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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.

****

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.

****

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.