“Ms. A.” died recently. She was the first patient that I helped care for to die.

When she first came in as a “stat trauma,” after being run over by a truck, she was a nearly ninety-year-old lady in terrible pain, but I thought she was lucky. She had no damage to her internal organs or to her brain and spinal cord. Her leg was broken, and she had some other bruises, but that seemed to be it. As I helped the trauma team in whatever small ways I could, mainly by trying to stay out of the way of people who could actually do anything for her, I saw something glitter on the floor. It was a gold brooch with a purple stone – I remember thinking that when this was all over, she would be sad to lose it, and I put it on the table with her other things. She was wearing heavy gold earrings, gold necklaces, and a gold ring with turquoise blue stones. She was at the age that wearing all that jewelry looked natural rather than gaudy – a lifetime of accumulated precious mementos.

Ms. A. was from one of the ethnic groups that have immigrated in large numbers to Boston, forming their own tight-knit communities, and she spoke very little English. Once the shock of the trauma was over and her leg had been fixed, she lay in her hospital bed moaning in pain, both the pain of her injuries and the pain of not being able to tell anyone about it. I tried to communicate with her through gestures and the few words she knew, and she would point to her right thigh, but eventually she just responded to my questions by shaking her head despondently and repeating “I don’t know, I don’t know.” I sat with her for a while, waiting for the interpreter, but eventually had to move on to other patients.

What I didn’t realize then was that the extent of the injuries to her legs made them unable to heal, and the tissue began to die. The only hope of saving her life was an above-the-knee amputation. Even that had a poor chance of survival, but the surgeons said they had done it successfully in much sicker patients. She would never walk again, but she would be alive. But before her leg surgery, even before she realized the choice she was truly making, she had managed to communicate to someone that “I would rather die than have an amputation.”

The family chose to respect her wishes, and made her status CMO – “comfort measures only.” We stopped giving antibiotics and all the other interventions modern hospitals are capable of. Once she was CMO but still alive, we stopped copying down her vital signs and fluid intake/output for our team rounds, leaving a big blank space on our daily worksheets. We avoided her room when we rounded on patients. Surely no one chooses to come face to face with the dying process when they don’t have to, and there was little left that we could do for her. But more than that, I think Ms. A’s decision flew in the face of what I’ve perceived in the weeks of my rotation as the ethos of surgery: we’re here because if someone has a problem we can fix it. Even more than other fields of medicine, surgical solutions have a component of immediacy and satisfaction. Once the decision is made to send someone to the OR, there is a life-saving change within a matter of hours or even minutes. The cancer in the colon is gone, taken out with that section of the colon. The terrible heartburn is fixed with an ingenious re-structuring of the stomach and lower esophagus. The fetus in distress becomes a baby with a chance, after a c-section has slipped it out of its mother. I can see the appeal. And when our team was talking about Ms. A, the members of my team acknowledged the odds and the tough recovery she would face, but kept emphasizing “we’ve saved people who are much sicker.” With the potential for a solution within reach, made possible by technically skilled surgeons and rehabilitation medicine, in some ways it was a slap in the face to not even be allowed to try. We accepted the family’s decision of course, but it was hard to each day walk by the room where an old lady was slipping more and more into the oblivion of morphine.

I wasn’t there, but I’m sure she passed peacefully, the drug taking away her hunger for air as it took away the pain. The intern and I were called to pronounce her. She was the first person in the hospital I had interacted with in life and then seen in death. As he felt for the carotid pulse in her neck, the last of the pulses to disappear, I held her wrist and felt for the radial pulse. The carotid pulse was gone, so it would have been impossible for the radial to remain. But I swear I felt a heartbeat, and I think it was my own, the blood pulsating in the tiny capillaries of my living fingertips as they rested against her dead skin.

What do I think and feel about the first death I have witnessed in the hospital? The answer is: I don’t know. It is not yet a language I speak, or a culture I am versed in. I wonder with the surgeons whether anything should have been done, whether more life would have ultimately been worth it for her, even without a leg. I grieve with the family that such a senseless accident that initially seemed survivable would lead to her death. And with the necessary practicality of hospital medicine, I pause for a moment by her bedside to say goodbye to the woman with the pain and the frustration and the gold jewelry, and then I move on to tend to the living.

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