She died on Saturday.

The Mother paged me on Friday to consider withdrawing support of Terminal Girl, her only child, but I was banging on someone’s chest in a CPR at the time. I called the mother and apologized that night but she graciously said they talked to the MICU resident and would come back tomorrow to make a final decision.

The next morning I went into her room. She was still on the ventilator, not responding to voice, but something was different. Her eyes were almost blinking. She would move her arms once in a while without us having to dig into her sternum. The neurologist said she had a slim chance of survival. We all laughed at him then, saying that was an overstatement. The surgeons said she would never survive the operation she needed to fix the hole in her esophagus. The plan was to convince the family that it was futile. She had too many chronic problems (cirrhosis, HIV, seizures) and some lethal new ones (esophageal perforation, anoxic encephalopathy).

The Mother looked like a bleached-blonde Mary Magdalene who happened to get caught in a lightning storm. Her hair frizzy and disheveled as usual. Her usual Prozac-overdosed happy demeanor replaced with a taciturn timidness. She was with the uncle, an older man who looked like Roger Ebert sans hairpiece.

“Hi Dr. Scott … how … uh, how is my daughter doing?” The Mother said. I knew she was waiting for me to tell her there was no improvement. I knew today that she would decide whether or not to end her only child’s life. The mother trusted me, I knew that my words would sway her decision irrevocably. Her daughter was in the Pit, and I was the Pendulum.

I told them I’d be back in a minute. I went in there with the intention of discussing how futile prolonging her daughter’s life would be. But I had to leave because I was having doubts. I was about to turn 180 degrees and start talking about hope. I had to leave and recollect myself. I told the MICU resident, Fuzzyhead, that I couldn’t go in there in good conscience and tell the family that their daughter had no chance of neurological recovery anymore. I was grabbing for straws, acting like a family member in denial. She had improved so much; maybe she would never wake up, but look how far she’s come.

I flipped through her chart as if looking for her true destiny. I looked back through her room window. The Mother was watching me. Trusting me. I saw the daughter lying there … in the most vulnerable of situations … and wasn’t I her doctor? Her favorite doctor even? How sick it made me to think I might be the one to influence her demise. What kind of grotesque perversion was this? She entrusted me with her life. Wasn’t a one in a million chance better than no chance at all? Was I not her keeper?

I told Fuzzyhead my doubts. I could see the confusion in his eyes. He was a year junior to myself so he remained polite but I felt like a traitor for changing the plan at the last second. For changing sides just before the endgame.

So we argued. I said that maybe we should wait a few more days. Maybe call the surgeons again to reevaluate her. You can’t survive with a hole in your esophagus and rotting food in your chest. Although statistically she should have been already dead from that too about 48 hours ago. Then I thought that even if they did operate on her, between her cirrhosis and her HIV she would probably never heal the wounds of the surgery. She would get infected and die horribly the way that the AIDS patients I remembered as a medical student did. Maybe she would be a mental vegetable. Unable to swallow her own saliva, getting pneumonias every other week … a 29 year old gomer.

Maybe she would miraculously recover again like she always did. Maybe Terminal Girl was really the The Lazarus Girl. God knows she’d been through her share of “you-should-be-dead-by-now” crises. Was I supposed to tell her mother to sacrifice her only child thereby branding myself with the mark of Cain in the process?

After the longest twenty minutes in my life, my conscience doing somersaults with my intellect and my heart, my mind racing a dozen moves ahead like some mortal Chess match against Father Time and Mister Death himself … like Gabriel’s horn, the answer announced itself to me.

It came down to quality of life.

I saw Fuzzyhead talking to the family already, and God knows what he would say after my recent confession of doubts so I stepped in. I told the mother that even if the surgeons decided she could go to the O.R., even if she survived, even if she woke up and could breathe without the ventilator, even if her immunocompromised and malnutritioned body could heal the massive surgical wounds … even if she got through all of this, she would still be as sick as she was before she came into the hospital, only sicker.

She would still be coming into the hospital every other week to have her abdomen drained or vomiting bile and blood. She would have all new postsurgical complications from the esophageal repair. She would spend even more of her last days in the place she knew most intimately and hated most vengefully.

I fidgeted as I told the mother this. My face twisted in pain after each statement. I looked away several times, not because I was lying, but because I was telling the truth and each truth hurt like the twisting knife of a sadistic interrogator.

The mother pulled out a framed picture of her 29 year old daughter. It was a Glamour Shots photo, taken before I met her, before she first came into the ICU vomiting blood 2 ½ years ago. Before she knew her liver was dying. Before she realized she was dying.

“She wasn’t always the way you’ve seen her, Dr. Scott. She used to be on the honor roll in high school. I wanted to show you how beautiful she used to be. She really loved her hair. That was the worst part for her. It just never grew the same after she got sick,” her mother told me.

It was a beautiful picture. She looked like a young farm girl from Iowa, with long thick wavy hair the color of maize in sunshine. She had a big innocent smile with full cheeks like a baby. This was not the picture of someone who traded sex for heroin, who drank until she vomited, snorted coke, and then drank again until she vomited blood. The MICU resident just dropped his jaw when he saw the picture. He remarked how different she looked. I thought she looked different but still the same.

“Wow, she is really beautiful. Thank you for showing me,” I said.

“I just wanted you to see it. She was such a good child. I wanted you to know why this decision is so difficult for me,” she said.

“I know it’s difficult for you. It’s … it’s difficult for me too … and I’m the doctor,” I say that as if being a doctor means you are always objective. I try to look away but she captures my glance.

“I know…. She always liked you. She always wondered what your fiancee looked like,” she smiled. How ironic it had been that she could have seen my fiancee working in the next room if she could have just opened her eyes.

Her uncle talked about the value of all of God’s children and how God would take care of her. But eventually they both agreed it was no way to live.

We asked them to leave as we disconnected the ventilator. Fuzzyhead reminded me to step back as she might start spewing from her mouth, as they sometimes do, when she was extubated. He reminded me she had AIDS and Hepatitis. I was vaguely offended by the fact that he was telling me ANYTHING about her at this point, but he meant well. He hid on the other side of the room.

She heaved when we pulled the tube out. Her limbs raised. Her eyes opened and closed and opened and closed. She started breathing rabidly and ferociously.

I thought she might just wake up and start breathing on her own. I thought she might once again defy all medical statistics and textbook cases – a rebel once again as always. I secretly cheered her on. Fight it! Wake up! Cough! Breathe! Turn this dismal tragedy into a melodramatic comedy. Make me proud. Her head bobbed up and down and I thought I saw her look around. But then I looked more closely ….

Her lids opened with the force of each breath but her eyes were rolled into the back of her head. Her breathing began to slow. Her lids stayed open. Her azure irises looked toward heaven. How horribly beautiful they were, like angels’ eyes on the Sistine Chapel.

We let the mother and uncle come back in. I usually leave when they come in, but I stayed this time. I offered a chair. She accepted passively and collapsed into it like a ragdoll.

A lifetime later, there was one less life in that room. I stepped up to examine my patient for the last time. I took off my latex gloves. I never examined her in life with gloves on, and I would not examine her in death with them either. I placed my stethoscope over her still heart and listened there for the faintest hint. I shined a light into her eyes wondering if she could see me somehow in some dying part of her neural cortex. I closed her lids. My hand caressed her neck as I rested my fingers where her carotid pulse had been. I gently searched for one … knowing this was the last time I would touch her. The one patient who made me feel like I was making a difference. No one could reach her but me for some reason. She opened herself up to me, her problems, her “friends”, her fears. That is, until the end, when I became discouraged with the way she continued to drink. She must have sensed this, because the last few times I saw her she would be quiet. As would I. As if we had a lovers’ quarrel and refused to make amends to each other. But she continued to see me. We were tied to one another. Somehow I thought that maybe she would live to be an old woman. Maybe we would laugh and talk about how rough those old days were. Sometimes I wondered what would happen to her once I finished my residency and moved away. Who would take care of my Terminal Girl then? Who would want to? I thought I would be relieved when I moved and she would no longer be my patient. But I don’t feel relief.

I feel alone.

She wasn’t just my patient. She was my fallen angel and I was her reluctant guardian. She was my hidden faith.

And as my fingers hesitantly left her soft pulseless neck, my faith left me.

Thank God I’m an atheist.