I softly scrub blood from the teeth of a man who died moments ago. From the chair where I sat quietly writing nursing notes while he quietly ended, my patient’s sallow skin and sunken cheeks looked so peaceful. But the weeks of stagnant residue on his teeth bothered me.

To brush the teeth of someone who was in the process of dying would have contradicted my orders to provide comfort care, and my own good sense. So I waited until he took his last breaths before I closed my computer screen and gathered my tools — washcloth, water, toothbrush.

I brush now, so briefly, for the pride of this man I didn’t know, and I brush for the family that I wish was here to care about him. He does have family — it is they who authorized removing his life support, in keeping with the wishes expressed in his living will. Their brief go-ahead over the phone satisfied their legal obligations, but their absence during his actual passing has left me feeling oddly confused.

As I brush, I think of my role as a seasoned ICU nurse in easing so many deaths — typically so frantic and full, but this time so quiet and empty.

I’m shocked at how strange this particular passing has felt.

Sure, I’ve had solo deaths before: on my first day of nursing, my patient died fifteen minutes after I’d come on duty, the color fading from her pink lips and rosy cheeks before her husband could arrive to see. But this felt different.

It was the first time, I realize, that I’ve given end-of-life care to someone whose family was willing to advocate for his death, but not to attend it.

I missed the cast of characters and unofficial rituals that normally surround the switching off of the life-sustaining medications and the removal of the breathing tube. Where were the nervous mother and the teary uncle, the tissue-box requests and the stale bereavement cookies? What about the clumsy face-shave, given more to console the living than to care for one soon to grow slack and cold?

I missed caring for family members, I realize. I know how to reassure them about agonal breathing: “When the breathing tube is removed, sometimes there are noises.” I’m adept at finding extra chairs and strategically placing tissues. I advocate for extra pain medicine as ferociously as if it were for a member of my own family. This time around, having no one but my comatose patient to tend to, I felt lost.

Without any family, life story or tradition to shape them, his last minutes were governed only by a set of instructions:

1.  Administer pain dose once, prior to extubation.
2.  Extubate patient.
3.  Administer pain dose every three minutes for respiratory rate greater than twenty,
or obvious signs of pain, as needed.
4.  Notify house staff at time of asystole.

Before beginning the extubation process, I paused to take a breath. I know exactly how to do this work; the steps are not difficult or new. Carried out with no one else to witness them, though, they felt foreign and frightening. The enormity of my power at this point in this man’s life, compared to my utter absence throughout the rest of it, paralyzed me.

In the face of the heavy silence, I stalled. I combed his hair; I meticulously labeled and color-coded each syringe of medication. I wrestled with the illogic of giving him a clean gown, but did so anyway.

I can’t let him die with tube-feed glop on his shoulder.

The resident popped in, her flinching smile telegraphing that the emergency-room doctors had admitted a patient who was now waiting for this bed: Hurry up! Our eyes met, shared the same sad question — Where’s this man’s family? Then she was gone.

I wanted to keep the man’s death from being just a procedure, but knew nothing of his preferences regarding the last moments of his life.

Nervously, I created a ritual: a bit of quiet, some jazz playing on my cell phone, a moment to note the setting sun.

But the jazz felt presumptuous. What if he hates jazz? I shut it off and stuck to my simple directions, carefully documenting them:

1640  Pre-extubation pain dose given per order.
1645  Extubated per order.
1650  Respirations 26. Post-extubation pain dose given per order.

Some breaths, but not many. Some work, but no pain, my simple, silent assessment.

1720  Asystole.

Silence.

I called the resident. She came in and made the pronouncement. When she left, I took a few seconds to gather up the toothbrush and cautiously set to work.

Who am I doing this for? I wonder, gently massaging the spit off of the dead man’s front teeth. Am I doing this out of guilt that no one has asked me to do it, or because this is what I do for all of my patients, and without it, my care would seem like euthanasia?

To be sure, my actions have mirrored his wishes. I could do no other: his living will clearly stated that he wanted no heroic measures. But without the usual complement of “nurse-y” tasks, such as consoling the family, I’ve felt too powerful, somehow. It’s a jarring sensation. Now I’m clinging, as family members often cling, to the tiny aspects of life that remain.

His teeth finished, my patient looks better. How odd that death can look better than life.

Still feeling uncomfortable, I move eagerly to the care I know — the preparation of the body after death. I am safe here, with the toe tags and cloth straps and thin plastic pieces. After death takes place, few family members ever ask about these rituals. The actions hold no human presence and are carried out in silence by the nurse:

Remove IVs and carefully dress them. Turn the patient to one side and give the back its last wash. Position a white plastic bag under the remains. Roll the body back in place. Gown the body in clean linens. Tag the great right toe. Zip up the bag and copiously label the outside. Cover the bag with a white sheet over raised side rails to hide the silhouette of death from curious eyes in the hall on the way to the morgue.

Done.

The room’s space feels lighter, easier. And now, after hours of rueing the lack of people, I take comfort in being alone. Through the window that I cracked open for myself, I hear a car horn. I notice the pink light of the day ending as the navy night begins.

I turn from my work, unsure who might be pleased by it.

Amanda Anderson is an intensive care nurse.  This piece was originally published in Pulse — voices from the heart of medicine. 

Image credit: Shutterstock.com