Glimpsing Death Through Zoom

Abstract

This personal essay brings readers into what it is like to experience a patient's death for the first time as a medical student, but with a topical twist: this experience happens over Zoom. The author is part of the 2023 cohort of medical school graduates who will have spent at least half of medical school online. Most people think of virtual medical education as a loss, but this essay is about how “Zoom medical school” actually allowed one student to experience a “good death” very unlike the deaths typically witnessed in hospitals. The essay details and reflects upon the experience of shadowing a palliative care physician’s Zoom appointments with a patient, Mrs. K, over the weeks leading up to her death from cancer, surrounded by children and grandchildren at home. In contrast, the author weaves in the story of her own grandfather who died last year from COVID-19, intubated alone in an ICU all the way in Tehran, Iran. The essay concludes that medicine is not just about preventing death, but about making a good death possible—and that a good death is embedded in the communities that brought meaning to one’s life in the first place.

Medical school should be spent in lecture halls, anatomy labs, and most importantly, hospitals and clinics with patients. But because of the pandemic, the first 2 years of my medical education was mostly online. Sometimes, I can only laugh at the absurdity of “Zoom medical school.” Still, it’s where I learned how to hold a child for a throat swab by a pediatrician demonstrating on a stuffed lion from home. It’s also where I first learned about death.

I met Mrs. K during a placement with Dr. B, a family and palliative care doctor in Scarborough, Ontario. Mrs. K, an 89-year-old woman, was dying of cancer. During weekly appointments with Dr. B over Zoom, I witnessed how she became frailer week after week, losing the strength to walk, let alone climb the stairs to her bedroom.

The first time we met, Mrs. K was smiling next to her daughter, Shari, in the kitchen after returning from a walk on a surprisingly warm March day. Dr. B asked Mrs. K how she was feeling, including how she was handling going up and down stairs. As I glimpsed into Mrs. K’s home, I learned just how much that question mattered: she lived in a multi-story house with a maze of stairs and landings that seemed challenging for anyone to navigate.

The challenges of navigating Mrs. K’s home reminded me of my impressively, yet stubbornly independent 91-year-old grandfather with a hip replacement and limited vision walking the treacherous sidewalks and stairs of Tehran to reach friends, the mosque, and his office. That is, until the final 2 weeks leading up to his sudden death thousands of kilometers away from his children and grandchildren.

Over several weeks, Mrs. K slowly lost the energy and vivacity from our first meeting. She spent most days in bed while her children and grandchildren traveled up and down those stairs to care for her. Shari would often call us from 1 of the only quiet spaces left in a home packed with family: a landing between staircases.

Shari would then bring us into Mrs. K’s bedroom where the head of her hospital bed was pushed against the window. Light streaming in from behind obscured Mrs. K.’s image from view until Shari gently closed the curtains and tucked in beside her mother, holding her phone camera up for us to see them both. We could often hear the chatter of grandkids in the background as they had taken the necessary precautions to safely move into their grandmother’s home for her final weeks.

In what turned out to be our second-last meeting, Mrs. K could still answer some of Dr. B’s questions and Shari shared how her mother had gained some energy back in recent days. Dr. B calls this the final “rally”: many patients exhibit a final burst of energy towards the end-of-life as their loved ones converge at their bedside. I didn’t know if I would see Mrs. K again after that call.

But next week’s appointment did happen. This time, Mrs. K was unable to speak for herself and even through Zoom, I could tell she was exhibiting the typical end-of-life breathing signs we are taught in medical school. Dr. B emphasized to the family that even if Mrs. K cannot respond verbally, it is still important to speak to her and especially use touch. Palliative care doctors have always valued touch in end-of-life care, and now we’ve all learned to never take touch for granted again. As Dr. B gently let the family know that this was likely their last 24 hours with Mrs. K, I witnessed Shari cry for the first time.

After that appointment, I went for a walk on an unexpectedly cool late-April afternoon, reflecting on all that had happened since first meeting Mrs. K and Shari: how Mrs. K went from going on walks to no longer leaving bed, how Shari ensured her mother was always comfortable and never alone, and how I felt sad yet also thankful for the privilege of witnessing this family experience death together while so many across the world could not—including my own.

My grandfather died of COVID-19 while intubated alone in an ICU in Tehran, Iran. My sole cousin still living in Iran tried keeping him home for as long as possible. He hired private home nurses, procured oxygen tanks, and even flew to another city to buy remdesivir, the popular albeit controversial treatment in Iran at the time. But my grandfather grew more and more delirious as his organs began to fail 1 by 1, and thus his physician recommended an admission to hospital for dialysis and intubation. In Iran, there is a strong culture of aggressive medical treatment until the very end of life, and so my cousin eventually resigned to the pressure of admitting him to the hospital—knowing very well he may never see our grandfather again.

Instead of the chatter of grandchildren echoing in the background as he approached end-of-life, my grandfather’s last days and weeks were filled with the beep of hospital machines and moans of fellow patients. Instead of dying at rest while held by family, he died beneath the hands of doctors trying to save him with yet more medical interventions. My grandfather didn’t have the opportunity for a final “rally” like Mrs. K.

He had lived a long and mostly healthy life, always immersed in communities that fulfilled him. It was perhaps his time to go, but not alone in this way.

The morning after that final Zoom call with Mrs. K and Shari, I woke up to an email I expected: Mrs. K passed away peacefully overnight, without pain, and surrounded by family. It was, I think, a good death.

There are several “firsts” that stand out for many medical students: the very first patient we work with—a cadaver, the first time we use a stethoscope, the first time we wear a white coat, the first time we help birth a baby, and the first time a patient whose care we’ve been a part of dies.

If not for this experience with Mrs. K, I most likely would have experienced a patient’s death for the first time in a hospital with pandemic visitor restrictions—without much sense of the home and cherished communities within which they lived rich, full lives. I study in Canada, and here research has found the vast majority of Canadians want to die at home, but most die in hospitals. ¹

I’ve only ever known loved ones to die in hospital. But now, thanks to the privilege of being given a glimpse into Mrs. K and her family’s life through Zoom, I also know what dying at home can look like: comfortably and lovingly surrounded by the very people and place that gave one’s life meaning. My point isn’t that good deaths can only happen at home. Rather, my point is that medicine should not only be about preventing death, but also making a good death possible for everyone, wherever that may be—yes, including a hospital—and in whatever context we may find ourselves—yes, including a pandemic.