“Carrying” is a strange term in the medical world. By carrying a patient, you take primary responsibility for their care, and you are the face they see most from the team. Today, for the first time, a patient I was carrying died.

I met Jane about a week ago. She was in her mid-70’s, and for the past two years she had carried a diagnosis of idiopathic pulmonary fibrosis (IPF): an irreversible disease of the lung which turns the normally-spongy tissue hard and brittle. I’d learned about IPF during my preclinical years, mostly through lectures. I thought it might look different in real life, but its clinical course was terrifyingly straightforward, almost exactly as described in the textbooks: progressive, irreversible respiratory failure.

Jane came into the hospital for shortness of breath that had precipitously worsened at home. Normally, medical students don’t carry critically-ill patients, but at the time she was stable and we thought there might be a reversible cause: an infection, maybe heart failure, maybe a side effect of a drug we could stop. Excited by a diagnostic mystery, I offered to carry her as my patient alongside one of the residents. “She’ll be a good learning case,” my senior offered.

When I met Jane for the first time, she was in good spirits, even joking with the team. Over the next few days, I got to know her as I made my morning pre-rounds. She was a former ER nurse from California, my home state, and had even worked in the same hospital where my mom did her residency. I wondered if their paths had crossed at some point. We talked about the Bay Area where she completed nursing school, met her husband, and lived and worked most of her life. She told me about her journey to becoming an ER nurse, then a scrub tech, later a charge nurse, and eventually a teacher for nursing students.

She loved teaching, and interacting with medical students was a highlight of her day. Once, when I brought a group of fellow medical students with our attending to do teaching rounds on her case, I ran into another student group doing the same exercise at her bedside. But when my group piled in shortly after, Jane’s smile widened. “Oh, I love having students! Come, let everyone join!” It was the end of a long day, but she graciously let us take turns auscultating the fine velcro-like crackles in her lungs and offered us words of encouragement. “You’re the future of medicine,” she told us. “Always remember to be compassionate and make time for your patients. And treat your nurses well!”

Early in her hospitalization, we invited the palliative care team to help facilitate goals of care planning.  Goals of care discussions are often difficult because they require the patient to picture themselves in the worst-case scenario and decide in advance what kinds of interventions they would want. But when we broached the topic of palliative care, she was eager to participate, having seen tragedies throughout her career resulting from poor understanding of patients’ wishes at the end of life. “I don’t want to be intubated if it’s irreversible. I would hate to put my family in a position where they have to make difficult choices.” She stated it matter-of-factly, the room heavy with the weight of her words. She reached out and squeezed her husband’s hand, smiling softly. “You’ll be okay.” He looked sad, but smiled back. We updated her chart: DNR/DNI.

As the days went by, she wasn’t getting better. Four different antibiotics didn’t seem to be helping, and high-dose steroids couldn’t assuage the inflammation raging in her lungs. Testing and repeat testing for reversible causes of her dyspnea came back negative. Her oxygen levels declined, slowly and relentlessly, and she became increasingly short of breath when speaking. I opened her chart to a new consult note from pulmonology. “Her prognosis is grave and maximal efforts to involve family/loved ones as desired and optimize the patient’s comfort should be pursued.”

“Alex, are you religious?” I was taken aback by the suddenness of her question that morning, unsure what kind of response would be helpful for her. I deflected: “Are you?” She smiled, as if sensing my hesitation, before telling me she had been a Buddhist for over 30 years. “My family was Methodist, but I tried them all! But I chose Buddhism because I liked its focus on inspiration rather than judgment.” I learned that a close friend of hers had introduced her to Buddhism while they were nurses together. She shared her beliefs in reincarnation and karma, which carries over to the next life. “Haven’t you ever had the feeling that you know someone, even if you’ve never met them? Maybe we’ll even meet again someday!”

Over the next day or so, she became hungrier for air, and her oxygen saturation began to drop from just speaking. Her throat ached from the dryness of high flow oxygen. She became delirious one night, briefly unaware of where she was or what was happening to her. “I’m getting more confused, and I’m scared,” she admitted to me one morning. “I don’t want to go yet.” I shouldn’t have been surprised to hear that given her prognosis, but I was. Earlier, during our many conversations, she seemed paradoxically invincible in the way that she confronted her terminal illness. All I could do was hold her hand.

That was the last conversation we had. Over the next day or so, her air hunger worsened, and priorities shifted to making her comfortable as her oxygen requirements continued to rise. She began aspirating her food, yet the decision was made to allow her to eat for comfort. Codeine pills became IV morphine pushes, 4 gram doses became 6 grams, and eventually she was placed on a continuous morphine drip for her air hunger.

On the last day of her life, the palliative care team planned a family meeting to discuss next steps. Afraid that Jane would have another episode of agitation, the family asked that someone sit with her during the meeting, so I stayed behind. For about an hour, I sat next to Jane. She was sedated, still laboring to breathe, but seemingly not in pain. Outside the window, the East River glistened in the morning light. A paper coffee cup from the hospital cafe and a half-used bottle of hot sauce sat on the windowsill, patiently contributing to the makeshift home that had been made of the sterile hospital room. Nurses and techs stopped by periodically to visit—she had won over the hearts of the entire floor’s nursing staff throughout the week. One of the newer nurses recalled how she had walked him through drawing blood on her own arm. “Don’t worry,” she said to him, “you’re doing wonderfully.” Others offered blessings, gratitude for her kindness, and assurances of the love she had earned from those caring for her. While she didn’t respond, I’m sure she heard every word.

As Jane’s family and friends returned from their conference with the team, I learned what the plan would be. Since she was struggling more and more to breathe with maximum oxygen support, with increasing morphine requirements, her family decided to palliatively wean her oxygen while controlling her pain. For the final time, we piled into the room. Her husband and sons sat at the bedside, holding her hand. The palliative care nurse delicately walked everyone—including Jane—through each step of the process, narrating her assessment and actions as she went. Tactfully, she pointed out signs of discomfort and explained the steps she took to address them. First, she removed the monitors and turned off the screen. The nonrebreather mask was next to go. The son leaned over to apply lip balm to Jane’s dry, cracked lips. Then went the high flow nasal cannula which had enabled many of our conversations together. Her labored breathing slowed, but it was a peaceful slowing. That afternoon, surrounded by friends and family, she passed comfortably and with dignity.

As I reflect on the short time I knew her, I’m struck by the ways in which Jane continued to care for others, even in the final days of her life. Though I carried her as my patient, I now realize that ultimately, she carried me and many others through the experience of her death. Up until the end, she was a teacher and a caregiver, generously giving her time to students and staff. She was scared, but stoic and loving towards her family, easing their burden as much as she could. She was a nurse at her core, and did everything she could to participate in her care, as if helping our team from behind enemy lines. What she said to us during our final conversation is something I’ll carry with me for the rest of my life: “I’m honored to have been cared for by you all now at the end.” It was an expression of her care for us, something only a healthcare professional would think to say. It was our honor to carry her.