Gender and Death

When I was on call, I admitted a patient who taught me two very important aspects of medicine. She was a male to female transgender patient with an end stage chronic disease admitted to our service for comfort care. She was a hospice patient but because they didn't have adequate staffing on the weekend and felt that death was imminent, sent her to the hospital. The first thing I learned was about gender. Though she was a transgender patient who identified as female, she was roomed with a man (it was terrible we couldn't even get a single room for a dying patient). I wonder how the hospital decided on this; certainly, it's not a rare thing for a transgender patient to be admitted. But it bothered me that nurses, staff, and even doctors referred to the patient as a "him." It can be hard to remember to call her by her preferred pronoun, but it's so important.

The second was about death and dying. When I saw her, she was extraordinarily cachectic with extreme wasting. Her thighs were the circumference of my wrist. I could see all the bones of her cheek, the zygomatic arch, the mandible. I could count her ribs, almost make out a liver edge. She was nonverbal at baseline. We quickly put in orders for morphine, titrate to comfort. It is a strange feeling, watching someone die. Her respirations were agonal; she breathed small gasps at 30 a minute (try doing that; it's extraordinarily uncomfortable). I checked in on her frequently and increased the morphine to decrease the air hunger. Over the course of the night, she became closer and closer to death; at around 5am, she had spontaneous conjunctival hemorrhages. A little after 8, we were called to bedside to pronounce time of death. The resident and I went over how to pronounce someone and we listened to her heart and lungs, felt her pulse, examined her pupils. After confirming death, I called the case manager, organ donor network, and medical examiner.

Unfortunately, the patient died alone. She was estranged from family and only had a case manager as her outside contact. I spent as much time as I could with her in her last hours because I remember learning that patients don't want to die alone. It was a very poignant evening for me. May Mother's embrace welcome her home.