Death and dying on the wards

I received this paper in my email, Medical Students’ First Experiences with Death. Admittedly, usually with these Medpage articles I usually read through the ones I’m most interested in right away and wait til the end of the day or week to read the rest. But this time it seemed very fitting.

I’m in the first week of my medicine sub-internship and I admitted my very first patient on my first day. On day 3, we are questioning whether this man will survive. It’s strange to me since when I did his admission and even on day 2, he didn’t look especially ill. He seemed happy; he was laughing and making jokes. But today on the third day, he looked progressively worse. My attending asked me if I felt comfortable talking to the him and his family about code status. And honestly, I’ve never had this conversation. I’ve asked about code status during initial interviews but my only experience was when my own grandmother was in the same situation. I was the only one from the family available since I had stayed overnight. She had decompensated quite a bit, and at that point the doctor pulled me aside and asked me how invasive I wanted them to be if something were to happen. Would I want them doing compressions on her very weak chest? Would I want them putting tubes down her throat to make her breath if she stopped? I had no idea. I didn’t know what I was supposed to do.

I told my attending that even though I had some experience working in hospice before medical school, I didn’t exactly feel comfortable talking to the family. So we discussed it in morning rounds and my resident told me to go ahead and start the conversation with the family. So I went in and started to talk to the two grown children about their father. Despite my explanation of his grim prognosis (he had stage IV lung cancer with mets to bone and liver, disseminated zoster with MRSA superinfection and health-care associated pneumonia), they were incredibly optimistic that he would make a grand turnaround. They explained to me that they “didn’t want to feel like they were making the decision to kill him.”

I left the hospital on day 4 (of his stay and my own day 4 at the hospital), and became very sad in the car on the way home knowing that he may not make it. It was hard whether it was because I felt hopeful for him and his family or that he’s my first fully managed patient. I saw him completely deteriorate in fromt of me despite all the best available treatments I carefully researched. It’s a tough thing being in this situation where you have to be the person to deliver the news that their loved one is dying, and hoping that they will accept that when I can’t even accept that on my own. It’s hard to encourage someone to put their family on comfort care when you know that they have some glimmer of hope that their loved one will make it through. Even I share that same glimmer of hope but have to keep it internalized, especially when other residents sign out to me in the morning that my patient is “circling the drain.”

I don’t know at what point in my career, especially because I have an interest in geriatrics, to which something like this becomes easier. And in reality, I don’t want it to become easier. While I may not feel as attached to all of my patients, I don’t want to lose my sense of humanity in the process.

My patient made it through the night. When I came in the next morning, he was no longer speaking and barely reacting to his family. At that point, we knew he probably had little time left. Eventually the family switched him to comfort care to ease his silent suffering. He died peacefully the next day with his family around him.

Perhaps medical students and clinicians aren’t adequately prepared for end of life care. Most medical students I had spoken to don’t know how exactly to deliver bad news and approach end of life care. It’s something that they just don’t teach you in medical school. A recent paper showed that that undergraduate medical education is currently failing to prepare junior doctors for their role in caring for dying patients by omitting to provide meaningful contact with these patients during medical school. This lack of exposure prevents trainee doctors from realizing heir own learning needs, which only become evident when they step onto the wards as doctors and are expected to care for these patients. There is little formal teaching about palliative or end-of-life care in their new role and the culture within the hospital setting does not encourage learning about this subject. With the growing geriatric population, it becomes especially important.

So this was my first real experience with death in medicine.