absence was akin to the pulsing chill one feels while walking out from a warm home into a cold winter's blast. Present, piercing, positive; logical, confusing, revealing. That is how silence shouted back, as I yelled into a dying woman's ears.
This woman I will call Rose, though her name and identifying details have been altered for privacy. Rose was a uniquely charming soul, equal parts welcoming and rambunctious. She was a multicultural concoction of European wit, Pacific island cool, and all-American toughness. Though kind and physically unimposing in her late 60s, she dominated the room with her eyes.
However, Rose also suffered from late-stage terminal lung cancer, diagnosed months before we met. Rose thus found herself in the world of hospice and palliative care, hoping for peace, comfort, and support in her last days. She was there uplifted by palliative care physicians, compassionate nurses, and an armada of home health aides, all of whom toiled to alleviate her suffering.
Yet the Latin word patient, an obvious precursor to our English word, does indeed mean “one who suffers,” and this ancient etymology held true for Rose. Chest pain stood stalwart throughout her days; struggled breaths ran from her sputum-suffused trachea; and that charming voice, though still a beautiful mix of Euro-charm and American soul, contained a harshness that seemed alien to her inmost being. There was then one triumphal blow: Rose, whose very presence was musical and melodic, suffered ototoxic hearing loss from her chemotherapy. When I first entered the room as her hospice volunteer, I had to shout.
During our conversations, Rose rarely spoke at all: she felt odd voicing her own semi-inaudible words, and so communicated through writing instead. Thankfully, ours was a successful voice-pen dichotomy, and we developed a trusting relationship within weeks. She and I came to discuss a great many things – her hometown; our mutual love for rainforests; and the touching letters she received while in hospice. My visits felt more like pleasant and regularly scheduled chats than they did service of the dying.
But during one visit, on a late winter afternoon, Rose showed signs of change. She forsook the pen in the middle of a sentence, and spoke with words that pierced like iron: “The doctors gave me six months to live,” she said, pulling out her fingers one at a time. “Five, six, seven… eight. It's been eight months of this. When is it going to end?”
Mine was now the inaudible voice. “It sounds like you're feeling restless,” I remarked diffidently, “or a bit surprised by the way your disease has progressed. What do you mean by it, or end?”
“This, this whole… thing,” she said, grasping me with her eyes. “I am hurting, I am tired, I am done.” Rose, as it turns out, had lived a meteoric life. Her greatest joys included dance – samba or salsa, I forget which – among more settled passions such as teaching, and hiking through rainforest showers. These were just a select few sources of meaning, but were ontological signposts nonetheless. When those signposts were uprooted – replaced with bedbound pain, fatigue, and deafness – Rose found meaning difficult to come by.
Our conversation continued through the early evening. I felt that Rose was trying to tell me something, if only I would listen. But my shift eventually ended, and it was time to go. I left Rose's room for the final time – though I did not know it then – as she made one last, salient request: “Please, pray for me,” she beckoned, with those gemstone eyes singing in tandem, “please pray that I die, soon. Pray that I die tomorrow, if possible.”
Rose grasped my hands with purpose and a flame which warmed my palms. Here was a patient whom I had spent weeks trying to comfort, now asking me to plead on her behalf, to whatever higher power might bestow comforting finality. Her sobering warmth confirmed that this was no mere impulse of guilt or depression. I was unprepared for the moment, nodding in affirmation and speaking bashful words of acquiescence. I squeezed her hand, confused in compassion, and left the room.
As a young man preparing for a career in medicine, I had entered hospice care with one primary goal: to live out the human vocation of self-giving love, by serving patients who walk through the most human of suffering. Asking probing questions; elucidating unvoiced concerns; holding a hand; or simply fetching water for the thirsty. These were my duties and the requests I felt prepared for. But to pray that my patient might die? This was no cursory request, regardless of one's political, social, philosophical, or religious beliefs. It was a sort of spiritual aid in dying, and the weight of it all was heavy.
Yet at the same time, I had to acknowledge, Rose was incredibly courageous in her request. The specific entreaty could not – at least by worldly powers – be actualized, making hers a true declaration of vulnerability. This vulnerability was not unlike the trust that patients place in their physicians, allowing them to prod and poke and probe in ways that would otherwise be despicable. Our voice-pen dichotomy had therefore given way to a new and poignant paradigm: I was moved and affected by Rose's courageous, honest suffering, but I questioned whether I could pray for the death of someone I cared for. If somehow actualized – much like actual aid in dying – that intercession would, of course, end another's suffering; but nonetheless my tension remained.
As I shot down the highway, returning home from my shift, electric stars began lighting the mountainside cityscape. Days later I would pour through position papers, ethical dissertations, and opinion articles on aid in dying, trying to form a waterproof stance on this leaky subject. Yet that moment with Rose – as with all of life's truest moments – seemed too real for rationalism. In the deafening silence of the open road, I wondered if my mind had jumped ahead of my heart, if clean answers could exist in a messy world. In that moment, heartful compassion seemed the lifeblood of any mindful, judicious, loving response to intractable suffering.
Finally, I arrived home. But as I laid in bed, a cacophony of questions rang still in my mind. “What did my silence signify, speechless in Rose's room?” “What moral principles might guide us in medicine, as we face tangible decisions amidst suffering and death?” And how would I respond to Rose, upon my next visit, confirming that her vicarious prayer had remained unanswered?
When patients are faced with intractable suffering, hospice and palliative caregivers have similar questions to confront: “What actions might give this patient a meaningful life?” “What role do we play in that patient's death?” Indeed, this last question has long perplexed the medical profession, evidenced by continued public discourse on aid in dying. Such discourse often sets up a sort of dichotomy, pitting the meaning of life against the duties of medicine. But perhaps this paradigm misses the point: perhaps medicine's role in death is not an exclusively rational topic. If that is the case, medicine must be silent enough to learn from human stories, lest it exude cold knowledge in lieu of a wisdom which lives and loves.
When it came time for my next visit with Rose, nonetheless, all questions fell by the wayside. Indeed, the visit never took place: Rose had passed away just days after our last meeting. Yet I never did pray that desired prayer. Perhaps, I thought, this amounted to some sort of impiety, or a shortcoming of care. But then again, I am not so sure. If pressed on the topic, I would support my patients and their rights, to live and to die their best lives and best deaths. Much more can be said on this issue, blending pragmatism, ethics, and humanism into circuitous amalgams. But of this I am confident: the most rational, philosophical, and ethical decisions in medicine, including that of a patient's death, must always be informed by complex, messy, generous love.
Indeed, it was in silence after my final moments with Rose in which I thought long and hard on the values of medicine. I considered the human stories, the human suffering that pulses through this ancient profession. I sat up from my bed that night, bowed my head, and prayed: “Please God,” I timidly muttered, “strengthen Rose in love. Embolden her, and amidst her suffering show compassion. Please give her… well, give her what she needs. Whatever that may be, and whenever she might need it.”
In deafening courage, in compassion and companionship, Rose taught me the meaning of silence. Now I need only listen, and discern her thunderous words.
