Diagnosis: Death

I have had a strange week, with quite dark themes. On an almost daily rate, patients have been dying this week when I'm close by.
It started with an old woman who has had a long history of liver cell failure and this time came presenting with behavioral abnormalities (in the form of aggression, cursing etc) alternating with disturbed consciousness. She was loud and hyperactive and very vulgar in the way she spoke. When I used to take her blood pressure every afternoon, she'd almost bite me or spit. It was the effect of ammonia and other jumbled up neurotransmitters in her brain; hepatic encephalopathy. 
A few days later, I was walking in the ward, looking for a box of latex gloves, when one of the relatives came up to me to tell me that this woman was not waking up. I went over there, reluctantly somehow knowing that I'd find something not so good over there. And surely, as I approached her bed I could distinctly tell that she was either in deep coma or dead. After checking for her vital signs and for pupil dilation, I confirmed that she was to a large degree, dead. Her skin was cooling, her pupils were fixed and dilated and her blue tongue protruded from her mouth. She looked almost comical. I know it is so morbid to say so, but I couldnt help but notice that.
I was at the bedside with her relatives all around me. In my mind I was saying "Hmmm ok so she's dead, probably not a candidate for CPR...can i announce death now? naah...i dont have that authority or experience to announce something major like that. What to say, though? The relatives are all around me...what on earth do I tell them now? I cant reassure them...and at the same time, I cant make a bold statement."
I looked up with a calm, neutral face...to see the relatives all staring at me right in the eye, waiting for a word.
I lowered my eyes and stood up straight. "you'll have to excuse me, I need to get my senior to take a look"
Phew..good one.
They knew she was dead. I knew she was dead...but neither side was ready to recieve or say.
I called on my senior and told her to take a look.
She was announced dead a few minutes later.
The ward fell silent.
There was no longer that echoing of curse words and hissing. She was gone for good. And it was a secret relief for her family, who'd been suffering along with her.
~~~
Today a well-built 40ish year old man with a thick strong musctache came up to me to give me a referral sheet containing details of a young male patient (28 years old) who had acute leukemia and came presenting with disturbed conscious level (DCL)...glascow coma scale: 3.
3?
3 is like equal to a vegetable. Perhaps if you poked a potato, it'd react more than a glascow coma scale of 3 in a person.
My mind was wondering about the possible causes of this disturbed consciousness in a man with leukemia. Blasts infiltrating the brain causing it to swell and herniate?
Blasts lysing and causing severe hyperkalemia which caused an arrthymia, which turned fatal and messed up the blood reaching the brain?
I thought of all the possible, weird, unlikely mechanisms but not the most obvious one...Leukemic patients have thrombocytopenia (in this patient it was 16K) which leads to a high likelihood of hemorrhage, especially in the brain. He's a ticking timebomb, waiting for a brain hemorrhage. And that was probably the most likely cause of his DCL.
They wheeled him in. Initial look, I knew he was dead. Checking vitals, confirmed that he had no pulse. And after monitor attachment, he was asystolic. The call for CPR was initiated and I stood there with the timer, while interns took turns to compress the chest of this lifeless man.
He was beautiful in a way. So young and serene and surrendered. He was wearing a T-shirt with some company's name on it and trousers that matched. He was wearing gray socks. At some point, he was awake to pick those clothes out of his closet and put them on. At some point he went to the barber to get his hair cut (which looked quite recently cut). During that time, he was awake and aware like us. And now, he's in the unknowns.
I was timing, each intern taking 2-minute cycles. I noticed that those who often find it hard to complete the cycle were the ones who have an over-confident beginning. They compress so hard and so fast for the first few times, then their triceps fail them.
Anyhow, the young man did not respond to the chest compressions, nor to the IV adrenalin. He was adamant to stay the way he was. I did notice something interesting though, his gums were swollen, hypertrophied. That was interesting since I knew that leukemic patients often had blasts infiltrating into their soft tissue including gums.
I guess the blast cells were stressed out, since their livelihood depended on the livelihood of the host. No host, no more blasts.
Silly, blasts. You are walking towards your own demise.
Cancers are so stupid. They're parasitic leeches that strive to live and divide in the host extensively, so selfishly. They get so greedy that they kill their host which results in their own extinction. I think viruses are smarter. They get what they want from their host and move on by infecting other hosts.
In a competition between viruses and cancers, who'd you think would win?
Oh and when virsus and cancers unite and join alliances. BOOOM. Major shit is going down.
HCV being the king of the castle. That's another story.
The 20 mins ended and the young man did not respond...and since I was the one with the timer I was one who announced the end of the CPR.
"3..2..1.. ok, doc you can stop now."
I looked up and once again found myself surrounded by relatives. They asked me directly "Is there hope after this?"
I looked at the most resilient looking one and said "No, I'm sorry. Al baqaa2 lil Allah"
That was the first time I'd announced the death to a family. Alhamdulilah they didnt beat me up or shout in my face or cry hysterically. They quietly wept and asked me what to do next.
I was shaken, in a way.
I had just announced the death of a human. Calmly. I did feel a certain sacredness in what just happened. I knew that such situations needed silence and contemplation. I grew irrirated at the surrounding buzz of interns behind me, going on their conversations as normal.
It's not their fault of course...but death is a sacred time. It is a time to at least realize that this is the fate for all of us.
I just hope that I dont need CPR. The idea that my sternum and rib cage will be disturbed this way, is unbearable. It'd be a blessing to die peacefully and quietly while no one is noticing.

Everyday patients keep dying. Patients I spoke to or even laughed with. It's not depressing, more than it is enlightening. It makes one less afraid of death, since its a common fact of life. Like giving birth and like getting old. The holy and sacred aspect of "what comes after it" is what needs to be remembered.
We should not become "immune" to the idea of death, just because we work in medicine. I'm not saying, lets cry everytime....there will come a point in which you will feel nothing after the death of a patient. But the idea is to consciously remind ourselves of our own finity. And remind ourselves of our post-mortem journey.

اللهم إنك عفوا تحب العفو فـاعفوا عنا