I woke up feeling exhausted. My first of my 4 alarms went off at 4:15 AM. I lay in bed just dreading the day ahead of me, before finally leaving the safe confines of my bed to get ready. By 4:50 AM I was in my car heading to the nursing home where I am doing a month long geriatric rotation. A giant stack of charts and a patient complaint list was awaiting us when we arrived. Going over the list there were the usual suspects; a follow up for lab results, a fall, abdominal pain, and at the bottom was a note on my patient: “deceased, requires discharge note.” Sharing the news with my colleagues there was a moment of sadness and a shared sentiment of “aww she was so sweet” and “poor thing” and just as quickly we all went back to the hustle and bustle of pre-rounding.
I sat down to write a discharge summary on the deceased patient, frustrated because I didn’t know how to appropriately check any of the boxes. In what condition is the patient being discharged? Fair? Stable? Improved? There was no option for deceased. What procedures or therapies should the patient continue after discharge? All I could think to write on that line was “N/A”. I reviewed the EMS records and hospital admission note trying to piece together what happened to this patient after she left our facility. The patient was found unresponsive in her bed Sunday morning, after 30 minutes of running a full code the patient was transported by EMS to a nearby hospital. Upon arrival to the hospital the patient had a pulse and was taking spontaneous breaths. The patient was stable during the course of her hospital stay, but ultimately passed away later that evening. Despite being of advanced age, she was a spry woman and was a pleasure to talk to. She shared with us that her hope was to survive until her birthday in a few weeks.
I finished the note, signed my name and left it on my attending’s desk. Being on a busy geriatric service, I went on with my day seeing the remaining patients and catching up on paperwork. I caught a glimpse of my patient’s room as I walked down the hall. Her red and blue quilt still perfectly spread out on the bed, the collection of bibles and rosaries placed neatly on her bedside, and the new addition of a large cardboard box on the floor to remove these items from what was once her home. An aide was sorting through the patient’s toiletries, haphazardly throwing the full bottles into the box and the remaining items in the trash. The whole thing was so unceremonious. No one was mourning the patient, and aside from a posted bulletin announcing her death, any memory of this patient would be gone before the end of the week.
I began to think, what a weird circumstance this is. How odd is it that we work in a profession where a patient’s death can be summarized on a post it note left on a chart? That you don’t have time to mourn the loss of life because of the resulting amount of paperwork that needs a physician signature? That a confirmation of her death is a check off of a “to-do” list. Does no one care that a life was just lost?
This is certainly not the first patient death I have had to deal with in my 6 years of working in healthcare. At 18, I got a research internship at the largest Level-1 Trauma center in Minneapolis. One of the studies we were doing at the time involved measuring CO2 levels with a capnography machine. To measure carbon dioxide, we would have to place a nasal cannula on the patient as the rest of the ED team did their full body assessment, lab draws and x-rays. One afternoon I was paged to the stabilization room for a trauma, the only information I was given was “42 yo male, attempted suicide by gunshot”.
If you have never witnessed a trauma team at work, it is the epitome of a collaborative effort. Despite 10+ people in the room, everyone knows their role and works effortlessly with one another to assess the patient. I walk into the stab room and was completely overwhelmed as the scene unfolded in front of me. The EMS team was busy disconnecting the patient from their own machines and sliding the patient from their stretcher to a bed as they gave report. The bits and pieces of the story I caught revealed a sad story. There had been numerous 911 reports regarding this man from several hours prior. He had been sitting on a grassy knoll overlooking I-94, the busiest road that connects Minneapolis and St. Paul, since earlier in the morning. It was early afternoon when he decided to use the gun that he had brought with him, to end his life. Only firing one shot, the bullet had passed through his mouth, blown off his ear and part of skull before bouncing around in his cranium and becoming lodged in the opposite side of the brain.
Despite the massive amount of trauma this patient had sustained, he was still alive when he arrived in our department. Unsure if I should go ahead and place a nasal cannula on this patient, I made my way to the head of the bed. The ED physician looked up and saw wide-eyed 18-year-old Kirsten standing in front of him, holding a clipboard looking uneasy. Without missing a beat, he instructed me to put on gloves and hold pressure on the left temporal region, where the bullet had blown off part of the man’s skull and ear. I did as I was told. I stood there as the ED team worked around me, just hoping for a Hail Mary that this patient would be stable enough to go for a CT scan prior to neurosurgery’s arrival. As the doctor began his assessment, he asked the patient a series of questions, not expecting any answer. To everyone’s dismay, the patient was able to whisper “help”. Over and over, he mouthed the word “help” as the team worked as hard as they could to save this man’s life. The patient eventually coded and despite resuscitative efforts, the patient was officially pronounced dead several minutes later.
That man passed away more than 6 years ago, and every once and a while he creeps back into my thoughts. What was going on in his life that caused him to take his life? Why did he sit overlooking the interstate for so many hours? Was he waiting for someone to stop him? To beg him not to do it? Did he regret it after he pulled the trigger? Was he in pain during his final moments? What more could we have done?
I tried telling my friends about the experience but they couldn’t relate. It seemed ludicrous that I would be upset about someone I didn’t even know. After all, people die all the time. And in a trauma setting there will always be some patients that do not survive despite everyone’s best efforts. I heard from some of my coworkers that it wasn’t my place to grieve. Some people were more blunt, telling me if I’d ever want to make it as a physician I’d have to toughen up.
Several years ago, a photo of a doctor mourning a patient went viral. A paramedic captured the photo of an ER doctor outside, crouching down holding on to a concrete wall after the loss of a 19-year-old patient. The photo spread like wildfire across the internet. It was a rare glimpse into the emotional toll a patient’s death can have on a physician. As doctor’s we often get a bad rep. We are deemed callous, hardened, uncaring. While nurses are with the patient day after day providing care, and going above and beyond to make the patient comfortable, most of the work as a physician is behind the scenes. Although we may only spend 5 minutes in a room on morning rounds talking about patients, it may take several hours of paperwork, charting and phone calls to verify medications, order the correct labs and imaging, and put in consults for various other physicians and services. I hear from patients all the time that they haven’t seen their doctor in several days or weeks depending on the acuity of their inpatient housing. What a patient may not realize is, that physician answers the phone call at 2am when the patient spikes a fever. That doctor stays late on a Friday to track down an X-ray. So despite only spending a few hurried minutes speaking to the patient, doctors invest many hours, sweat and tears into their patients’ care.
For patient’s family members, we have incredible resources out there to help them navigate their mourning period. From pamphlets to social work consults, we do everything within our power to lessen the overwhelming sense of grief they are experiencing. But what about the medical professionals who worked the case? We often spend weeks or months at a time caring for patients. When a patient passes away, not only do we feel sadness for a life lost, but many times there is a sense of guilt that maybe we didn’t do enough or worse, maybe we did too much. Many hospitals will have a social worker available for staff members to talk to, but when you’re working 60-80 hour weeks, taking time to go talk to a social worker may mean giving up a chance to run to the restroom or scarf down a quick snack.
In medical school we learn how to help our patients and their families navigate the 5 stages of grief, but aside from the orientation “Don’t Kill Yourself” speech no one ever addresses grief as a doctor. We are taught that showing emotion is not only unprofessional but it is a sign of weakness. Well I wholeheartedly disagree. I have always been able to maintain my composure at work, I have mourned each and every single one of my patient’s who has passed away. I don’t think that feeling for my patients is a weakness, in fact I think having compassion is a skill that is too often lacking in medicine.
I never let my own emotions interfere with my ability to provide quality care, but I will cope with my patient’s death in my own way and in my own time. After a patient did not recover from her above the knee amputation during my surgery rotation, I wrote about the experience in a journal. After a tragic loss of 3 young teenage boys who died in a freak motor vehicle accident when I worked as a CNA in the surgery department I went to a church to pray after work. After I saw a child peer through the stabilization room window as ED doctors pounded on his father’s chest in vain trying to recover a pulse, I drove straight to the gym after work and ran until my legs felt numb. Long story short, it is okay to mourn the loss of a patient. Having feelings for a patient is not inappropriate; being overcome by your feelings is inappropriate. For too long we have been encouraged to stifle our feelings, to toughen up. Instead, I say acknowledge the sense of loss, learn from it, make that interaction with your patient matter. Physicians are only human after all.