Abstract
Wasn't it ridiculous for us to imagine that they felt as we did? As ridiculous as it would be for us to try to imagine what a child felt? We were putting into these gomers our fear of death, but who knew if they feared death? Perhaps they welcomed death like a dear long-lost cousin, grown old but still known, coming to visit, relieving the loneliness, the failing of the senses, the fury of the half-blind looking into the mirror and not recognizing who is looking back, a dear friend, a dear reliever, a healer who would be with them for an eternity, the same eternity as the long ago, before birth.
As with all previous generations, my intern class was nervous about our new position in the medical hierarchy. We received a short 1-week orientation on “How to be a good intern” which involved lectures on advanced cardiac life support (ACLS), common medications, computer training, hospital protocols, and death. The last lecture had everyone's attention given our hopes that it would mitigate our anxiety. We all had heard stories of interns losing patients on their first day and then being dubbed “dark clouds.” Unfortunately, instead of dealing with the pressing psychosocial elements surrounding the process of death and dying, the discussant focused on details of completing the death certificate. “Make sure to use a black pen…do not write outside of the box…if you make a mistake you will have to start over…” One of the braver interns raised his hand to ask a most important question, “How do you…umm…know if they are dead?” The senior resident responded “Of course, well it depends…just ask the nurse and she will tell you the protocol.” This ambiguous answer ended the day and we went our separate ways to clinics, wards, and ICUs praying that this event would not happen to any of us anytime soon.
Of course, none of us were able to escape the inevitable process of having a patient die and rumors began to fly regarding which patient died on whose service, etc. Some interns focused on the etiologies of their patient's death while others concentrated on their resuscitative efforts and how to hone their life-saving skills. A few fellow interns confided in me as to how the combination of long hours and loss of life had begun to make them question if medicine was the right career choice.
As a psychiatry intern, I began my medicine ward rotation later in the year and thereby, was one of the last members of my intern class to lose a patient. It was clear, however, from my first day on medicine that many of the patients in this university-affiliated hospital were closer to death than life. Each patient seemed to be triple or quadruple my age and had a long list of diagnoses that were only overshadowed by the length of their medication reconciliation form. Within minutes of stepping foot on the medicine floor, a 75-year-old patient I had inherited from the previous intern coded and needed to be transferred to the intensive care unit (ICU).
Each day began to blend together; pre-round, breakfast, round, lunch, consults and orders, dinner, update the sign out, sleep, and then start again. This schedule was only punctuated by days that my team admitted or had the dreaded over night call assignment. The names and faces of my patients began to fade and their stories blurred into the common diagnostic categories of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes mellitus (DM), etc. These diagnoses were neatly organized on both my sign out sheet and in my mind.
This somewhat neatly structured perspective came apart on the day I lost my first patient, an 85-year-old demented woman who was admitted for CHF exacerbation. It had started as a normal morning in which I was gobbling down breakfast while writing my progress notes. Unexpectedly, I received a page to come to the unit as soon as possible. When I arrived one of the senior nurses was leaning over the patient whom I noticed appeared extremely pale. She declared that the patient was having “the death rattle” and due to her do-not-intubate/do-not-resuscitate (DNI/DNR) status there was nothing to be done. I examined the patient and then made my senior resident aware of the situation. She agreed with the examination and stated that she would call the patient's family so I could finish my progress notes before rounds.
As I began to leave the room I thought of an epiphanic experience I had a few months prior to starting internal medicine. There was a hospital-wide outbreak of gastrointestinal flu that I had succumbed to but since I was single and had only recently moved to this city, I was left to fend for myself. This ultimately entailed spending a few days sick and alone in my apartment. I had mentioned to my parents how my misery was compounded by being alone and isolated. It suddenly struck me how my patient was equally isolated and alone at this critical moment. So, instead of returning to my breakfast and charting, I turned around and sat down next to her bedside. It became surprising clear that I was not going to leave her room until either a family member arrived or another staff member became available to sit with her. It was not the first time I had sat with someone while they were dying but it was the first time I paid attention. I heard each breath, watched every rise and fall of her chest, and noted each of her twitches. After an hour or so, my senior resident came to tell me that we were rounding but when I calmly stated that I did not want her to die alone, she nodded approvingly and left the room. Finally after 2 hours, the patient passed away.
My questionably abnormal, if not atypical, behavior was noted by many of the nurses, interns and residents. Some felt it had emanated from the fact that I was training to be a psychiatrist while others believed it was a naïve, rookie's waste of time. When questioned about the episode, I answered with another question; “Would you want your grandmother to die alone?” This answer seemed to both put the inquiry to rest as well as generate some soul searching in a few of my colleagues.
Reflecting back on this experience, I believe the counter-transference issues between the interns and their patients are critical to understanding what was transpiring. As physicians we have been trained from day one of medical school to do everything possible to save our patients' lives. This perspective was uniquely challenged in Samuel Shem's infamous The House of God as he told of the trials and tribulations of the intern year. Some may argue that this book's continued popularity among succeeding generations of physicians is based on its address of the young physician's universally greatest fear. Namely, the inability of our interventions to save all lives.
My experience seemed to emanate from the conscious and unconscious discomfort my intern class and I were having with death. Were we upset with our dying patients for making us feel inadequate and like failures? As new physicians, we struggled with our impotence to reverse the irreversible dying process and unfortunately, were prone to attribute this to our easily taxed sense of (in)adequacy. With hindsight, whatever the force that guided me to sit with my patient was, it allowed me to learn that although I could not perform a procedure to cure her, I could still provide some measure of comfort (for me and hopefully her too) through companionship. This free and simple intervention was not only humanistic but also a learning experience.
I believe that there needs to be a shift in the paradigm of our medical education so that students as well as more senior physicians will be able to view death alongside birth as part of the normal life cycle. After all, as one of my attendings put it “none of us will get out of here alive.” Thus, a patient's death should not automatically be viewed as a medical failure with the attendant self-denigration of inadequacy but rather with the wisdom and comfort of acceptance of the inevitable. Until this happens, interns may continue to believe patients follow the “House of God's Rule #8: They can always hurt you more.”