Silence Is Not Golden

Professionally, I do not like silence. As an anaesthetist, my job is to maintain normal physiology as best as I can during surgery. Two of the monitors I use daily are the pulse oximeter and the ECG. Taken together, they form the rhythmic beep I hear when a patient is anaesthetised. The tone indicates the oxygen saturation, while the rhythm indicates the heart rate. If these go silent, I immediately check to see if the patient is ok. Likewise, as an intensivist, I fear the silence related to critical illness. It could be the loss of the familiar “Lub-dub” of the heart valves, indicating valvular pathology, or worse still, a cardiac arrest. It could also be the absence of breath sounds in life-threatening asthma. Even with traditional less “vital” organs like the bowels, silence may occur in a condition called ileus, where the bowels fail to carry out their normal propulsion of food. This sometimes happens in the context of surgery, and can sometimes lead to severe malnutrition, breathing difficulties, biochemical disturbances and even death.



Indeed, silence is the harbinger of death in medicine, and the sound of failure. The silence which follows a failed resuscitation attempt may be cold, heavy and costly. But unlike the adage, it is not golden. Yet, I have also witnessed many expected deaths. While this silence may not be golden, it can be calm. When I was a newly qualified doctor, I worked on an elderly ward, and several of my patients were expected to die. Do-Not-Resuscitate orders were signed early and they were allowed to die peacefully. The rituals performed after death were always reverent. There is invariably silence in the room. The curtains are always drawn. The nurses would have usually made sure that the patient was neatly tucked into bed. The blanket was always immaculately folded at the waist or chest. The patient always had their hair combed, their beard shaved and their arms placed in neat positions. There was an intrinsic order to the conduct and presentation of death, and the nurses always performed fantastically. After my examination, I would leave the room and then write in the notes:


No heart sounds No breath sounds No carotid pulse For 3 minutes. Pupils fixed and dilated. Death verified at [time]


Indeed, silence is the harbinger of death in medicine, and the sound of failure.


This was a precious silence. It helped me focus on the patient before me, ensuring I did not miss a heartbeat or final breath (there was never any). More importantly, it provided time for ritual, tradition and reflection. In fact, the modern-day fear of the process of dying may be unfounded. Psychiatrist Bruce Greyson performed interviews of patients who had recovered from cardiac arrests, and thus near-death experiences. In his book ‘After’, he recounts how most patients describe feelings of warmth and comfort, rather than the panic and fear we expect.


These days, sudden deaths form a minority of all deaths. Instead, many people experience one of two other deterioration trajectories towards the end of life. They may slowly decline, usually through the final year of life. Alternatively, they may experience a decline punctuated by episodes of sudden deterioration and subsequent recovery, until death ensues. This is completely opposite from an actual scene of a cardiac arrest. Oftentimes, there is panic, dread and chaos amongst the medical team. Shouts and firm commands are common. Medical packaging is usually littered all around the bed and floor. Intubation is sometimes performed without anaesthetic drugs (because the patient is indeed already completely unconscious). CPR looks barbaric. Multiple professionals are usually involved in a tight environment, squeezing past each other, performing various tasks. There is little concern for aesthetics or civility during a cardiac arrest. Yet, according to Greyson, patients are frequently unaware of the chaos. Instead, they may describe muted sounds or silence, outer body experiences or the warmth and comfort of a cocoon. They may see light or hear their name softly called. In other words, the patient’s experience of near-death, and perhaps by extension, death, may not mirror the healthcare professionals’ experiences.


Because of intensive care capabilities, there are times when death may not actually be silent. With modern intensive care, we are remarkably good at supporting organ systems. Ventilators can support the lungs. Drugs and machines can support the failing heart. Renal replacement therapy can help to replace the function of the kidneys. Yet, none of these are benign, and each intervention carries their own set of side effects and complications. Nevertheless, the ability to support organ systems can sometimes cause confusion regarding the diagnosis of death. I recall a patient called Louise during my intensive care training. She had suffered a catastrophic intracranial bleed and we were about to perform brainstem death testing. In other words, the parts of her brain that normally control automatic functions had been irreversibly damaged. For example, there are no primitive reflexes nor the ability to sustain breathing. In fact, this forms a part of the various tests we perform to confirm brainstem death. The inability to breathe, along with the irreversible capacity for consciousness forms the very definition of death. But brainstem death does not fall neatly into the “silence” of death. This is because the heart maintains its own rhythm and continues to pump, even if the brain is damaged. It is for this reason that heart transplants are possible. The normal nerve connections to the brain are not essential for functioning of the heart. So even though I could hear Louise’s heart sounds and saw the pressure waveform of each heartbeat on the monitor, she was indeed dead. Without the ventilator, she would not be able to sustain breath or life.


That evening, after Louise’s family said their last goodbyes, we took her to the operating theatre. I was about to learn how silence could indeed be golden. Louise was to be an organ donor. Her heart, lungs and kidneys would be harvested. Already, the recipients were making their way into their various hospitals in preparation for transplantation. Inside our theatre, there was a baseline buzz of activity. The specialist nurses in organ donation were busy making phone calls to various units, ensuring logistical arrangements were in place and making sure all relevant tests were performed on the organs. The surgeons (four in all), carefully dissected down to the various organs. When everything was eventually ready, the lungs were clamped at their origins as we turned off the ventilator. No more breath sounds. No more ventilator hum. Silence. Not quite. The aorta was clamped. Heart beating. Beating. Slowing down. Fibrillating. Stopping. Stopped. Silence. The voices of multiple surgeons seemed disproportionately loud against the silence of the body. This was no silence of death. Instead, the cessation of life for Louise was soon to be the beginning of new life for those recipients of her organs. Her silence would soon transcend death to mark the start of new chapters in several lives. Indeed, several months later, we received a letter from the organ donation team. Louise’s organs had been successfully donated to several patients, who were all doing very well.


Her silence would soon transcend death to mark the start of new chapters in several lives.

After the organ procurement, I sat down in the staff room and sipped my tea. In the silence I considered the new lease of life for those recipients of Louise’s organs. And I thought to myself,


“This silence…is golden.”


So in the silence of the Holy Communion, as you contemplate the death and resurrection of Christ this Easter, remember how silence can indeed be golden, and how we can play a tangible part in the gift of life within this world; a small reflection of what Christ offers us eternally.


Mark ZY Tan is an anaesthetics and intensive care junior doctor. His professional interests include medical humanities and point-of-care ultrasound. He is also an academic clinical fellow researching healthcare resilience with the Humanitarian and Conflict Response Institute based in University of Manchester.


He is a regular presenter for BBC Radio 4’s The Daily Service since his widely acclaimed short piece Telephone Lament for Coronavirus and Lent Talk Letter to Lydia were broadcast. He lives with his wife and two daughters in Manchester. They spend their free time tending to the garden, growing mushrooms and vegetables, rearing chickens and keeping bees, though not necessarily in that order.



(The ideas from this piece have been adapted from a longer, more detailed piece entitled “Silence is not golden”. Visit Mark's website at www.markzytan.com)


 

To find out more about organ donation, here are some resources. Legislation around becoming an organ donor varies between countries.


Singapore: https://www.liveon.gov.sg/index.html

Malaysia: https://www.dermaorgan.gov.my/

UK: https://www.organdonation.nhs.uk/



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