Officium

Siobhan McKenna

2024 Honorable Mention, Felice Buckvar Prize for Nonfiction

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“How do you do it? How do you watch people die day after day?”

He asked the question as we passed each other on the threshold of his wife’s room. He was leaving after having said all the goodbyes that could be spoken with words. I was arriving, the night-shift nurse gone and my arms stacked with towels, washcloths, and a gray basin. As every death necessitates, I was to perform a final washing for my patient. Scarcely an hour had passed since her husband had lost his partner and best friend, and somehow he emerged through his grief to ask a question that I, myself, still struggle to understand.

Over my mound of supplies, I met his gaze. “We just do,” I replied. I couldn’t tell him the truth, not then, there wouldn’t have been time to explain.

The truth is: I like it. I like taking care of a person as they’re dying. The incredulity of witnessing the final exhalations of a person’s life overpowers the melancholy. My proximity to death did not happen as an accident; I arrived at this position because I was frightened of the next life or lack thereof.

As a high school graduate on the eve of the rest of my existence, I’d experienced the first grapplings with my own impermanence that summer before college. One August night, standing on the edge of the Atlantic Ocean, its black water indistinguishable from the night sky, I felt my mortality and was overcome with crippling fear. Where do we go? What does it mean to die? The mystery of humanity had hurtled into my lap, but my twelve years of Catholic religion lessons proved to be of little solace. That night, I curled in my parents’ bed. My mother laid next to me, stroking my hair; my father brought me frozen M&Ms. I held them and cried, as the dye bled onto my hands. My parents gently prodded me with questions, wondering if someone had died to have triggered my mortality meltdown. I shook my head, staring at the candies sweating colors into my palm.

Like many eighteen-year-olds, I chose to sink these anxieties into my bones and hoped they’d disappear. But instead, they festered and intensified. With time, or perhaps after listening to a This American Life episode about a hospice nurse, I decided that the best way to ease my fear of the afterlife would be to confront mortality directly. I became a nurse, thinking that the profession might give me a chance to examine whatever life’s end truly held—the spiritual, the bizarre, the mundane. I quickly learned I was right: there is no better place to observe the dying than in an ICU.

Dying in an ICU can be a slow, drawn-out process. This is frequently because the decision to transition to end-of-life care often comes only after weeks of conversations with the medical team, the families, and sometimes the patients, if they are lucid. “Comfort care” entails ceasing supportive IV medications, stopping the mechanical ventilator, and prioritizing pain management over prolonging life. From a medical perspective, this shift in care occurs when the prospect for a patient’s recovery and return to a good quality of life is no longer feasible. From a patient and family perspective, it means letting go and allowing nature to “take its course.”

In the past, family members were tasked with caring for their loved ones in the home until they passed on. Instead, “corpses are now handled with efficiency by strangers,” as Christine Quigley writes in her book, The Corpse: A History. Quigley is not entirely mistaken, but I have two objections to her statement. First, I shudder when I hear the word “corpse.” They are still my patients. The color has not yet drawn from their faces, their families are at the bedside—they are not empty shells.
Second, it feels perplexing to be labeled as a stranger. In a basic sense it’s true, but her statement does not capture the warmth of my arms around a daughter as her ninety-six-year-old mother departs. It doesn’t capture the whispers of “I know, there’s never enough time.” Quigley forgets the days, weeks, and occasionally months of caring for a “corpse” before death arrives, of listening to spouses and children share memories about their loved ones. And even with the families that I have less time with, the barrier of the unfamiliar strips away during these intimate interactions.The first patient I cared for at end of life was a woman in her sixties I don’t remember her medical history or even her name, but I do remember that the room was dark; it was raining outside, and her two sisters stood by her side as she passed. I remember them sharing stories about her, smiling and even laughing through their tears in the shadowed room. They had loved her fiercely, but they knew that it was her time. In that moment, I saw my own future reflected to the day when this would be my sister and me. When I began tearing up, the sisters noticed and comforted me with a squeeze on the arm.

As a nascent nurse, I was embarrassed that my emotions had interrupted their grieving and left quickly. Only in hindsight did I understand the momentous occurrence—the sisters embraced the universality of death at hand better than I in that moment and welcomed me into it. Through their touch, they communicated that, yes, this is life, too.

Nurses have always cared for the dead through the practice traditionally called the last offices, the care of the body soon after death. Nowadays, there has been a retreat from this term as it evokes the last rites in Christianity, the cleansing and anointing of the dying with oil. Yet, I find myself drawn to the phrase—the word office derives from the Latin officium, meaning a service, a kindness, or a duty. This reverential framing elevates the entire process of end-of-life care—the managing of comfort near death as well as the care of the bodies after death—to be as essential as every other treatment performed to sustain life. Understanding the fluidity in care as patients transition was drilled into my practice by my nursing preceptors. They are the ones who taught me to tend equally to the moments after death—warming the washing water to show respect, cleansing the patients absolutely and gingerly.

When I began working at other hospitals, I learned that end-of-life protocols varied widely. One night while helping out with a recently deceased patient, I was running my fingers under the water in the sink. As the water warmed beneath my fingertips, the patient’s nurse stared at me in disbelief. “We don’t need to do all that,” she said, and began gruffly wiping away bits of blood and yanking out medical lines. For her the washing was just another task to check off. At least that day it seemed so. Perhaps there were other emotions simmering beneath her icy surface—the recent passing of a loved one, her own mortality—something that prevented her from moving closer to death. I couldn’t know.

It might be my status as a recovering Catholic that is the undercurrent moving me to meet the sacredness of washing. Years of prescribed theology ingrained the notion of our bodies as vessels for our souls, which ultimately depart for heaven, purgatory, or—God forbid—hell. This essence lingers even in my bones, as I seek to decipher my place beside a transition simultaneously revered and feared.
In lieu of faith, history is where I find solace. I’m captivated by the notion of belonging to a historically feminine system. In my home city of Philadelphia, historians have noted that women in the eighteenth and nineteenth centuries worked as watchers and layers of the dead. These women took care of the physical and spiritual needs of the dying, as well as the washing and dressing of the dead in preparation for burial. When I look around my ICU, not much has changed: the landscape is mainly feminine, and though not often spoken aloud, nearly all of the patients are straddling the threshold to the afterlife. In the grip of death’s imminence, a nurse must decide whether to treat death as another task, or to embrace it as an act that braids our existence into the fabric of the watchers and layers who preceded us.

Remembering the women who labored in the heavy stillness of death soothes me. Perhaps that’s selfish, but it’s how I survive. It’s how I finish the shift, go home, and return the next day to do it again. I try to focus on the services at hand to block out what is to come. I don’t want to know the death of rigor mortis long settled, the death of formaldehyde and makeup, the death of coroners and morticians. I want to remember the final warmth and lingering stories, to let the last song they heard on the radio keep playing. I want the death of knowing who they were before they moved on. I ritualize because that’s the only power I wield.

As my patient approaches death, I begin my ritual by arranging the room with chairs and making space for the family to pray or not pray, to rest or pace. I dim the harsh lights and smooth out the hospital blanket. I answer any questions the family might have. Then I try to prepare them for the death rattle, the rasping noise sometimes emitted during the final breaths. I administer narcotics and sedatives, if needed, to relieve the patient’s discomfort. From the outside, all you can see are the prescribed steps, but my mind is simultaneously focused and soothed in a way that is different from any of my other nursing roles.

Once death seems close, I turn off the monitors so that the family members are not subjected to alarms and beeps. I move quietly between the patient’s room and the cardiac monitor at the nurses’ station that keeps me informed. Eventually, the monitor notifies me when asystole has occurred. There will be no CPR. There will be no gasps of life returning to the body, no medical miracles to behold. Instead, we allow nature to take the reins. I hand out tissues, record the time of death, and call the physician in to pronounce the death. She places her stethoscope over the patient’s chest, pauses to listen, and then confirms what the flat green line has told us. A silence hangs in the air. The family takes the time they need—it could be minutes, it could be hours—and then they leave.

Now I am alone with my patient. I pause in the quiet to think about who the person beneath my hands is. Was. I wonder if their essence is still in the room, and I glance at the windows. In a nod to ancient tradition, I’d like to crack one open to let the soul escape. Hospital windows don’t open, but part of me is sure the soul won’t be stuck in this ICU forever, that it will find a way out. Then I pause, aware of the sacredness of being alone with someone whose warm and steady heartbeat, which moments ago I palpated, is now absent. Finally, I begin to wash.

I fill a gray basin with warm water and swirl Johnson’s baby soap with a washcloth, the scent of newborns and innocence hovering faintly around me. Then I scrub any crusted blood from the skin, pull out IVs and catheters, and place gauze over oozing wounds. I think “thank you” into the stillness, though I’m not sure who or what I’m thanking. Thank you for life in all its ephemerality? Thank you that this is not me? Not yet. Thank you.

After I’ve finished washing, I call a fellow nurse into the room. We roll my patient’s body gently to one side and scoot the body bag under. Then we roll her the other way and unfurl the rest of the thick impermeable plastic, making sure the feet—I mean her feet—are in the bottom. (When does her become the?) I tie a paper ID tag around her right big toe and with a zip of the white bag, the finality of it all comes closing in: the startling whiteness of the bag where once was color, the sealing off of someone’s precious love.

I am lifted from my trance. A life has passed, and yet I am still here. There is no gray area. I’d prefer to return to the lingering moments just before and after death when there’s a chance the cosmos might share its secrets, where the thinning veil of the afterlife might reveal itself. But of course, to the disappointment of my adolescent self, I’ve come to realize that watching death does not divulge any of those mysteries. I control the only things I can. I warm the water, add a splash of soap.