Death is a traumatic event. Sometimes emotionally. Sometimes physically. Sometimes both. We lose sleep when we lose patients, especially after the first one, or the ones where we were so invested in fighting for a good death, but got just the opposite. It’s when the house is quiet, the event has passed, and the chaos has calmed that we notice the moments replaying in our minds, haunting with what ifs and maybe I could haves. The resentment of families blaming you for their loved ones dying; for “giving up”; for failing them; for causing the death carries a palpable weight. The reality of death is that it is the only truth in life; despite our ability to probe the depths of space, and define the intricacies of the fibers that make us human, death still prevails in spite of our efforts. Medical education teaches us how fight death, not embrace it and grapple with its aftermath.
In The Death of Ivan Ilyich, Tolstoy poignantly reminds us of the patients and families we face in their grimmest hours,
In the depth of his heart he knew he was dying, but not only was he not accustomed to the thought, he simply did not and could not grasp it.
The hardest deaths you’ll face are when the end is imminent, no medicine can fix the unraveling catastrophe in front of us, and a family unable to see the forest for the trees forces your hand in continuing the cruelty modern medicine is capable of. It’s really easy to impose our values and beliefs onto patients because we don’t agree with theirs. Sometimes they choose to suffer, and that’s not our choice.
Dr. Jessica Machue, MD, a third year Family Medicine resident reflects on her hardest deaths, and the process of processing those traumatic events,
There are two deaths that will never leave me. I have resolved them, but they are always there in the back of my mind as reminders of where I never wanted or want to go in caring for patients. I cared for a chronically debilitated man, Hugh, the duration of my residency who unfortunately survived a massive head trauma at a young age. We had conversations with family over the course of years on each hospital and ICU admission that the patient was going to die. Over time, they began to deeply resent me, because I was the one delivering the truth they did not want to accept. These conversations are not all warm and fuzzy. They’re dirty, and can be filled with anger and resentment. It’s hard to talk with someone with compassion who resents you so much, because you start to resent them; you have to remind yourself where they’re at, constantly.
The other patient, Aubrey, lay on a gurney with Dr. Machue’s fist in her femoral artery for three hours, while she frantically begged her to keep her alive – a woman who had been dying slowly for months. Although she was stabilized enough to transfer to the ICU, she was dead within a week from septic shock.
You will continue to have emotion about these traumatic events as you process them. The most important thing is to not carry resentment towards patients and their families; to stay compassionate even though you feel what you’re doing to that patient is wrong. You will do things that don’t abide by your morals. Those are the patients I don’t forget.
In talking about coping with death, there are a few crucial components to this process we felt worth noting.
The moments of end of life care – the weeks leading up to death – will be filled with a catacomb of emotions. During and after death, recognizing your own emotions is crucial to staying human in the process. It’s ok to take a moment and feel what you’re actually feeling. The hard part is having and finding the divisive line where you’ve invested, offering the most compassionate care you can while still preserving your perspective as a physician. When we interviewed families of patients who had passed, there were several occasions where families told a story of asking their resident “what would you do… if this was your family?” and the resident maintained their professionalism, but did cry, and ultimately gave them not just medical information, but their personal opinion for medical care. Families said in those moments, they were able to connect as humans, not as family and provider separated by the chasm of a dying patient between them. That vulnerability was the single most memorable moment in the eyes of several dying patients’ families. Recognize emotion. Respond to it. You’re still human despite the jaded and cynical people that can surround you in medicine.
Talking with Colleagues
After your patient has died, you will inevitably replay the events leading up to that death. It may not come back to you until later on, but it will. You will wonder if there’s anything else you could have done. You will question the decisions you made. You will want to know with absolute certainty that your medical care did not contribute to the death of that person. Talk with the people involved in their care. Just as you lost a patient, so did the nurse, NP, PA, RT, PT, and everyone else that took care of that person – they will be asking themselves the same questions. Support them, and be open to receiving support from them. You’ll find your resolution of death occurs faster when you’ve been able to talk out the details – think of it as CBT, which we all know the data on how CBT improves outcomes in traumatic events.
Somewhere in your coping process, there will be a moment of clarity. There’s frankly no rhyme or reason to it other than it comes when it’s good and ready during your processing of death and dying. In the case of Aubrey, Dr. Machue resolved,
It was HER that decided to continue with these interventions, and it wasn’t my responsibility for her suffering. The relief of that burden was insurmountable.
When talking about coping with the extensive suffering forced upon her hand with Hugh, Dr. Machue said
When Hugh died, I was able to detach myself, because I didn’t have a choice in his care… I tried so hard for a very long time to help his family understand what WOULD happen, and felt good about what I had done and the care I had provided, but in the end it wasn’t my decision to code him. And that’s ok. The values to continue treatment without any quantity or quality of life aren’t mine to decide, and ultimately, we as providers have to acknowledge and respect autonomy. When I talk about code discussions with families now, my language is careful now to state that “it depends on what type of person you are and what your values are.”
Patients and families will CHOOSE suffering sometimes, and you will inflict that suffering, but it’s not your fault; do not blame yourself, because your intentions in pursuing medicine were to heal, to offer respite for the hopeless, and show compassion and empathy regardless of ability to pay you for your services. You are a servant, at heart, right? Isn’t that what they want to know in your med school application? Funny now, on the other side to stare death in the face. What would you have told that young twenty-something former self of yours? Would you say this has all been worth it? Maybe they should run away?
Yes, patients will die. Some will be traumatic. Some will be peaceful. But isn’t it worth it to be the shepard in that process, gently guiding human beings on the beautiful trajectory of life to their final home? Isn’t that part of the calling of medicine? It is our belief that it’s a birth-right for every human to have a physician that can openly and honestly discuss death and dying, and to have a physician who will care for them to the end. You have entered a great calling in life, and remember the terrible travesties you will bear witness to are not a reflection of your intentions while causing pain or suffering. Rather, those are the patients who need your compassion and empathy the most. Those are the families who need your vulnerability and emotion to be at the peak of your capacity as a human being in the time of their loved one dying. You will impact many lives in your time as a physician, and families will be grateful for your appreciation of the human condition.
Lastly, help your intern or med student decompress and understand what they’ve been a part of. It’s the weeks leading up to death that can be traumatic. Let them know “You did everything you could do to help them understand, and everything you could do to take care of her. What happened to her is not your fault, and not your decision. You were making caring decisions.”