Death and the physician

Hey,
Wow! I just read Schauns Nov 1 post, and it definitely struck a cord. I’m not terribly emotional but I felt a need to “talk” with somebody. It made me wonder how I will deal with times like that both as a student and as a physician. I hope that I can deal with death and dying in a way that will allow me to 1) actually help the patient and his/her family prepare and deal with it, 2) not let it adversely affect my sanity and practice of medicine, and 3) not get to the point where it doesn’t affect me at all.

Last year I went to a seminar related to the topic. It was given by Frank Boehm, an Ob/Gyn faculty at Vanderbilt. He has written a book that has been on my to read list. The book is titled “Doctors Cry Too”. He gave an anecdote that sparked the same kind of feeling in my gut as Schaun’s diary entry. Briefly, when Dr. Boehm was early in his training he encountered a delivery that turned very bad and resulted in the death of the mother (and possibly the baby). He recounted going out to the waiting room with the attending and watching as the attending flatly and unemotionally told the family and then left. He said that he was unable to prevent tears from falling as the family broke down and couldn’t understand how the attending could be as he was. A short time later he went to the call room to gather himself and found the attending, head in his hands, crying.
I’ve copied Schauns post below so that people can read it with out having to go back and forth to the diary section. Thanks for listening. How do all you medical students and doctors deal with death of your patients? Are you getting any guidance or training in school and residency?
Schauns Diary post.
“Over the past two years of class I learned how to tell you what your Cr clearance is. I know how to determine if you have leukemia, meningitis, and a plethora of other illnesses. I never learned how to watch someone die.
I’ve heard a lot about DNR orders, but all my patients have been full code patients… until today. Today I had two patients (John and Jane)present as DNR status with conditions that assured they would not leave the hospital alive. As I sat at the nurses station preparing paperwork on Jane, my resident came up to me and softly said we needed to get to John’s room. You see, John has cancer, and is very immune compromised because of his chemotherapy. He has developed a systemic infection, and the resident and I are going to be with him and his family as he dies.
I hope that I can offer some comfort, some soothing words, but as I enter the room, I realize I can’t. I sit for a moment with my hand on John’s head, praying that God would remove John’s pain and be with his family in the days to come. My resident and I approach his wife and softly ask if she would like us to stay there with her. She quietly says, “No”. I put my hand on her shoulder and ask her if there is anything I can do for her. Again she says, “No”. We quietly leave the room to let John and his family spend their last minutes together.
With all the knowledge I have been presented with, I didn’t have the ability to do anything but watch and pray. What a humbling experience.”

Irvin Yalom, MD, a psychiatrist still teaching at Stanford, addresses this issue of death and dying very candidly in one of his classic books, “Existential Psychotherapy” (1980). One of the many things he says is that physicians are seen by humanity as persons who have the ability to hold death at bay, which is seemingly in-human considering we’re all destined to die. I’ve seen this same reaction in many friends (and clients) now that i’m consciously aware of it. It usually manifests as, “I saw The Doctor today and he said I should…”.
So I’ll build on this to give an opinion on what i see as your question: How do I deal with death, myself? Remember that although people expect you to be extra-human, you’re actually not. When someone dies, go to their family member and say what you need to say, and speak from your human side. “There’s nothing more I could do,” is very ok to say. “I’m very sad myself that she is dead, I can tell by your reaction that she was a very special person.” This acknowledges your pain and theirs, and takes away the “I need to be superhuman” nonsense that some medical people seem to say in a mantra to themselves all day.
Lastly, you were lucky to have encountered the deceased and their family on this day. Remember that at the very least, you had that moment with them, despite it appearing painful while in the moment. All relationships begin (eg.: a child is born, two people meet and fall in love, or perfect strangers become friends) and relationships end (eg.: tragic car accident, divorce, or other distance-creating event). Nothing changes this. As a doctor you will see all of these examples everyday. Just think of all the people you’ll meet, all the relationships you’ll start and end for yourself, and what you’ll learn along the way. Each day you finish in a different place professionally, literally, personally (human-ly), compared to where you started.
Could there be any greater profession?

Hi…
I’ve read “Doctors Cry Too” also. One of the best things a doctor can do is remain down-to-earth/human and let his or her patients see that…as well as have medical expertise.
Being a part of this culture where death and dying are typically not dealt with well, I know that I have things to learn about end-of-life aspects.
A LONG time ago, “60 Minutes” did an article on hospice care. When I saw it, I knew that someday I’d do hospice work. This year seems like a good time to start that; recently I finished the training involved to be a hospice volunteer. My first patient is an elderly man who’s very with it mentally, but declining physically. Tonight I’ll bringing the newspapers to him and we’ll sit and visit a while together. It’s not easy…he’s dear. He could just as well be an old friend/neighbor instead of “my” patient, but we’ve met specifically because he is dying. I can’t even begin to pretend to be cool, cold/distant about this, but I do keep in mind that he’s a patient and that his family’s grief is necessarily different than my own. That idea gives me some clarity and “appropriate distance” emotionally. I don’t know how I will react to his death or any other patient’s death.
A friend who has done decades of various volunteering/teaching/service of on sort or another, said that her hospice work stood out in her heart and mind as the most rewarding of all. She’s a woman of real strength and vivacity! (I hope to handle this half as well as she has).
Lots of nursing homes are now involved with hospice services, if anyone here want to check it out, just give’em a call.
Pronouncing death, as a physician, must feel…I don’t know! Maybe odd somehow. I don’t know if doctors ever really get used to it, but maybe it becomes easier over time. Anyone have ideas on this?

Always remember that long before you strapped your doctors coat & image that you are a human being. More than perfection, your patients want you to care, empathize and to be compassionate. Everytime you start to make a medical decision, you should bear in mind that “just because we can does not mean we should”. Once of the most powerful things I have heard a Doc say to a family member was, "I am sorry, but we are no longer doing things for your mother, we are doing things to her. Is this what she would have wanted? Is this what you want for her?"
Becoming a physician amounts to far more than an enormous fund of knowledge of human biology – you are striving to earn the priviledge to care for the precious possession of your fellow man…the health of their loved ones.

Well said!!! rolleyes.gif

Hi Folks,
I have been taking care of a young patient who is has decided to withdraw mechanical ventilation. She has a tracheostomy and has a very, very restrictive lung problem. After surgery, she was emergently trached because of respiratory failure. She knew going into the surgery that her recovery would be very difficult but she begged one of my attending physicians to perform the procedure that she underwent. She said that she felt that surgery would give her the best chance at living a quality life but after two weeks, this is not to be.
Four days ago, she signed a DNR (Do Not Resuscitate) order and requested not to be placed on a dialysis machine as her kidneys were failing. Since she is so young, her family disagreed with her decision and begged her to reconsider but she felt that she was tired of trying to fight to live. She was ventilator dependent and realized that dialysis would not guarantee a higher quality of life so she opted out. It has been very difficult for the STICU personnel to watch the decline of this patient over the the past four days.
We enlisted the help of our palliative care specialist who spent much time with the patient making sure that she was clear about her decision. The dynamics of her family have been played out in the STICU and for the patient’s comfort, we all needed to be sure that she understood the gravity of her decision. Later today, she will say say “good-bye” to her parents and six siblings. She has asked to be alone in the room. We will hang a Fentanyl drip so that we can bolus her. We will then remove the ventilator and allow her to die. We have assured her that she will not suffer from air hunger in her last few moments thus the Fentanyl drip for comfort.
Even before surgery, my patient had been immobile. She was suffering from circulatory problems, skin breakdown problems and respiratory insufficiency. In the first couple of days post-operatively, she had picked up an infection that had damaged her kidneys. She had a respiratory arrest and was transported to the STICU for care.
Since I came on this service, I have watched her family beg for her to reconsider dialysis and remaining in mechanical ventilation. This patient has been totally mentally capable of making her own decisions all along. What we feared most was that she would become too uremic to be capable of decision making and thus the family would force dialysis when we knew that she did not want to be dialyzed. Even on dialysis, there was no guarantee that her kidneys would pick up their previous function.
It has been difficult to watch the patient die. It will be difficult to remove that ventilator and watch her stop breathing and die. This goes against everything that we have been taught in medical school but she has made a decision and I respect her for making a decision about her quality of life and sticking with it in spite of her family’s begging her to reconsider. It was very sad to listen to the palliative care specialist explain to this patient how she would spend the last few minutes of her life.
Natalie

Natalie,
Knowing you here, I know you will do everything you can to care for this patient and her family…this must be one of the most difficult things for any doctor. Please be sure to care for yourself too!

QUOTE (Mary Bois Byrne @ Nov 9 2002, 12:09 PM)
I know you will do everything you can to care for this patient and her family....this must be one of the most difficult things for any doctor. Please be sure to care for yourself too!

Thanks for the post Natalie. I second what Mary said.

Also, thanks to everybody else who has posted on this topic. It's great to read everybodie's perspectives.

Borrowed this from ‘that other’ website where I originally posted it.
In my young career, this death was the most painful and difficult to handle, not only for me but for many of the ancillary personnel as well. We tried so hard to save this young man. It was devastating to see the reactions of the family, for some reason more so even than usual.
His obituary and picture were in the paper this weekend. College sophmore, basketball and baseball player. Handsome kid.

"rough night"
Trauma call. Midnight, home in bed. Pager goes off: Adult Red Trauma Alert, ETA 10 minutes.
Twenty year old male, unrestrained front seat passenger in highway speed collision with utility pole. Teenage driver dead at scene. Backseat passengers taken to nearby Level II center with broken bones and head injury.
Arrives hot unload off Lifeflight (they don’t wait for the propeller to stop turning), intubated, CPR in progress. Pulseless electrical activity on monitor. Chest tube placed on left for diminished breath sounds, with immediate return of 1,000cc blood. Pressure improves to 70 palp. O negative blood started. Abdomen is distended; pelvis is unstable; deformity of right femur under MAST trousers. Foley catheter returns frank blood. Diagnostic peritoneal lavage with grossly positive return (obvious intra-abdominal bleeding).
Call to OR - anesthesiologist is doing stat c-section; back up lives 30 minutes away. Tell OR to prepare room - we are starting the case without them.
To OR. Surgery intern places monitors, hooks patient to ventilator, finds and pushes paralytics. Spray of betadine and belly entered with rapid midline incision. Massive blood. Abdomen packed. ‘Anesthesia’ (still the surgery intern) hangs more blood on Level one infusor. Pressure again recordable. Packs removed and large splenic laceration identified. Spleen rapidly removed. Huge retroperitoneal hematoma arising in pelvis. No intra-abdominal bladder injury. Anesthesiologist shows up and yells because no one recorded the OR times. Belly closed with running skin stitch only - no time for anything else as patient is bleeding out from retroperitoneal bleed from pelvic fracture.
To interventional radiology. Left hypogastric artery avulsion seen on angiography. Vessel coiled/ablated. Extraperitoneal bladder rupture identified with cystogram. Patient now going into DIC (disseminated intravascular coagulation). Blood pours from nose, mouth, every venipuncture. Blood product total at this time: about 48 units. Bloodbank calls. They are out of fresh frozen plasma and have sent for more. To cat scan: head CT negative.
To ICU. Patient cold, coagulopathic, hypotensive. Massive resuscitation continues without effect. Additional blankets thrown to cover his bloodstained, broken, swollen body; face wiped clean of blood, but nose and mouth continue to ooze. Family sent for.
Mother collapses outside door - is unable to view her son in this condition. She is carried back to the waiting area by her parents. Dad enters the room. He involuntarily breaks into huge, racking sobs. He puts his hands over his face and sits down on the toilet seat in the corner. Every medical person in the room turns away with tears streaming down his or her face…
Home again. Getting ready to take a shower before starting three day vacation - going to Indianapolis to meet new nephew and see baptism. Can’t stop crying.
Thanks for letting me decompress.


GED2MD,

What a heart wrenching story. I have a 3 year old daughter and I can't even imagine the horror of what these parents are going through. I also feel for you and the other medical staff who tried their hardest to save this young man. Enjoy your new nephew and have a safe trip.
Kristen