Death’s Door
Sometimes things are too obvious to notice. I am not sure why, but it has taken over twenty years in the medical profession to realize this blazingly obvious fact: one of the main differences between us in the healthcare field and people of most other professions is that we face death in our jobs.
I have just discovered a delightful blogger from South Africa named Bongi, who posts on the blog other things amanzi. In a recent post he discusses becoming disillusioned when a senior resident over him reassures a patient that “everything will be fine” when in fact the patient is clearly going to die.
he had boerhaave syndrome, a tearing of the esophagus, usually into the left hemithorax, associated with overeating and drinking which in turn causes discoordinated vomiting and voila! if you diagnose it immediately and operate, they have a chance (fair to good). if you give the sepsis time to set in, causing a mediastinitis, the chances drop. if necrosis of the mediastinum has been allowed to develop, no chance at all.
i was totally dissillusioned. my first call and i stood there innocently believeing in our noble profession while my senior lied to someone. ok, the guy maybe felt better emotionally in the last moments of his life, but i could not justify lying to the guy. i also realised there are some fights you just can’t win.
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This brought back to mind a situation that really defined my approach to death, as well as another situation in which I was able to make a difference.
The first situation was where I was a fourth year medical student. I was doing a rotation in cardiology and there was a woman who I was taking care of who had a non-Q wave MI. I had gotten to know her and her family better than any I had up to that point. I was a “sub-intern,” where you (supposedly) have the responsibilities of an intern before doing your internship, and so you spend more time with your patients.
I was paged with a sudden call on this woman, that she had suddenly gotten worse and was being transferred to the ICU (So much for me being “in charge”). So I ran over there to see what was going on. As I came to her room, I saw her worried family standing outside the door.
“She’s not doing well” one of them told me, with a pained expression on her face.
I walked in to find the resident and several cardiology fellows huddled together, looking at rhythm strips.
“This looks like Torsade’s,” argued one of them.
“No, I think it is just V-Tach,” said another.
I looked at the woman - she was clearly dying. Her face was pale and her respirations labored. I thought about the family standing outside the door, not sharing this last moment with their beloved. Still, the argument among the physicians took priority to their need.
I said nothing to the other physicians, as my status was more “sub-intelligent” or “sub-important” rather than “sub-intern;” my mind, however, was filled with outrage. What should have been a transcendent moment - the passing of a loved one from life to death - had become an academic exercise. I vowed to myself that I would never put the intellectual “fun” over the real needs of the patients.
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The second situation was about five years later - when I was on call and covering for some other internists. One of them checked a patient out to me that was in the ICU. “He’s going to die; it’s just a matter of time” the other physician told me.
When I did my rounds the next morning, I wondered if this patient would still be alive. I did not expect to have much to do if he was. What I found, however, was a patient being aggressively kept alive with pressor drugs (to keep the blood pressure up) and antibiotics. He had a bunch of labs drawn, so I had multiple questions regarding the results of those labs.
I was confused. I thought the physician had told me this patient was dying. Why was all of this being done? Why react to a bunch of labs only to prolong the last hours of a person’s life? The nurse had no answers for me. She seemed confused and frustrated. She told me that the patient’s family was in the waiting room, so I made my way out to see them.
I introduced myself, and started asking questions - trying to discover just what had been told to the family. “He’s dying, isn’t he?” the wife of the patient asked me.
I hesitated. “I think he is.” I said.
“Then why are we doing all of this stuff to him? We can’t be in there with him.” she added.
“I can move him to the ward” I said. “He won’t last long if we move him there. Much of what they are doing in the ICU is keeping him alive.”
She nodded as I left to write the transfer orders. As I did so, the ICU nurse looked at me and smiled. “I didn’t have to do much convincing. This is what they really wanted” I explained.
I got a phone call from the med/surg floor in a few hours. He had passed away and the family wanted me to come in.
As I entered the room, I saw the patient lying silently in bed. Around him was a semi-circle of family members holding hands and singing a hymn. When the singing stopped, the wife of the patient came over and hugged me. “Thank you so much. That was what he wanted.”
There still was sadness, but there was also resolution. There still was grief, but there was also the celebration of a life. The final moments for this man were as any of us would have wished: spent surrounded by the arms of love.
Regardless of your beliefs about death, it is a sacred event. It divides us from our loved ones and then separates us as conscious beings from this earth. We as medical professionals are given an incredible trust and a huge responsibility. We can play a huge part in determining how this event takes place. Is the person alone? Are they in pain? Are there monitors, tubes, and devices measuring the person’s life? Or is the true measure of their life those people standing around them in the room? Can they die in the arms of their spouse? Are they sent off in love?
I sure as heck know how I want to die.
September 18th, 2007 at 5:28 am
I came across Bongi’s site a little bit ago and instantly liked this author. I added him to my blog roll. He’s a great find.
September 18th, 2007 at 7:47 am
WHen my grandmother had a massive stroke at 85, she had the kind of relationship with her docotr that allowed him to essentially do nothing. She had never had surgery on her rheumatic aortic valve (I ssupect she refused it). so we all knew it was amatter of time. She had been failing at home, and in our minds we had all been prepared for this.
So the entire family gathered around her bed that night at the hospital, where her only care was an IV and some nasal prongs. Together we held her hand and took our turns saying goodbye. Every one of her children and grandchildren were there that night.
It was a beautiful death.
September 18th, 2007 at 11:34 am
Nice post, Dr Rob! I’d like to go in my sleep at home, like one of my grandmothers did.
September 18th, 2007 at 1:05 pm
I did a series “on death” a while back. We share the same views. I sense there may be a slight awakening, but in general I think the profession as a whole does a poor job with these issues. For lots of reasons.
And I agree about bongi. To practice in his world…
September 18th, 2007 at 1:28 pm
I observed this so often when I worked in a teaching hospital. Doctors making academic arguments about treatment when it was obvious to all that it was time to let the patient go. Nurses in the med room of the nursing station angry with frustration at treatments they were obliged to give.
Good post Dr Rob
September 18th, 2007 at 2:23 pm
Dr. Rob, that was really powerful - thank you for posting it. I’ve had both good - and (very) bad - experiences with loved ones dying in a hospital. I think that the attitude of the physician, and of the nurses, makes all of the difference in the world.
In my mind, honesty - always honesty, about a patient’s condition. They have the right to know that it’s time to “prepare” themselves in whatever way they need … and they should be able to spend those last moments, in private, with their loved ones - away from prying eyes, and callous comments, no matter how well-intended.
Excellent post, Dr. Rob!
September 18th, 2007 at 3:56 pm
So, what do you think is the difference between the doc who can recognize and help provide a good death and the majority of docs, as suggested by Sid Schwab, who see the dying patient as an illness-object, and relish the debate about the diagnosis? Why did some guys turn out like Dr. Rob/Sid Schwab, and some guys turn out the other way?
Chris and Vic
September 18th, 2007 at 6:20 pm
I am not sure what makes the difference. I think the main thing is empathy, which we seem to have in varying amounts. I don’t know why I got more than some have, but it seems I have.
TBTAM - that is exactly what I am talking about.
September 19th, 2007 at 4:55 am
As my son lay in his isolette fighting for his life after his premature birth, my husband’s grandfather lay in a hospital bed on the other side of the city, dying. On the night that I held my son for the first time, my husband spent his night with his extendded family surrounding his much loved and adored grandfather as he passed over. He died surrounded by all of his family.
Hubby has often told me that when he dies, he wants to be surrounded by his family like his grandfather did. As you said, it was incredibly sad (I made it there for his final breaths) but the love in that room was undeniable. There is definitely a time where the medical profession needs to step back and let the family and love take over.
Great post.
September 19th, 2007 at 9:32 am
There is something of a paradox with doctors and facing death. We may see it from time to time, maybe for some quite a bit, but it seems many still haven’t come to terms with it. It’s easier to focus on the data - the labs, the vital signs, the drug doses, the X-rays and scans — so that we can keep away from the human side, keep the lid on our own emotional ineptitude in dealing with the intense emotions we sometimes see at the bedside with the family. Some point out that for us death represents a failure we don’t want to acknowledge. Probably true to some extent, but it should also temper the hubris we may feel at our “successes.”
September 19th, 2007 at 3:06 pm
Thank you Dr. Rob for an incredibly moving post. I can only hope that when/if I ever face such a tragedy, I will encounter a doctor like you.
September 22nd, 2007 at 4:28 am
Thanks for the kind words. I agree with your post. If we make a mistake it could actually mean the death of another human being. Sometimes knee deep in a tricky operation i wonder why i studied this. There would be a lot less stress as a street sweeper. But also less job satisfaction. I sometimes think there should be debriefing.