Doctors and the ‘D’ Word

When I was a first-year medical student, I earned a few extra dollars by working the 4 p.m.-to-midnight shift in our hospital’s nursing office, where I scheduled private-duty nurses. One evening, about 9 p.m., a nurse called to inform me that her patient had “expired” and that she would need to be assigned to a different patient for the next day.

Expired?

I had no idea what she was talking about. I had an image of the rubber air mattresses we used during camping trips when I was a kid: When you opened the valve, the mattress would shake and shimmy as the air whistled out, gradually deflating unevenly until it was a flabby rumple of green rubber.

But then it slowly occurred to me what the nurse probably meant. “You mean the patient … died?” I asked, tentatively.

“Yes,” the nurse replied impatiently. “The patient expired.”

Expired. The word rolled so oddly on my tongue. What a strange way to refer to death. My own experiences with death at that time were limited to my anatomy cadaver and the vagaries of the pentose-phosphate cycle.

When I started my clinical clerkships, I began to hear the verb “expire” more frequently, and gradually it ceased to sound strange. As an intern, I witnessed my first deaths and was responsible for writing “expiration notes” in patients’ charts. Cartons of milk had expiration dates. Coupons expired. I guessed people could too.

I could understand why other people might prefer euphemisms for death, but why medical professionals? Weren’t we supposed to be much more comfortable with the workings of the human body? Didn’t we pride ourselves on our technical accuracy? Didn’t we say “umbilicus” instead of “belly button”? Didn’t we refer to the “lower extremity” instead of the “leg”?

Conventional wisdom holds that doctors become inured to death by seeing it so much, but the existentialists posit that seeing so much death has the reverse effect, making us acutely aware of our own mortality.

I think there is a little bit of both. Each time we see someone die, we realize that it could be us, or our parents, or our children. We doctors are just as terrified of death as any other human being scurrying around this little planet. And like any other human, we use euphemism to shield us from that fear. But unlike others who get to indulge in gentler plays of language (“off with the angels” or “at a better place”), we need to institutionalize it as just another piece of medical terminology — terminology that we are in control of.

A few years ago I was supervising on the medical wards during the month of July with a team of new doctors fresh out of medical school. There was one intern who hailed from below the Mason-Dixon line (something of a rarity in our New York City hospital). One morning she came up to me, her eyes heavy, and reported that Mr. Gonzalez had “passed” during the night.

My first reaction was to ask whether it was gas or stool that he had passed, since we’d been concerned about his intestinal symptoms. Then it dawned on me what she was saying.

“Oh, you mean he expired?” I said.

She looked up at me awkwardly and narrowed her eyes, then nodded slowly as she got what I meant. I recognized in her the same uncomfortable transition I had those many years ago, when my everyday words for dying were replaced by the medically acceptable terms.

The experience reminded me of a story published in the very first issue of the Bellevue Literary Review called “Cousin Esther Goes to Chicago,” by Cori Baill. The chief resident admonishes a new intern to stop giving such intensive care to a patient — Esther — who has terminal cancer. “That poor woman should have already gone to Chicago,” he says, trying gamely to convey his empathy. The housekeeper in the story — who is mopping the floors while overhearing this conversation — wonders if in Chicago when someone dies, they say that person “went to Baltimore.”

My intern’s use of the term “passed” also brought to mind a wonderful poem called “Gaudeamus Igitur,” by John Stone, a cardiologist from Atlanta. This poem — the title translates to “Therefore Let Us Rejoice” — was delivered as a commencement address to a class of Emory medical students who probably didn’t realize how lucky they were. I read this poem to all of my students and interns because it speaks to the emotions of moving on in medical training and in life. It includes this passage:

For this is the end of examinations
For this is the beginning of testing
For Death will give the final examination
and everyone will pass.

When Dr. Stone died in 2008, I thought of this line. I know he would have been relieved that he didn’t fail.