Teaching Death to Nursing Students with Leo Tolstoy

 To make an end is to make a beginning.
The end is where we start from.
T. S. Eliot

We’ve come to the close of our annual month-long reminder of the obvious: We’re all going to die. It’s a truism that we learned as kids in Sunday school and CCD—the first of the four Last Things: death, followed by judgment, and then heaven and (rather, or) hell—although we Catholics are reminded of death year-round. It’s front and center in our liturgy, our creed, and even our routine devotional prayers. “Pray for us sinners,” we repeatedly implore the Blessed Mother in our rosaries, “now and at the hour of our death.”

Even so, the reality of death—the actual dying part—makes us all … well, squirm. “Can’t we talk about something more pleasant?” is how Roz Chast’s aging parents deflected the topic, and we frequently do the same—that includes my nursing students. They’re mostly young, and prone to delusions of invincibility (remember those days?) Plus, they’ve grown up with television dramas that feature doctors and nurses rushing in at the last moment to successfully resuscitate patients on the verge of oblivion. The patients recover, the sub-plots are resolved, and all the loose ends are tied up by the time the credits roll.

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Such tidy packaging of complicated and dire healthcare situations is great marketing for nursing school—who wouldn’t want to be the hero and save lives, right? Yet, there’s a downside as well, for it conditions those future nurses to expect unrealistic routine outcomes. The truth is, despite winning plenty of battles at the bedside, we’re always bound to lose the war against physical death, and that’s not easy to hear when you’re a budding life-saver.

Consequently, I put death and dying at the very beginning of my introductory medical-surgical nursing course—it puts everything else in context. “All the pathologies, diseases, and chronic illnesses we’ll be studying the rest of the semester,” I tell them, “are merely hints of what we’ll all face sooner or later—yes, you included!” Our cancers, our heart disease and diabetes, even our mild colds and bouts of indigestion are experiences in miniature of everyone’s inevitable final ailment. In temporal terms, physical death is the end game, and I’m inclined to deal with it up front.

So, what is there to say about physical death? Less than you’d think. Regardless of cause, death is pretty simple, and has been traditionally defined by common sense observations: We need air to breathe and blood to circulate in order to live, and so it has long been understood that their absence is the best indication that life has ceased. In medical terms, this is what we call a lack of vital signs: heartbeat, breathing, blood pressure, temperature. Once these are completely and irrevocably gone, we can be certain that physical life is gone as well—a natural conclusion to biological existence in scientific terms.

For Christians, however, and particularly for Christian healthcare workers, that’s just the beginning. To start with, we vehemently reject the widespread notion that “death is just a part of life”—nonsense! Instead, with the Catechism we affirm that death is a “departure” in which the “soul is separated from the body” and the “end of earthly life,” not a part of it. Furthermore, it’s a “consequence of sin,” and the “last enemy of man left to be conquered” (CCC 1008).

Yet, it’s an enemy that we conquer primarily by a conscientious surrender, and not chiefly by avoidance or resistance—which are both futile in any case. Sure, in most situations, extending and enhancing physical life is an appropriate goal of self-care and healthcare. Moreover, when death is imminent, there’s no question that we should emphasize the best palliative treatments available: Alleviating pain above all, as well as the many other distressing symptoms associated with the end of life.

It’s crucial to emphasize here that promoting comfort at the end of life must not translate into hastening death. This is the core of ancient medical ethics, captured in the Roman maxim, Primum non nocere (“First, do no harm”), and it honors the Fifth Commandment’s proscription against intentional killing. Thus true palliation, authentic comfort care, will always and absolutely exclude euthanasia, physician-assisted suicide, terminal dehydration, and every other form of clinical homicide.

All that being said, I think it’s essential for my students to develop an end-of-life perspective that takes the longer view, one that encompasses an integrated, holistic vision of human health and flourishing. Since death is inevitable, our care for those who face it must be oriented to preparing them for what lies ahead—both physiologically and otherwise—then helping them manage that journey.

That’s why I have my students read Leo Tolstoyhis “Death of Ivan Ilych” to be exact. It gives them an intimate glimpse into what it’s like to go through the dying process, from initial anxieties, to jarring realities, to the final dramatic conclusion. This extra reading is necessary because death is unlike the other topics we cover in med-surg—like pneumonia, or osteoarthritis, which they read about in their text, hear me drone on about in our class, and then see close-up when they take care of patients at the hospital. Dying is usually not something students get to witness in a clinical rotation. They’ll hear about it if it’s happening on the unit, but the families involved understandably prefer to avoid student nurses and the extra oversight involved.

Tolstoy is a superb substitute, for his Ivan is so normal, so human—that is, so much like us. He’s religious, but only nominally. He’s cocky and doing all right for himself: rising up the ranks in his career, with a tolerable marriage and family, envious friends, a nice home, nice amenities, nice. Even when an incidental injury develops into a debilitating condition, he expresses more annoyance than fear—at first. “We sick people probably often put inappropriate questions,” he tentatively says to his doctor. “But tell me, in general is this complaint dangerous, or not?…”

My students jump on the physiological clues in Tolstoy’s story—is it a floating kidney? An appendix problem? What is it? What’s the prognosis? As the narrative proceeds, however, they’re slowly drawn into the underlying drama taking place, which is only peripherally related to Ivan’s deteriorating condition. “It’s not a question of appendix or kidney, but of life and … death,” he admits at one point. “Yes, life was there and now it is going, going and I cannot stop it.” Then, in self-pity and anger, Ivan lashes out. “It is impossible that all men have been doomed to suffer this awful horror!”

When we read those words, we want to make things better for Ivan—to take away his fear, give him hope of heaven and eternal bliss. The students are stymied, however, by his lack of faith, and they’re often at a loss as to how to react to this literary patient’s despair.

In steps, Gerasim, the “butler’s young assistant” who volunteers to assist his master and elevate his legs, offers Ivan some relief from his discomfort. Few words are exchanged, and certainly nothing that hints at evangelization. Instead, Gerasim’s service is plainly selfless, pure, and simple, and my students immediately recognize the character’s generosity as an object lesson in compassionate nursing care.

After this, Gerasim fades from Tolstoy’s story, but his gesture of sacrificial love stands at the core of the narrative, for it stirs in Ivan a reflective instinct that leads to reconciliation and redemption. In his final moments, Ivan finally comes to terms with his selfishness and sin, and he makes an attempt to heal his broken family.

With a look at his wife he indicated his son and said: “Take him away … sorry for him … sorry for you too….” He tried to add, “forgive me,” but said “forgo” and waved his hand, knowing that He whose understanding mattered would understand.

That’s what I want my students to see! Good nursing care makes room for enlightenment and encounter, even if we can’t ourselves elicit the same—and even if we’re not around to witness them when they do happen.

And there’s another lesson here as wellone that goes well beyond my objective in nursing class. Ivan’s excursion from health to illness to death is a reminder for all of us that every day—every moment—is a gift that allows us to get ready for our ultimate destination. “Death can be very beautifullike a wedding—if we make it so,” Solanus Casey observed, and making it so requires a great deal of preparation: choosing virtue, pursuing holiness, loving God and neighbor, availing ourselves of the mysteries of grace.

It can be arduous, to be sure, but we have it on good authority that it’s well worth it. “I am the resurrection and the life,” Jesus declared. “He who believes in me, though he die, yet shall he live.” Tolstoy’s Ivan gives us an insight into this victory, and it’s all the more sweet given the odds stacked against him. “He sought his former accustomed fear of death and did not find it,” writes Tolstoy of his hero. “In place of death, there was light. ‘So that’s what it is!’ he suddenly exclaimed aloud, “What joy!”

May it be so with us.

Editor’s note: The image above is Leo Tolstoy on his deathbed. 


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