Four physicians, each at different points in their careers, share personal experiences on dealing with patient deaths with the hope to convey the importance of reflection on guilt, resilience, and growth.
The Initial List
Dr. Amanda Clark (avclark@umc.edu; @amandavclark) is an assistant professor of medicine at the University of Mississippi Medical Center.
Before I started medical school, people gave me advice about many things—for example, which study materials are best, how to do well in Gross Anatomy, when to start studying for board exams. There were books, e-mails, and conversations filled with advice about various classes, professors, and studying strategies.
No one ever told me what to do when a patient died. No one told me about the twinge of pain I would feel when we told the family this would be his or her last day. Worst of all, no one prepared me for the pain and guilt of an unexpected death.
Like many things in medicine, I “learned by doing.” My first patient that died was unexpected and while I was calm during the conversations, the OR, and the code, I cried in my car, at home, and in the shower for weeks. Seeing someone’s mortality makes you question everything.
The second was no easier. He was younger than me. I couldn’t stop thinking about his lifeless body after the code ended. I began to keep a list of initials: E.A., J.W., R.Y.
And then there was the one on the first night of call my intern year. Also unexpected and this time, as the physician, I was sure it was my fault. He was set to be released from prison the next week. He was kind.
As time lapsed, the deaths kept coming. The lady in the ICU waiting on a new liver. The unexpected massive stroke. The man who was happy to be discharged home. The young mother. The man who didn’t feel well in clinic. The young girl with cystic fibrosis. The avid football fan. The lady with the worried eyes. The many high-grade cancers.
It’s now been more than 10 years since that first death and there have been many more. I don’t keep a list of initials anymore. Written down or not, they stay with me and they still hurt.
We are all human and we make mistakes, but I now understand that some patients are very ill and sometimes they die—maybe unexpectedly and despite our best efforts. We are not God. We took an oath to heal and do no harm and, while we do our best, sometimes our best is not enough—not because we aren’t strong or smart enough, but because life can unexpectedly end. There is no crystal ball. I have stopped asking myself “Was this my fault?” and now ask “Were we doing all we could?” Because now I understand. Our best is all we can do.
Why didn’t anyone teach me how to deal with death? Probably because it’s complicated, there’s no one way to cope, and well, it’s tough to be vulnerable. Talking about the things we want to put behind us is hard, but these conversations must happen. We must debrief. We must grieve. We must find a way to move forward. And most importantly, we must allow space for our trainees to do the same. Otherwise, the initials will add up, the grief and guilt may become insurmountable, the burden too heavy to bear.
The Final Text
Dr. Adrian Sims (msims@umc.edu) is a second-year resident in internal medicine at the University of Mississippi Medical Center in Jackson, MS.
Discharge orders in, check. Follow up appointment scheduled, check. Medication reconciliation completed, check. “I’m finally getting the hang of this discharge process,” I thought to myself sometime mid-intern year. “Let me go check on her one last time before I head to clinic”, I told myself. The neurotic idea of checking a twelfth time somehow made me feel that nothing would be missed, and I would have accounted for every possible variable that could happen. What a silly notion.
“Is your mom on her way?” I asked. She was young, thirty years old. “I just texted her. She’ll be here in about an hour,” she said with a smile as she thanked me, an intern with no real medical prowess, for taking care of her. She was chronically ill having battled lymphoma for some time and had now suffered a small stroke. “I’m on my way to clinic but I look forward to seeing you in follow up next week” I said. The follow up would never come. As I was gathering my things to leave for clinic, the nurse knocked on our workroom door. “Your patient in 477 is having a seizure, I think,” she said frantically. No way. How could this be? She didn’t have a seizure disorder. I arrived to find her convulsing on the bed. “This doesn’t make sense. She just spoke to me,” I thought in bewilderment.
After emergent intubation, central venous access, and running through the Hs and Ts, she was quickly escorted to the CT scanner. Her aorta had ruptured from a pseudo-aneurysm. “Did you talk to vascular surgery like I asked?” my resident inquired. The blood pooled in my feet and I felt overwhelmingly faint. I suddenly felt very hot and needed to vomit. My resident had asked me to call surgery prior to her discharge about an incidental finding that was discovered on imaging. It was not intentional. It was not out of malice. Negligent perhaps, but not on purpose. She soon coded after that and was pronounced dead after valiant resuscitative efforts. Disclosing the details to her befuddled mother was, by far, the most difficult thing I’ve ever done. We sobbed. I considered quitting.
Emotionally, I spiraled into a very dark place for quite some time. Mentors, leadership, and friends assured me that making the consult would have not changed her outcome. After all, she was very sick. It provided no solace.
Over time, I did recover with a lot of help from people that knew a broken physician couldn’t adequately care for patients and who truly care for me. I also realized that I was far from the only person who has experienced an unexpected death such as this. There are many good physicians who are good people that deal with bad, unexpected outcomes. The experience, for better or worse, has now equipped me to be able to help others that experience difficult events.
I kept in contact with that young lady’s mother. I called her once and she told me something unexpected. “I know you did everything you could, sweetie. My baby was really sick. I don’t blame you,” she said. Her words pierced me, and I felt a globus sensation clutching my throat. I vowed that day to put my thoughts on paper, to share her story, and to help other clinicians that experience similar events. Our conversation ended with her words, “Besides, I’ll always have her last text message she sent me. ‘Love you mom and I’ll see you soon.’”
The Eleventh
Dr. John Caleb Grenn (jgrenn@umc.edu, @jcgrenn) is a third-year medicine-pediatrics resident at the University of Mississippi Medical Center.
You didn’t feel good this morning. Honestly, you hadn’t felt good for at least two weeks, probably two months. But today, I saw something different, something urgent. How are you feeling? A weak shake of the head. Do you want me to call your family? I know they’re coming to see you tomorrow, but do you think if they could, maybe today? A thumbs up. A nod. OK.
Your daughter was at work, but was going to try to get here. She knew, too, that this was coming. Though I wanted to express my new, odd, gut-felt urgency, I have been wrong about so many things so many times. I’ve seen too many linger, too many stew, but I knew that it would be today. I should have said that, but I didn’t.
She wanted to be here, and so did your wife. I saw that in their eyes every day they sat there with you. Tears leaked from wrinkled corners. I wish I could have been there, too. I think you hoped one of them or at least someone would be there, but we weren’t.
Somehow your death has me sadder than I thought I would be by now. I tend to cope with each patient’s death a little differently, but I’ve never had to wear my sadness, to bear its heavy weight. This time I’m wearing it. I guess it’s because you hoped someone would be there with you, because I think you knew today was the day like I did. Dying alone frightens me, too. It might just be because you met my expectation sooner than most of us thought you would, and it sneaked up on me when I wasn’t ready to be surprised. Maybe I should have always felt this way, and it’s normal. But in truth I think it’s because you taught me that I’ve seen this enough now to know that you were going to die on the eleventh. Not the twelfth or the thirteenth or the next week. I knew that today was your last, and that it passed by stoically with the buzzing, the beeping, and the shallow, slowing breathing until it stopped, and the room went quiet.
Two years later, I realize that on the eleventh, your eleventh, I learned to speak up. I tend to trust my instincts a little more. Pressing premonitions get me on the phone with families faster. I make firmer recommendations; I tell people to come soon, that time is precious. The burden I had to start wearing that day weighs the same, but now feels lighter.
Learning from Death
Dr. Elizabeth Fryoux (efryoux@umc.edu, @Eamfryoux) is a chief resident in internal medicine at the University of Mississippi Medical Center.
As a resident, you try to learn as much as you can and as fast as you can. You realize how much there is to learn and how much you do not know. You feel so responsible for your patient’s care. You realize, some sooner than others, that you will face losing a patient. Early in training, saving lives has been indoctrinated, so as physicians we equate death as a medical failure rather than a natural process.
As a new intern on our first call day, my resident asked me to go see a previously healthy 22-year-old man who presented with a two-week history of fevers and generalized myalgias that was associated with pleuritic chest pain, non-productive cough and a sore throat. He was admitted for fever of unknown origin and later diagnosed with Adult Onset Still Disease. He was on our service for the entire month and every morning I looked forward to seeing him and his family. Treatment was initiated immediately, but he continued to worsen each day and was ultimately further diagnosed with Macrophage Activation Syndrome and subsequently died from complications. This was the first patient that I took care of who had died, and I was devastated. I ached for the loss of such a young man and for his mother and girlfriend, who never left the hospital upon his entering. I constantly ruminated what I or we as a team could have done differently to have prevented his death. I felt hopeless and completely responsible that I let his family down. In time, I came to the realization that I could learn from his death. I made a vow in memory of him that I would view each patient as an individual rather than a disease. I would pay more attention to how I talked to my patients, how I managed them, how I touched them and the continual need to be a lifelong learner. The numerous sacrifices I would make as a resident would be for him rather than a means to an end. My work would be my calling rather than just a job. I reminded myself even though we could not save him and that his death was inevitable, this experience would allow me to help many others and do so as a better physician.