On the Meaning of Life

Bureaucratically speaking, that is.

I was walking through the emergency department when I heard my name called by an arriving EMS crew. An elderly woman lay still on their stretcher, her eyes closed, apparently at peace. From their low, urgent summons — with hand-waving, and furtive glances toward the charge nurse — I understood that the paramedics wanted a private consultation.

The lead paramedic said: Doc, we picked this lady up from the nursing home for shortness of breath. However, on the way here, “I think she died!”

The paramedics thought about CPR and such, but the patient had a Do Not Resuscitate (DNR) order. So … now what?

Their anxiety was understandable. First, someone had just died in front of them — always unsettling. Second, there was real danger of bureaucratic jurisdictional nonsense.

Had she died in the nursing home with a DNR, the paramedics would have refused to transport: EMS is not a hearse service, and hospitals do not accept the dead. You can be “not dead yet,” i.e. getting frantic revival efforts, but if you are truly, officially deceased, the hospital won’t register you as a patient. (After all — cue the eye-roll of disgust — no one can bill for your care if you’re dead.)

Everyone in EMS has heard horror stories of an ambulance wandering the highways in limbo with a dead person. A frightened nursing home staff cries “just take the body to the hospital!” and an inexperienced EMS crew complies — only to learn that there is no direct access to a hospital morgue; that the emergency department is for the living; that state regs do not allow 911 to transport to funeral parlors or private residences; and that nursing homes have a firm “no returns” policy.

While the paramedics explained, I studied the patient’s face and felt for her (absent) radial pulse. She was indeed quite dead. I inspected her DNR and it was valid.

This is OK, I told the EMS crew. Let’s go talk to the charge nurse.

I’ve known this particular charge nurse for many years, yet even so I approached her the way I might a strange and possibly unfriendly large dog: Slow movements, soothing voice, hands visible.

“So, we have an unusual situation, but it’s going to be fine,” I began, and then explained: This patient has died —

What! She’s dead?

— she has a DNR; just needs registered and a room —

But we can’t register a dead person!

Well, she’s not officially dead. I haven’t pronounced her.

What?

That’s right. She’s not dead yet. Not officially.

(Brief staring contest.)

So, ahem, I need a room, where I can examine her and decide what to do next.

It doesn’t need to be a big room, I added, and she won’t need it for long.

Registration had doubts too: how could they confirm her identity? I insisted they just take her name and date of birth off of her nursing home bracelet.

Despite some frowns of disapproval, the patient was given a quick pre-registration and assigned a room. It was actually the room she’d been pre-assigned when the medics had called her in on the radio as “shortness of breath”, only now her chief complaint in the computer had been updated to “cardiac arrest”. That, plus the small drama at the charge nurse station, attracted nurses and techs as I escorted EMS down the corridor, they wheeling their stretcher with its deceased passenger.

In the room, everyone seemed uncertain how to proceed, so I talked us through our usual steps:

OK, let’s move her from the EMS stretcher to the bed.

No, she doesn’t need undressed.

Yes, you can put her on the monitor.

EMS, let’s have your report.

Reverting to routine had a calming effect on the room. Even so, staff were antsy.

Techs told me: She doesn’t have a pulse! She’s asystole on the monitor!

I thanked them and told them no CPR, just stand by.

I examined the patient, felt for her pulse (absent), listened to her heart (silent). She clearly needed nothing further from us. But registration was having some difficulty with the intake process — they were scowling at their computer-on-wheels screen and muttering. I figured I shouldn’t pronounce her dead until she was registered. But it was starting to feel vaguely ridiculous just standing there.

So, I left.

I announced I was going to get the ultrasound machine — “I want to take a look at her heart”. This was utterly unnecessary except as a stalling technique. “Don’t do anything at all to her while I’m gone,” I added. I almost laughed at the looks of consternation on some of the faces as I pulled the room curtain behind me.

Three minutes later, with ritual gravitas, I confirmed cardiac standstill by ultrasound. More to the point, she was now registered. I pronounced her dead. There was visible relief all around. This was familiar now, and nurses and techs began to move about more fluently, preparing her for the morgue. Nursing and I conferred, and I told them I’d contact her family.

Back at my computer, sitting next to two of my fellow emergency physicians — one furiously typing, the other rapidly dictating — I was struck by how satisfying all of that had been. I gave a brief account to my colleagues and asked, “Is it weird that my favorite patient of the day was a dead person who needed nothing from me?”

It’s not weird at all, they both said. “I wish all of my patients would arrive dead like that,” said one. The other continued to type furiously even as she agreed vehemently: “One and done. Perfect.”

Note to readers: I do appreciate having this great opportunity to share via Substack. But since writing is not my full-time job, I tend to post intermittently. Apologies for the occasional longer runs of silence. I hope you are enjoying the articles! If you are planning on paying to subscribe: Please keep in mind that the only time I will ever put an article behind the paywall is when it has been published elsewhere simultaneously, as I did for example with recent articles published in The Nation and The Boston Globe. Otherwise, everything I publish here will be open access and free. An abbreviated version of this article has also been published earlier at Emergency Medicine News.