Death Package

Mr. Clarkson came into the hospital because his urine is the colour and texture of tomato juice. I am the evening ward clerk. My desk is centrally located in the nursing unit, and I overhear the resident as he briefs the staff physician.

“Eighty-seven-year-old male with prostate cancer, on cytotoxic drugs which are basically taking out the lining of his urethra. He was up in Medicine for three days, during which time Urology inserted a catheter.”

“Sounds pretty straightforward,” says Dr. Wong as she scans the printed notes. “So what makes you think we need to bring in psychiatry for a consult?”

The young resident takes a deep breath. “Because the patient says he bought a stepladder for the purpose of throwing himself down six flights of stairs.”

Dr. Wong puts down the notes and looks at the resident. “Do you have corroboration on this?”

“The family says he’s so fixated on it, maybe it would be better if he acted on his wishes.”

“Family, as in . . . ?”

“A wife of forty-eight years, and two daughters who live in town and visit regularly.”

“And this man is fixated on dying?”

The resident shrugs his shoulders. “Apparently.”

*

“I am Maria Garda,” she announces, the rs rolling off her tongue. “They stole my laundry.” A plastic bag suspended from her hand swishes against the wheels of her walker.

She is small and hunched; wiry grey hair neatly arranged with black sequined headband; blue cardigan over aquamarine shirt with “Napoli” scrolling around the beaded collar; hospital pyjama bottoms and slippers.

She came to the unit a few days ago because her diabetes was making her blood sugar levels unstable. She has underlying dementia, most likely Alzheimer’s, superimposed with a delirium brought on by a recent urinary tract infection. She paces the halls relentlessly. This is the third time she has approached the nursing desk since I started my shift an hour ago.

“Yes, Mrs. Garda,” I say evenly. “I know who you are. No one stole your laundry.”

“Well,” she sniffs, “that’s what I get here. I didn’t do anything wrong, and that’s what I get.” She turns her back and ambles away.

I turn to the stack of charts on my desk. This is what I know—paperwork and filing and telephone calls. I am paid to perform mundane clerical tasks, not to have opinions about the medical care of the patients. This detachment serves me well on days when I can hear a patient down the hall shouting in pain, or when a nurse reports that she tried four times to insert an IV line but the vein “blew” each time. I don’t know what she means by this, and I don’t want to know. This delicate oblivion takes the sting out of working in a hospital. It’s the only way I can do my job.

In three minutes Mrs. Garda is back. She holds out her plastic bag. “They stole my laundry.”

I peer over the counter, looking into the bag to appease her. Some bright pink items are balled at   the bottom.

“You see?” A sour look on her face. “I had more than that. A few days ago, someone did my laundry. They took it.”

“Mrs. Garda, no one stole your laundry. You’re at the hospital. We’re here to help you.”

She scowls at me, and pushes off down the hallway.

*

The plane crash is all over the news the next day. It’s a horrific scenario: A pilot has purposely flown a plane into a mountainside. In the days preceding the crash, a doctor deemed the twenty-seven-year-old man unfit to fly, but the pilot had withheld this information from the airline. Instead, he imposed his suicide plan on one hundred and forty-four passengers and six crew members.

Jasenka, a nurse, comes into the station and says to anyone within hearing range, “You know what Mr. Clarkson just said?” Her Croatian accent sounds thicker than usual, a sign that she is worked up. “He was watching the news on TV in his room and he said to me, ‘I wish I was on that plane.’ He thinks it’s a waste that other people died, when he wants to die so badly.”

She shakes her head.

*

Mrs. Garda is on the other side of the desk, her forehead wrinkled in concern.

“I am Maria Garda. I need to get to the garage. The Salvation Army people are coming to pick up the clothes.”

“You are in the hospital. You don’t have to worry about that.”

“But they are coming.” A smile plays on her lips. “Every year I give things to the Salvation Army. It is just a small thing, to give away old clothes.” Then she frowns. “I tell my husband, but he does not care.” She waves her hand. “Men do not care.”

I have read Mrs. Garda’s chart. She is widowed and lives in an apartment. There is no husband, no garage.

I try redirecting her. “Are your sons coming for a visit today?”

“What?” She looks confused.

“Your sons,” I say in a loud voice. “Are they coming to see you today?”

She breaks into a smile. “Ah, you know them, my sons. The Garda boys.”

“That will be nice for you.” I look down at the work spread out on my desk.

“No one comes to see me here. No nurse, no doctor.”

I look up at her forlorn face. She holds my gaze. With a sigh, I stand up and come around to the other side of the desk.

“Mrs. Garda, the doctor comes to see you every day. And the nurse checks on you every hour. And you have a call button to ring any time you need help.”

She looks petulant. “No one comes to see me here.”

I challenge her with my eyes. “That’s not true. Your son came yesterday.”

She looks down. The plastic bag catches her attention. “They stole my laundry.”

I persist. “Robert came yesterday. And your other son will come today.”

She looks up with a smile. “Roberto.” She pauses. “And . . . and Gianni. The Garda boys.”

“Yes.”

She frowns. “No one comes to see me here. No nurse, no doctor.”

*

“Mr. Clarkson thinks tomorrow’s meeting is to discuss his right to assisted suicide,” the resident says.

Dr. Wong looks up. “But it’s a family meeting. To tell them what options are available after discharge, to discuss his cancer treatment . . . ”

The resident nods and interrupts. “I know. I tried to make that clear to him. But he still thinks we’re bringing his family together to discuss options for assisted suicide.”

Dr. Wong shakes her head. “I thought he scored well in the cognitive testing.”

The resident nods again. “Yeah, no signs or delirium or dementia. But he’s stuck on suicidal ideation. He gave me a lecture on how it should be everyone’s constitutional right to have access to assisted suicide.”

*

“I am Maria Garda,” she says.

I keep my pen moving across the medication order, thinking that if I don’t engage with her, she will go away. But when I finally look up, she is still standing there, looking at me. I glance around the nursing station for the social worker or another nurse, but I’m alone at the desk. The situation makes me uneasy. I am not trained for this.

“Hello Mrs. Garda,” I say, in what I hope is a professional voice. “I remember you.”

She purses her lips and looks puzzled. “You remember me?”

“Yes, you’re a patient here, so I know who you are.”

Lines furrow her forehead. “They come into my home. They take my things.”

“Who?” I ask.

“Those people,” she says, shifting her small frame so she can turn around and look behind her. “They take my things.”

“You’re in the hospital, Mrs. Garda. No one is taking your things.”

She looks at me. “I do not ask them, but they come into my home.”

“You mean the housekeeping people? Do they come into your room?”

“My room?” she asks, blinking at me. “What is my room?”

I stand up and glance at the white board at one end of the nursing unit, where patients’ names are written beside room numbers.  I come around to the other side of the desk.

“Let’s go find your room,” I say. She looks up at me, unsmiling, not understanding. I put a hand under her elbow to guide her down the hallway.  

*

“Well, that was a tough meeting,” Joanne, the social worker, says as she reaches into the box on the counter. “I need a chocolate. Who are these from?”

“The Peters family,” I answer, motioning to a card on the desk. “Delores went home this morning.”

“Mmm,” Joanne murmurs as she bites into a chocolate truffle. “I love these. Almost makes up for the family meeting I just came from.”

Dr. Wong comes into the nursing station and collapses into a chair. “Can you believe that?”

Joanne hands Dr. Wong the box of chocolates. “Here, maybe this will help.”

Dr. Wong shakes her head. “No thanks. I’m trying to be good.”

The resident sits down beside Dr. Wong and takes the box of chocolates from Joanne.

“Clearly the family is past knowing what to do,” Dr. Wong says. “He’s worn them down to the point where they’re on his side.”

Joanne nods. “So it was good that you told them they can’t help him in any way with his plan.”

Dr. Wong looks sad when she says, “But that actually makes it harder on them, because now they feel like they’re just prolonging his suffering.”

*

“I am Maria Garda,” she announces, her brow puckered with concern.

I look up from my paperwork. “Hello, Mrs. Garda,” I say. I decide to circumvent her complaints before she can speak. “I like that shirt you’re wearing!”

“What?” She looks confused.

“I like that shirt. You look very nice in pink.”

She looks down to see that she is wearing a rumpled pink blouse. Then she looks up at me, her mouth turned up in a sudden smile. “You like this? It is old. You like it?”

I nod and smile. “Yes, it’s my favourite colour. Look, I’m wearing pink too.” My words sound childish to my ears, but she gives me a smile. I point to my name tag. “My name is Jane.”

“I am Maria Garda,” she says. “It is nice to meet you.”

*

“Well, he’s not depressed. He just wants to die,” Nancy reports to Margaret, the night nurse who is coming on for her shift. “He smiles when you go into his room, and his mood seems generally good.”

“Seriously?” Margaret asks.

“Yup,” Nancy answers.  “Psychiatry came for a consult this morning and they said he’s not depressed.” She glances at a medication record. “I mean, they started him on an antidepressant just for good measure, but his mood isn’t bad at all. Oh, and I changed his leg bag at six this evening. Urine is still very red.”

*

Just as I’m transcribing the last order onto a patient’s medication record, a man of about fifty approaches the desk. Gianni, Mrs. Garda’s son. He smiles. “How’s my mother today?”

I smile back. “The nurse can give you an update.” I consult the list trapped under a plastic blotter on my desk, then look up at Gianni, who is fidgeting with the zipper pull on his jacket. “Her nurse today is Jenna.”

“Oh, sure,” he says, looking relieved. “She was Mom’s nurse the other day. I know who she is.” He nods his thanks, and starts down the hall.

A little while later, as I’m turning off my computer for the night, Mrs. Garda and Gianni shuffle towards the desk. She hangs onto his arm, and his hand is placed protectively over his mother’s.

“I am Maria Garda.” She looks immensely pleased. “This is my son, Gianni. He came to visit me.”

Gianni looks embarrassed, but I smile at Mrs. Garda as if this is all news to me. “Well, how about that?” I say. “Aren’t you lucky to have sons who come to visit you?”

“They are good boys,” she says with a smug smile.

*

The next day, Darlene sits down in the chair beside Dr. Wong. “You know how you wrote an order to get blood from Mr. Clarkson, to test his CBC and INR?  Well, I can’t get it.”

Dr. Wong looks at the nurse. “What’s up?”

“He’s refusing all bloodwork,” Darlene says. “And all his medications.”

“All his medications?” Dr. Wong looks concerned.

“Can you go talk to him?” Darlene asks.

“Definitely,” Dr. Wong answers, and strides out of the nursing station, the resident two steps behind.

Five minutes later, Dr. Wong is back. She pulls Mr. Clarkson’s chart from the turntable and flips through the pages until she finds the phone number she’s looking for.

“Hello, Linda? This is Dr. Wong from the Civic hospital. I’m calling about your father. He wants to stop all his medications…yes, I understand you have power of attorney…” She talks for a few more minutes, then hangs up. She writes something in the chart, and brings it over to my desk. She points at the page.

“This is an order to discontinue all bloodwork and medications for Mr. Clarkson. He’s refusing to have his prostate cancer treated anymore, and his daughter says if that’s his wish, she has to go along with it.”

I look at Dr. Wong, then back down at the order. I begin transcribing the order into the patient’s care plan.

A few days later, there is another order written in Mr. Clarkson’s chart in Dr. Wong’s neat handwriting: Nurse may pronounce death, as death is not unexpected. And there is a requisition for a consultation with Palliative Care for “comfort measures only.”  Mr. Clarkson’s cancer treatments and all other active care have stopped. Everyone is waiting for him to die.

*

“I’m concerned Mrs. Garda is still really confused,” the resident says to Dr. Wong. “Her delirium isn’t clearing as quickly as I’d hoped.”

Dr. Wong scans the medication list. “Let’s keep her on the antibiotics and hope the delirium lifts. Of course, she’s still very compromised by the Alzheimer's, so it’s difficult to tell what’s what. She’s a complex little lady.”

*

The next day when I start my three o’clock shift, I ask the day clerk, “Everyone still with us?”

“So far,” he answers.

A folder sits on the turntable beside Mr. Clarkson’s chart. “What’s that?” I ask.

“Death package,” he says.

I think he’s making a joke, until I see the words on the front of the folder, which read “Death Package.” I open the folder and see a stack of forms: Physician’s Checklist on Patient Death; Nursing Staff Checklist on Patient Death; Certificate of Death; Nursing Policies, Procedures & Protocols - Post Mortem Care. There are other forms, but I close the folder and put it back on the turntable.

“Keep it handy,” the clerk says.

But Mr. Clarkson is still there the next day when I come in to work, and the next, and the next.  

*

Mrs. Garda wanders in the hallway a few feet away from the nursing desk, and does not move out of the way when anyone tries to pass her. She is agitated and seeks an audience, but today the unit is busy, and the nurses do not have time to stop their work and comfort her. Out of the corner of my eye, I see Dr. Phillips come into the nursing station. Tall and well-dressed, gentle and respectful, he is the picture of the caring psychiatrist. He extracts Mrs. Garda’s chart from the turntable and tucks it under his arm, then strides over to a nurse who is administering medications.

Mrs. Garda looks at me. “I want to speak to the personnel officer. I want to resign from this place. I am tired of being here.”

I look at Mrs. Garda, but I’m listening to the nurse as she talks to the psychiatrist: “ . . . a bad night, didn’t sleep at all . . . we had to borrow a geri-chair from A5 and secure her . . . Haldol in the right arm . . . ”

“ . . . I have to get to the garage . . . ”

“ . . . refused Trazodone this morning . . . didn’t eat lunch . . . ”

“ . . . they will be coming. I try to do a good thing. It is not much. But this is what I get. I did nothing wrong.” Then she narrows her eyes, calculating, changing tactics. “If you do not let me speak to the personnel officer, maybe tomorrow I just do not come in. Maybe I just stay home from work.” She shrugs defiantly, her chin held high.

I hear the psychiatrist’s footsteps coming our way.

“Hello, Mrs. Garda,” Dr. Phillips says in a quiet but animated voice, sounding genuinely pleased to meet her. She gives him a confused look, and he places a light hand on her shoulder. “I’m Dr. Phillips. May I talk with you for a minute?” Before she can refuse, he asks, “What’s in your bag? May I see?”

I return to my paperwork, and I hear the psychiatrist’s comforting voice as he leads her down the hall to her room. “You don’t need to worry about that….you’re in the hospital…it’s my job to worry about you…we’re going to help you relax…”

I don’t see Mrs. Garda for the rest of my shift. The supper trays arrive at 5:30 p.m. and an attendant goes from room to room delivering today’s offering: reconstituted mashed potatoes and a slice of dry roast beef with a blob of dark brown gravy and a side of something green; a small cup of canned peaches; a plastic mug of lukewarm coffee.  On the turntable beside my desk, the patients’ charts sprout medication orders as the physicians make adjustments to medications.

*

“How’s his appetite?” Nancy asks as she comes on for the night shift a week later.

“Good,” Margaret reports. “He’s still eating and drinking well.”

“Hmm,” Nancy says. “So he likely won’t go just yet.”

“Maybe, maybe not,” Margaret says.

“What colour is his urine?”

“Still very red.”

*

The next day when I come into work, I see Mrs. Garda’s name on the discharge side of the whiteboard, followed by “Westhaven Manor” and a date a few days hence.

“What does Mrs. Garda think of that?” I ask the unit manager.

“She doesn’t know yet. The family meeting is scheduled for tomorrow morning.”

I don’t see Mrs. Garda that day, or the next. She is not out pacing the hallway. I hope the new medication the psychiatrist prescribed has brought her some peace.

*

And then one evening, Jasenka bustles into the nursing station.

“Dr. Wong,” she says, her Croatian accent very thick. “I think you should talk to Mr. Clarkson.”

The doctor looks alarmed. “What is it?”

“It’s his urine,” Jasenka says. “It’s not red anymore. It’s tea-coloured.”

Dr. Wong relaxes. “Well, I’m not surprised. We took him off all his medications, including the cytotoxic one for his prostate cancer.”

Jasenka waves her hands. “But he has decided maybe he doesn’t want to die now.”

Dr. Wong looks at Jasenka. “Are you sure?”

“Yes, yes!” Jasenka says. “He told me, ‘Maybe I don’t want to expire right now.’ Those were his words.”

“You’re sure?” Dr. Wong asks.

“You go talk to him!” Jasenka instructs the staff physician with a wave of her hand.

In a few minutes, Dr. Wong is back, a puzzled look on her face. “You’re right,” she says to Jasenka.

“See, I told you!” the nurse says with a note of triumph in her voice. “His pee isn’t red anymore, so he thinks maybe he’s getting better. He thinks maybe he doesn’t have to die so soon.”

Dr. Wong reaches for the phone. “I’m asking psych to come take another look at him, to make sure this is really what he wants.”

*

Mrs. Garda takes up her place in front of my desk.  It’s her final night on the unit before her discharge tomorrow.

“I am Maria Garda.”

“Yes, Mrs. Garda,” I smile. “I remember you.”

“You do?” She looks at me suspiciously. “How do you know me?”

Her nurse steps in beside her, but speaks to me. “Big day tomorrow. The anticipation has made her really confused. Sorry she’s bothering you.” The nurse takes Mrs. Garda’s hand and leads her back to her room before I can say anything.

*

Dr. Roberts, the psychiatrist, has just come from Mr. Clarkson’s room. “He’s serious, all right. He’s decided he doesn’t want to die anymore.”

“Could it be that the antidepressants are kicking in?” Dr. Wong asks.

“Perhaps,” Dr. Roberts answers. “Although I still don’t think he’s depressed. I think he just changed his mind.” He smiles. “You know, there are studies which show that in the ICU, fifty percent of patients say they want to die. But if you talk to them later, after they start to get better, often they say they’re glad they didn’t die.” He pauses. “I mean, who are we to judge?”

“Well in that case,” Dr. Wong says, “I’d better order stat bloodwork and get him back on his meds.”

*

And then it’s Friday. When I take over from the day clerk at the start of my three o’clock shift, the first thing I see written in the daily record is that Mrs. Garda was discharged that morning.

“How did it go?” I ask.

He shakes his head. “Rough. She didn’t want to leave. Got totally delirious and combative. They had to give her Haldol.” Then he looks thoughtful. “The strange thing is I’m going to miss her.”

*

Ashley, the young night nurse who is taking over for Jasenka, listens while the other nurse briefs her on the patients.

“Mr. Clarkson doesn’t want to die anymore?” she asks with wide eyes. “Are you serious? But I thought he was palliative.”

“He was,” Jasenka says, “but not anymore. Not since yesterday. You can ask Dr. Wong.”

As Ashley looks at the list of medications that have been re-prescribed, Dr. Wong emerges from the tiny office behind the nursing station.

“I heard my name,” she says, looking around.

Ashley looks at the doctor. “Is it true Mr. Clarkson isn’t palliative anymore?”

Dr. Wong nods her head slowly. “Correct. Mr. Clarkson is getting better.”

There is a pause while Ashley absorbs the information. Then she says with a half-laugh, “In that case, I really hope he doesn’t get sick now.” Then she notices I’m looking at her, and she adjusts her expression to a more serious one. “No, I just mean, what if he gets an infection now, and gets sick and dies? That’s all I’m saying.”

I nod my head. “I was thinking that, too.”

“That would be really bad for him,” Ashley says.

“Definitely very bad for him,” I say, eyeing the Death Package folder stowed beside Mr. Clarkson’s chart on the turntable. I hesitate, and then withdraw the folder. I walk over to the cupboard where seldom-used paperwork is stored, put it on the shelf, and close the door.

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