They taught me a lot in medical school – how to talk to a patient, do the physical exam, create a differential diagnosis (a running list of what I think might be the problem), treatment. I spent a lot of time memorizing etiology, gene mutations, and medication side effects. I left medical school ready to see the MD letters after my name, introduce myself as doctor, and finally wear that coveted long white coat. Little did I know that I would face so many moments questioning how those four years of training gave me the power to do certain things. Such as finding myself, less than a month into residency, proclaiming a death. As I heard myself say, “Time of death: 9:15am,” I knew that was a moment I would not forget anytime soon. Because, despite my whole FOUR years (yes, sarcasm), nothing in my training taught me what I learned during that night.
1. Sometimes in medicine the best thing I can do is shut up and listen.
This was my first rotation in the hospital and my job was to work overnight managing all the medical patients after all the primary medicine teams left for the day. As one team left, they told me about a patient, Mr. Doe. In the last few hours, he was admitted to the hospital and switched to comfort care status per his sibling’s wishes. Comfort care status happens when actively trying to save a life will harm the patient more than help them, so the focus shifts to making the patient comfortable as they pass. This is a difficult decision for a family to make – especially when there are 20ish people at the bedside, with no formally designated decision-maker, nobody with the DPOA (durable power of attorney). In medicine, we defer to the next of kin, as was done prior to my taking over care for Mr. Doe.
However, apparently not all 20ish people agreed with the decision. From the start of my shift, they asked me who had the power to make the decision, why the 17 year old daughter did not make that decision, why we weren’t giving him fluids and why were we just “letting him die”. Medically, I knew this man’s prognosis – even with medical intervention, very grim. Morally, I wondered who should have more of a say in determining a loved one’s care, the siblings or the daughter. Overwhelmed, I did the only thing I could think of – listen carefully to their concerns, let them get everything off their chests. As they talked, I realized they weren’t disagreeing with the switch as much as they needed to feel that their concerns were heard.
2. I have never been more unsure of my capabilities as a physician than the moment I pronounced the death.
In the last hour of my shift, I got the page, “Re: Mr. X -guppy breathing, respiratory rate 3”. I went to the room and quietly explained to the 4 people left (the rest of the group had gone home) why I was there and what I would do next. I explained the exam I would perform. I did the exam. I listened to his chest for a minute, sure that I could hear heartbeats before I realized it was my own pounding in my head. I checked for reflexes, several times to be sure, which were absent. I subtly checked for any response to pain – nothing.
The entire time, my head was racing – what if he wasn’t actually dead and I called it? What if I had done the exam incorrectly, or missed something? Fortunately, I knew the parts of the death exam because the senior resident had already pulled me aside to discuss it. But, still – four whole years of training, and I would have had to resort to Google to properly diagnose and call a death if it hadn’t been for that senior resident – how does that seem right?
However, I didn’t call it. Not because I was worried that my doubts were at all correct (this gentleman had unfortunately passed from our world). Clinically, he was ready to be pronounced dead. But when I looked at the eyes of the family members, I hesitated in calling the death, which brings me to my next point.
3. No matter how jaded I might become, it’s important to remember these aren’t just patients – they’re a beloved parent, sibling, significant other, friend.
I started medical school doe-eyed and bushy-tailed, sure I would never lose my compassion. However, as an intern who is running between rapid responses or codes, answering pages, and putting in orders, it’s hard to stop and remember this is for more than just a patient, it’s for someone’s loved one. I don’t say this to sound callous or harsh – if anything, it’s moments like this one that make me want to cling tightly to this feeling.
Back to Mr. X – I was at the end of my shift, and from a medical perspective I should have called the death – however, when I looked at the few family members left, I couldn’t. Instead, I found myself saying, “I’m extremely sorry for your loss, however I feel it’s important for you to know that I do not have to officially pronounce anything now if you’d like a little bit of time to adjust.” They asked if they could wait until Mr. X’s brother drove in (about 20 minutes away), and I of course said yes. By the time he was there, there were more doctors at the bedside – I stayed late because I didn’t feel it would be right to leave and the primary team from the day prior came by as well. It was a little later that I found myself saying, “Time of death: 9:15 am”.
That morning will stick with me forever. I remember the tears I cried as I hugged the 17 year old daughter, held her as the reverend said a solemn prayer. I remember feeling like the angel of death because I had not only ended that shift with a death but had started that same shift (15 hours earlier) with a patient coding and dying. I remember the blue of the sky, sun shining brightly, and Rainier peering from the distance when I finally left the hospital. I remember all those little lessons they didn’t teach us in medical school – probably because some of them aren’t lessons you teach, but ones you experience and learn.