Death was not taught in medical school — just the methods to keep people living. There were no chapters to memorize, no questions on the examinations, and no evidence-based algorithm to follow. I was told that when death occurs, all that was left was to check for signs of life, officially pronounce the death, make the appropriate calls, and fill out the necessary paperwork.
People are living longer and better than any time previously. Modern advances have turned the processes of aging and dying into medical experiences, yet I am not so sure we in the medical world are prepared for it. Discussing patients dying, although inevitable in our profession, is sometimes taboo. Yet, there is an opportunity in death: to learn as a physician, to grow as a person, and to value respect, dignity, communication, and honesty. There is no escaping this tragedy of life — that we are all dying from the day we are born. But, when a patient dies, it never gets easier.
Physicians experience distress and grief in response to their patients’ and families’ suffering, as we are reminded of our own mortality. These emotions can compromise physicians’ personal well-being, because unexamined emotions may lead to burnout, compassion fatigue, and poor clinical decisions.1 It is important for physicians to find coping mechanisms, such as self-awareness and reflection, which can reduce burnout and promote empathic engagement.2,3
… Beep, Beep, Beep, Beep, Beep, Beep … The constant noise from machines singing and echoing throughout the halls kept me alert. As an intern, I entered the coronary care unit (CCU) with fear. Only a few months into my first year, I was responsible for the care of six complex patients. The hours were long and death was not uncommon.
Charlie was a well-liked 78-year-old navy veteran who had a personality that filled the entire CCU floor. He had a piercing stare, as if he was looking directly into your soul. Shortly after meeting a new member of his care team, he would already have a nickname for them. Mine was “mick-mick,” likely because of my Irish heritage and jovial personality. Before I prerounded on my patients, Charlie and I would welcome the morning sun together as we chatted about life’s uncertainties.
Just down the hall from Charlie’s room was the intern call room, a small simple square structure with a hospital computer and a twin-sized bed. There, I reflected on my two weeks with Charlie and contemplated advice for fellow trainees.
Know the Patient and Family
He was a man of service to his country, his community, and family. He was a well-known chef to his church, which he fed often. His brother once told me a story in which Charlie was preparing a giant feast for his church and filled his car with raw dough to transport there. On a hot midsummer’s day, Charlie, with his gray comb over and bright blue eyes, had forgotten about the dough in the car as a friend struck a conversation with him. After a few minutes, the dough started rapidly expanding in his back seat and began to protrude out all over the place. Charlie, laughing to tears, leaned his shoulder into the back seat like a football player to push the dough back into the car!
Charlie had longstanding heart failure, kidney disease, and chronic mucus plugging in his airways that was complicated by pneumonia, which made breathing difficult. He had bleeding in areas of his distal small bowel that were hard to reach. An enteroscopy done on admission to the CCU was only able to stop a couple of active bleeding sites and, given he was not a good surgical candidate to begin with, our options were limited. Our interventions consisted of optimizing his heart function, frequent transfusions, and antibiotics for pneumonia. He would gaze up at me as he reached for my hand while the nurses stuck him with needles, something he hated.
I watched a man go from fighting by all means necessary to surrendering completely to his chronic illnesses. He was scared, but prepared to die. A family conference was held, and the team recommended a transition to comfort care. Charlie and his family agreed, wishing for a discharge to home hospice services.
Prognostication Is Key
I stayed late one evening to make sure all hospice arrangements were in place, like home oxygen and a hospital bed. However, overnight, Charlie developed increased difficulty breathing. Our concern now was that he might not survive the ambulance trip home. Charlie and his family decided to stay in the CCU so he was stable enough to have family come in to say goodbye.
Patients May Rally before Death
The next day, family members swarmed in to show Charlie how much he was loved. Charlie had a smile on his face; nothing made him happier than being with family. While wearing his BiPAP, I remember him FaceTiming his grandchildren laughing.
Know Your Limits
I was hesitant on Charlie’s end-of-life care management because of previous adverse reactions, so I called the palliative care attending (who graciously answered although I could hear her children screaming in the background). She helped walk me through symptom management to ensure Charlie was comfortable.
Be a Coach for Your Patients and Their Family
It fell to me to turn off the BiPAP machine that was keeping him alive. “Charlie I know the attending had promised you that you will be comfortable throughout the entire process, and I am here to make sure that happens.” He nodded back with his BiPAP machine on. I told him and his family that I was going to give him pain medication before removing the machine, which helps prevent air hunger.
Signaling he wanted the BiPAP off to speak, he reached out for my hands and his cold gray fingers wrapped gently around mine. The nurse stood watching. Nobody else moved. Looking on to me with his piercing eyes, holding my hand while struggling to breathe, he gasped “Thank you, Jesse. Thank you so much for everything you’ve done.”
Calm Yourself as Death Enters the Room …
Holding back my own tears, I took a deep breath before turning the machines and monitors off. Beep, Beep, Beep, Beep, Beep, Beep … the song of Charlie’s heart monitor no longer sung. Surrounded by loved ones, hours later, he passed. Among all the frantic beeper pages and running to codes across the hospital, time seemed to stop in the stillness of his room. As I quickly examined Charlie for breathing, pulses, response to stimuli, I saw how at peace he looked.
Some deaths stay with us longer, lingering on as we examine the next patient, affecting us harder. It deserves a reminder that it is healthy to feel, and to feel deeply. That’s the nature of our job. Our profession has implications for our patients, families, staff, and ourselves. We are human, after all, and it is appropriate to act that way. I will likely never be comfortable with death, but … that is okay.
This story was previously published in the Journal of Palliative Medicine, June 2017, 682–683.