I remember a night during my first year of residency in oncology when I was on call. It was after midnight, and I was sitting at the ward counter.

I often struggle to sleep during night shifts, especially when I’m the only doctor on call. I prefer to stay at the counter because I dread the thought of some terrible thing happening and not being able to reach the ward in time from the on-call doctor’s room. I’m a deep sleeper, and I worry that the staff might not be able to wake me up or that I could find myself in a difficult medico-legal situation the next day if I were not alert when needed. These frightening thoughts make me restless as I wait for my shift to end. However, once I finally get home, I am exhausted beyond imagination, and that fatigue-induced deep sleep is one of the best feelings in the world.

That night, we had a patient who had been admitted a week earlier. She presented with quadriplegia, which is paralysis of all four limbs. Upon workup, we discovered a large tumour in her neck that was unresectable, along with multiple other tumours on several thoracic and lumbar vertebrae. While I can recall the faces of both the patient and her son, the details of her case are somewhat hazy for me now.

Given that the tumour was unresectable and considering her multiple metastases and the advanced age, the treating physician and the family collectively decided to keep her on palliative care to ensure her final days were as comfortable as possible. Since she came from a remote area, her family opted to keep her in the hospital instead of taking her home, even though we had thoroughly explained her prognosis and indicated that she had only a few days left.

That night, there were four of us on duty in the ward, which had almost fifteen patients. I was the only doctor present, accompanied by Khuda Bakhsh, the senior staff nurse, and two junior male nurses who had gone for a tea break. This left me with Khuda Bakhsh alone.

I remember him quite well. Khuda Bakhsh was likely between 35 and 40 years old. He was a dark-skinned man from Sindh who spoke fluent Urdu and Sindhi. He had a prominent black moustache and very dark hair. He was notably thin and lean, in fact, very thin. He always wore a golden watch on his wrist, which made him stand out even more in his crisp white uniform. His dark complexion, combined with the shiny golden watch, made him very prominent among the other nurses. Above all, he was exceptionally tall.

Around 4 a.m., a male attendant called us to that patient’s room, indicating that she was unwell. We hurried to the room, where we found that elderly lady who appeared to be short of breath. She wasn’t speaking; instead, there were only muffled sounds coming from her throat. We immediately checked her vital signs, and her oxygen saturation was dropping. We attached an oxygen mask and started her on supplemental oxygen. After some time, her saturation did not improve, so we increased the oxygen flow slightly. It was evident that she was terminal, and her level of consciousness was altered. She was only able to produce incomprehensible sounds.

Khuda Bakhsh noted that she felt warmer than usual and checked her temperature. She had a fever, and her pulse was elevated. I advised him to bring paracetamol infusion so that we could help reduce her fever. We started the paracetamol, and in the meantime, I spoke with her attendants, two anxious boys. After a while, I learned that one of them was her son, who had just arrived from abroad that day to see his mother, while the other was the house help. At that moment, the rest of the family was not present.

Within a few minutes, she began gasping for air, and her complexion turned pale, somewhat blue and ashen. Since she was under palliative care and had previously decided and documented a Do Not Resuscitate (DNR) order, we did not take further action. After a while, she passed away.

Khuda Bakhsh attached the ECG leads, and I auscultated her chest. The reading showed a flat line, and there were no heartbeat or breath sounds. Her pupils had become fixed and dilated, confirming that she was gone.

But now came the most difficult part: Declaring the death. Along with this announcement came the denial from the son, which represents the first stage of grief. Although the patient had a Do Not Resuscitate (DNR) order and was indeed very sick, the son, who had arrived just a day before, found it unbearable to lose his mother within a day without having been there to care for her.

He was devastated. His face turned bright red, and he shouted at the top of his lungs, “tum logo ne ghalat injection laga k meri maa ko maara hai.” (You people killed my mother by giving her the wrong injection!). He lost control and ran out of the room, crying loudly. In his anger, he grabbed the monitor from the nursing station outside and smashed it. Many patients had been awakened by the loud commotion in the corridor, and attendants were standing in the doorways, watching.

I was paralysed with fear; there was no one there except me and Khuda Bakhsh. We both ran out of the room, my mind blank with shock. Then, I witnessed an unexpected scene: Khuda Bakhsh attempted to calm him down and grabbed him by the wrist. Khuda Bakhsh pulled the boy to his chest and hugged him tightly. The boy began to sob. He cried and cried, letting his emotions pour out. Khuda Bakhsh held him for what felt like an eternity, gently rubbing his back to offer comfort. He allowed the boy to cry until the sobs muffled, and there were no tears left.

Once he was calmed down, Khuda Bakhsh took him to the counter, helped him sit down, and offered him a glass of water. He arranged for the ambulance, called the female staff, and prepared the body. He did everything he could, and we said our goodbyes to that family.

I had never witnessed anything like this in the hospital before. This experience taught me a valuable lesson from a nurse who not only wore a golden watch but also had a heart of gold.

That night, I learned that sometimes words aren’t necessary. A shoulder to lean on, the feeling of being held while you cry your heart out—sometimes, just being there for someone is enough.

It has been more than six years since that day. I’ve become less naïve and fearful and am now in a better position to handle these circumstances. However, there are still many days in oncology when I feel overwhelmed. Declaring death remains a challenging task for me, particularly in unforeseen situations. I experience instances when my heart feels heavy, my knees grow weak, and my voice shakes, especially when a patient passes away unexpectedly.

A month ago, I admitted a 30-year-old female teacher for induction chemotherapy due to acute myeloid leukaemia (AML). Her tumour was discovered after she underwent a cholecystectomy, and the sample analysis revealed myeloid sarcoma.

Myeloid sarcoma is a rare tumour made up of immature white blood cells known as myeloblasts, which develop outside the bone marrow. It can either occur as a manifestation of acute myeloid leukaemia or independently. The prognosis for myeloid sarcoma is generally poor and is closely linked to the prognosis of AML. Survival rates vary; some studies indicate a median overall survival of less than 12 months.

She was a pretty, tall, and decent woman. On the first day I saw her, I was taken aback by her grace and attention to hygiene. It was quite different for me to witness such a beautiful lady dressed in pristine, freshly ironed clothes in our ward, where most patients are quite poor and least concerned about their appearance due to their circumstances.

Her features were beautiful. She had spotless skin and well-groomed hair. She began her induction chemotherapy for AML, a toxic treatment, but a standard option to start with. While many patients typically report discomfort during the process, she managed to stay well throughout her treatment. Her two children were staying at home with her mother, while her husband and elder sister accompanied her. Her elder sister was also a qualified nurse, which was comforting, as she knew about managing a patient’s needs.

Every day, I saw her looking neat and clean, with fresh clothes, nicely combed hair, and a smile on her face.

After chemotherapy ended, she became severely ill. She developed multiple infections, required several transfusions, and showed no signs of improvement. Despite our best efforts, nothing seemed to work, and she grew very sick. Ultimately, she was moved to the ICU. I visited her daily. She was on ventilatory support for a few days; whenever the sedation was lowered, she became aware of her surroundings, moving her legs and hands and opening her eyes. She was perceptive about what was happening around her. Unfortunately, she grew weaker each day, and her sepsis did not improve. Eventually, she developed multi-organ failure, and her family decided not to pursue further interventions.

One morning, when I checked on her and entered the ICU, I had already been informed of her critical condition. Her mother and sister were sitting by her side while she was unconscious and gasping for breath. The elderly mother was quietly shedding tears, while the sister recited verses from the Holy Quran.

She must have been restless, her right hand restrained. I held her hand and felt her squeeze my fingers. I continued to hold her hand, removing the restraint and squeezing back gently. I wasn’t sure if she could perceive anything, but I wanted her to know that we were there for her—that she was loved and supported until her last breath. It was difficult. It is incredibly hard to see the same patient with whom you’ve talked, laughed, and listened to over many days, knowing that they’re going and you can’t do anything more. While I can’t compare my grief to that of the family, I’ve learned one important lesson in the past six years: sometimes, just being there for someone is enough.

I have learned that there is no need to fear death. All of us will die one day, sooner or later. Nevertheless, it’s a soul-sucking moment to witness the blush on a person’s face turning pale, their once healthy lips becoming parched and sometimes turning blue, as their regular breath changes into inaudible and incomprehensible sounds.

I see daily warm and energetic handshakes transform into numb, cold, and lifeless fingers. The smiles fade away, laughter gives way to deep silence, and the shine in their eyes blurs and fades. Sometimes, a tear trickles down alongside their last breath, signalling that they are leaving. Their journey with me is coming to an end, and I know I won’t see them anymore. Those moments stay with me for a long time.

On such heavy days, I don’t fear death. I just need to be there for my patients, because sometimes that’s all I can do—just being there for them.

“˹He is the One˺ Who created death and life in order to test which of you is best in deeds. And He is the Almighty, All-Forgiving.”
– Al Quran—Chapter 67; Verse 2

Damane Zehra is a radiation oncology resident in Pakistan.