Fillers A memorable patient

The power of song

BMJ 2004; 329 doi: (Published 11 November 2004) Cite this as: BMJ 2004;329:1141
  1. Ian Nesbitt, consultant in anaesthesia (iannesbitt{at}
  1. Freeman Hospital, Newcastle upon Tyne

    Like most doctors, I have seen a great many deaths. Those in intensive care epitomise the undignified nature of death in modern Western society, but one becomes used to, inured to, fully monitored deaths, where coloured lines chart final dysfunction.

    While working in Samoa, I helped to treat a middle aged patient. Two days after his admission to hospital with back pain, a diagnosis of dissecting thoracic aortic aneurysm was made, and he underwent surgery. The procedure was difficult and prolonged, with a large false lumen, no identifiable re-entry site, and probable carotid artery damage.

    Within hours of arriving on the intensive care unit, he required an emergency thoracotomy for cardiac tamponade and developed evidence of incipient multiple organ failure. In the following discussion about treatment options, I was a firm advocate of quickly withdrawing treatment. However, surgical optimism overcame our pessimism, and he received increasingly heroic support with inotropes, haemofiltration, ventilation, and (literally) gallons of blood products.

    Throughout the first four days, his immediate family kept a vigil at his bedside. His wife spoke no English, and, despite translation, I was aware that none of our conversations was entirely successful. I felt that the fact her husband might die had been accepted, but little other information had crossed the barriers of language and culture.

    On the fifth postoperative day, the patient's condition deteriorated again, and we finally convinced the surgeons that further treatment was futile. A priest was called, and the extended family, about two dozen in all, arrived. A sermon and invocation in Samoan was followed by an impromptu chorale, offering prayers and songs for the doomed. The juxtaposition of the rhythm of an intra-aortic balloon pump and melodious, reverberating psalm raised goose bumps on my skin. The family left, I switched off a dozen machines, pronounced death, and followed the family into the relatives' room, prepared to deliver “the usual spiel.” Much to my surprise and embarrassment, I promptly burst into tears.

    More than four days of translated talk, more than all the obvious high technology support we had provided, those tears broke the cultural barriers and showed the family what we had been trying to do. I was hugged, called brother, and comforted by those I had intended to comfort. Through my tears, I realised that I was providing the family with something positive, a more human face to Western medicine than perhaps they had previously encountered.

    It was a strange and humbling experience, and has taught me much more than the fact that dying in intensive care does not have to be undignified. Few people in the West now die surrounded by so many friends and family as did this patient. As these things go, it was a good death. It has also, perhaps, refamiliarised me with the wider ramifications of death in intensive care.


    • We welcome articles up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. Please submit the article on Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.

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