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When I was an intern in internal medicine, I admitted a patient to my service with pancreatic cancer.  Pancreatic cancer is a bad one; back then, only ten percent of patients with it would be alive within five years after being diagnosed.  My patient was a farmer in the full bloom of late middle-age health when he began rapidly losing weight. An abdominal CT scan ordered by his primary care physician revealed the cause:  a three centimeter mass in the body of his pancreas.  It had already metastasized to his lymph nodes and liver.  He went downhill quickly and was admitted to my service within two months of being diagnosed for palliative care.  I ordered a morphine PCA (patient controlled analgesia) pump, which immediately made him comfortable, and then essentially waited for him to die.

It happened one night when, thankfully, I was on call.  His nurse paged me.  “I think he’s gone.  Can you please come and pronounce him?”

I’d never pronounced anyone dead before.  I’d never even seen a dead body in real life outside of the cadaver I’d dissected in my first year of medical school.  But this experience, like that one, was a rite of passage I’d known no doctor got away with missing, so I’d prepared.  When my patient had first been admitted, I’d asked my senior resident how one went about making certain a patient you thought was dead had actually died.

“You listen for breath sounds,” he’d told me, “and for a heart beat.  Check for a response to deep pain.  If you want, you can verify lack of brainstem activity by looking for an oculocephalic reflex.”  That last maneuver consists of turning the head rapidly in one direction and watching to see if the patient’s eyes remain focused on the midline or continue to point in the direction of the head, like the painted-on eyes of doll.  The presence of “doll’s eyes” tells you that the most elemental brain functions have ceased.

When I entered my patient’s room, I found myself confronted with at least ten people—family members—and a priest.  My patient’s wife was sobbing over my patient’s bed.

The priest gave me a knowing look and nodded somewhat nervously.  “I think…”  But his voice trailed off.

I nodded back.  Then I approached my patient.  I realized instantly none of the maneuvers my resident had suggested was actually necessary.  My patient lay on his back in a way even sleepers never do:  without any movement of any part of his body whatsoever, a condition I recognized as distinctly unusual only in that moment of first seeing it.  I wasn’t struck so much by the complete absence  of the rhythmic rise and fall of breathing as by the strange slackness I could see in every part of him, especially in his face and jaw.  I knew before I touched him that my patient was dead.

Nevertheless, I put my stethescope to his chest.  His wife backed away quickly, with a movement that suggested desperation—perhaps, I thought, for me to tell her she was mistaken in her belief that he was gone.  I watched and listened for breathing, acutely aware the entire room had paused to hold its own collective breath.  I heard nothing.  It was the first completely silent chest to which I’d ever listened.

I stood up and nodded.  “He’s gone,” I said quietly.

At that moment, my patient’s wife let out a wail, the sound of which I will never forget, and collapsed on top of her husband’s body.  I looked at the priest, who nodded to me again, this time with more confidence.  Now he knew his role, a role I imagined he’d played numerous times before.

I don’t remember the specific reactions of the other family members in the room.  I left quickly to leave them all to their grief.

That night I learned about death certificates (and how notoriously inaccurate the cause of death printed on most of them is), the transportation in hospitals of dead bodies (in zipped-up, black burlap bags), morticians, and funeral arrangements.  And the critical importance of one thing more that, until that night, I’d never thought about even once:  rituals.

Why do we have funerals for the dead?  They’re gone and know nothing about them.  Why do we celebrate the birth of newborns whose eyes can barely see five inches in front of their faces?

The obvious answer is that these rituals are for everyone except those for whom we hold them.  Psychologically, rituals seem an invaluable aid to mark transitions—especially painful ones—with some kind of formality.  Rituals held around transitions make the transitions seem more real somehow, especially when the transition is one we’ve dreaded and don’t want to believe has actually occurred.  Often it’s the ritual to which our memories return and the ritual on which they rely to explain to us what happened that day when our loved one was lost, rewriting the experience into a particular story that only partially reflects the truth of what happened as we know memory does—hopefully in a way that makes it easier to bear.

Which is why rituals are so important.  The experiences for which we create them may be painful, but the rituals themselves can be imbued with loving care.  Patients, for example, have been found to recall the way doctors deliver bad news for the rest of their lives, recounting the story of their experience over and over again to friends and family members, focusing not so much on a retelling of the bad news itself but on how they were treated by the doctor delivering it.

Doctors play a unique role in helping people through transitions with rituals.  My patient’s family needed the ritual of my officially pronouncing my patient dead in order to begin the process of grieving.  Patients in general need to go through the ritual of receiving an official diagnosis in order to begin marshaling the emotional energy they’ll need to withstand whatever treatment is offered.  People often create rituals for themselves to help them through difficult transitions as well:  they throw out all keepsakes from failed relationships; they give away their dead loved one’s clothing to charity; they attend graduation ceremonies.

It seemed to me as if my patient’s family needed me to pronounce my patient dead before they would believe it even though they already knew it.  It made me realize how much rituals matter and how we can harness their power by fully giving ourselves over to them.  When life brings us to a transition point, especially a painful one, we shouldn’t underestimate the power of marking them with a ritual.  It just may provide us the comfort we need to make it through to the other side.

Some hours after I’d pronounced my patient dead, the priest appeared at the nurse’s station where I sat.  “That was a difficult moment,” he said after a pause.  “But a moment they needed.  Thank you for your kindness.”

I was glad to have heard him say that.  But I felt anything but kind.

Next Week:  Most Effects Are Smaller Than We Think