advice requested regarding experience with patient demise

[hackinmage]

I just had a question for more senior physicians than i (i'm just a 4th year, will be starting my residency in july!)

So at this point, in addition to my EMS career and working in community hospitals i've had my share of patient death, doesn't really phase me. But today i had a 2 month old pass on me, granted the patient was in asystole from contact (i was on the ALS rig) but i still felt absolutely nothing, we had done all we could and i was satisfied with that.

The question is... is this healthy? should i see someone? I don't know, i may have seen too many tv shows, but i feel like i should be having more of an emotional response rather than just looking at it as just another call. I was hoping to see anyone had any input?

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[Entgegen]

I don't have much in the way of advice, but I can quasi-relate. I'll be starting a pathology residency this summer and have done my fair share of pathology electives along the way, and happened to see a few autopsies. Two of those were of babies. When I've told people about this, they usually say something to the effect of "omg, that must've been so sad." Well, not really. At least to me. If I felt anything it was that of curiosity and fascination. They weren't my kids, I didn't know them or their families, I was never their physician who participated in their care, I had no relationship with them, so I just didn't feel anything. At the risk of sounding a bit callous, they were just objects to me.

On the other hand, seeing the effects that disease/death has on others does affect me. I'm currently on a pediatric heme/onc rotation and witnessing my attending break the news to parents that their kid has cancer is a pretty rough. I probably would've had the same reaction as you if I were in your situation, although if mom was wailing in the corner of the room while everything was going on, that would be a different story.

Overall, I don't see what you're describing as much of a problem, unless it starts to affect the way you approach treating the patient. If you were apathetic toward the prospect of a patient dying and therefore not doing all you could to save them, then it's a problem...but you said otherwise in your post, so no problem.

 

[erin682]

I've found that when the patient is essentially dead or close to it when I first get to them, it really doesn't get to me. Speaking with the bereaved family often does. The patient deaths that I remember are the ones that come in talking and then die unexpectedly. Those are fortunately pretty rare, but they stick with me. Having the ability to turn off the emotion in a critical situation is key to being able to have control of it. I think the instinct to do this is almost automatic.

 

[Birdstrike]

I just had a question for more senior physicians than i (i'm just a 4th year, will be starting my residency in july!)

So at this point, in addition to my EMS career and working in community hospitals i've had my share of patient death, doesn't really phase me. But today i had a 2 month old pass on me, granted the patient was in asystole from contact (i was on the ALS rig) but i still felt absolutely nothing, we had done all we could and i was satisfied with that.

The question is... is this healthy? should i see someone? I don't know, i may have seen too many tv shows, but i feel like i should be having more of an emotional response rather than just looking at it as just another call. I was hoping to see anyone had any input?

When you're a physician, families expect you to save their family member, period. They expect you to "bring 'em back" just like on TV. When you're fully responsible, the "end of the line", and you can't, you may feel different. When you're EMS, or first responder, nurse or tech, you can always give the family false hope and say, "Don't worry, he'll be okay. The docs are working on him now. He'll be okay". When you are the one who's supposed to save him, and you can't, and you go in to drop the nuclear bomb on the unsuspecting family member, its different. Or when you tell a set of parents who doesn't even know their child is in the ED, that their child is dead, and you FAILED to save him. You may feel different. Because that's why most of us choose emergency medicine, right? To be the "hero". Most of the time you can't be the hero, you're just messenger for the worst news in someone's life. Or, when it's a situation or patient that reminds you of someone you care about, you may feel different. Performing death notification, in my experience is BY FAR, the most painful part of the job, especially when you're delivering the news to unsuspecting loved ones of a child or young person. Enjoy right now not having to be "the man". Remember, the best job in sports is back-up quarterback. When you're the star quarterback, not only do you get all the glory, you've got to take all those hits. Don't beat yourself up. You'll see your fair share of tragedy that will "get to you".

 

[Tornadoman84]

When you're EMS, or first responder, nurse or tech, you can always give the family false hope and say, "Don't worry, he'll be okay. The docs are working on him now. He'll be okay". QUOTE]

I agree with what Birdstrike said. I would just be careful about the comment that you can give false hope if you're not a doc. It doesn't matter who you are (nurse, tech, paramedic), you should tell the truth or else it could potentially open you up to litigation. Something like "the docs are working on him now and we'll do our best" is all that needs to be said.

In terms of "not feeling anything," it's possible that we're all putting up defense mechanisms (isolation of affect, rationalization) to avoid these negative feelings. These aren't necessarily bad defense mechanisms. The problem appears when you ignore them and these feelings start building up inside possibly leading to depression or anxiety. I think the important thing to realize is that suppression of these feelings is okay in order to accomplish a task (ie. trauma code). However, we should all find colleagues and friends to talk to about these feelings and blow off some steam.

My 0.02 cents

 

[Birdstrike]

[/QUOTE]I would just be careful about the comment that you can give false hope if you're not a doc. It doesn't matter who you are (nurse, tech, paramedic), you should tell the truth or else it could potentially open you up [/QUOTE]

I wasn't implying anyone should give false hope just that it's a lot easier to be the consoler on the front end than it is the be the guy to deliver the bad news

 

[The right Path]

I would just be careful about the comment that you can give false hope if you're not a doc. It doesn't matter who you are (nurse, tech, paramedic), you should tell the truth or else it could potentially open you up [/QUOTE]

I wasn't implying anyone should give false hope just that it's a lot easier to be the consoler on the front end than it is the be the guy to deliver the bad news[/QUOTE]

Is it? I don't know, man.... it's not a picnic to deal with the aftermath of bad news. Physicians can generally "escape", but the RN, not so much.

And hopefully anyone with patient interactions knows better than to give false hope/reassurances or promises they aren't 100% sure they can't deliver.

 

[pseudoknot]

It doesn't matter who you are (nurse, tech, paramedic), you should tell the truth or else it could potentially open you up to litigation.

I agree that providers should not give false hope. I don't know anyone in EMS who would tell a family during a code that the patient was going to be fine, although I'm sure Birdstrike has seen this happen.

I don't agree with the "liability" part. People ought not to do this because it's wrong, not because of fear of some phantom lawsuit (and I'm not a lawyer, but I very much doubt you could be sued for such a thing anyway).

 

[Tornadoman84]

I agree that providers should not give false hope. I don't know anyone in EMS who would tell a family during a code that the patient was going to be fine, although I'm sure Birdstrike has seen this happen.

I don't agree with the "liability" part. People ought not to do this because it's wrong, not because of fear of some phantom lawsuit (and I'm not a lawyer, but I very much doubt you could be sued for such a thing anyway).

I agree with you Pseudoknot. You shouldn't do it because it's wrong. But you can't ignore the lawsuit component. You can technically be sued for anything... Telling a family member that the patient is going to be okay, when you know that the probability leans toward that it's not going to be okay, just makes you vulnerable. The family member will point towards you and say, "YOU TOLD me that he/she was going to be okay."

 

[pseudoknot]

That "you can be sued for anything" is a myth, and a destructive one at that. Yes, in theory even the most absurd lawsuit can be filed. In reality most lawyers will not take a case unless it stands some chance of being successful, and again with the caveat that I'm not a lawyer, I fail to see how the above scenario could really lead to a winning case. I'd be very surprised if anyone could find a real example of a case where an EMS provider or nurse was sued for giving overly optimistic prognostic information.

I think this is a real problem because from what I've seen so far, people in the medical profession have this hysteria about lawsuits that feeds on itself. And tort reform isn't going to help if people already think they are liable for things they aren't.

 

[Entgegen]

That "you can be sued for anything" is a myth, and a destructive one at that. Yes, in theory even the most absurd lawsuit can be filed. In reality most lawyers will not take a case unless it stands some chance of being successful, and again with the caveat that I'm not a lawyer, I fail to see how the above scenario could really lead to a winning case.

To take this a bit further (and this is an honest question), is one even required to have a lawyer to take you to court? Couldn't the plaintiff just represent themselves? I'm not saying that they would have much potential for winning the case, but if a sufficiently pissed off and determined individual were able to get the case to court without a lawyer, you'd still have your own legal costs/time lost for dealing with it all.

 

[pseudoknot]

To take this a bit further (and this is an honest question), is one even required to have a lawyer to take you to court? Couldn't the plaintiff just represent themselves? I'm not saying that they would have much potential for winning the case, but if a sufficiently pissed off and determined individual were able to get the case to court without a lawyer, you'd still have your own legal costs/time lost for dealing with it all.

Yes, this is known as "pro se" or "in propria persona/in pro per" representation. It's not easy. Most commonly this is done by prisoners since they have a tremendous amount of free time, access to libraries, and motivation to use the court system for whatever.

But again, I think it's helpful when thinking about legal risks to try to educate yourself about what is LIKELY to happen, not what may happen in theory but never has.

 

[docB]

That "you can be sued for anything" is a myth, and a destructive one at that. Yes, in theory even the most absurd lawsuit can be filed. In reality most lawyers will not take a case unless it stands some chance of being successful, and again with the caveat that I'm not a lawyer, I fail to see how the above scenario could really lead to a winning case. I'd be very surprised if anyone could find a real example of a case where an EMS provider or nurse was sued for giving overly optimistic prognostic information.

I think this is a real problem because from what I've seen so far, people in the medical profession have this hysteria about lawsuits that feeds on itself. And tort reform isn't going to help if people already think they are liable for things they aren't.

Yes, this is known as "pro se" or "in propria persona/in pro per" representation. It's not easy. Most commonly this is done by prisoners since they have a tremendous amount of free time, access to libraries, and motivation to use the court system for whatever.

But again, I think it's helpful when thinking about legal risks to try to educate yourself about what is LIKELY to happen, not what may happen in theory but never has.

Good points. I do frequently mention to med students and residents that you can get sued for anything. But I consider that a way to point out the absurdity of the legal system and a reason to fight against it, not so much as a rational to make any clinical choices.

 

[Arcan57]

I would just be careful about the comment that you can give false hope if you're not a doc. It doesn't matter who you are (nurse, tech, paramedic), you should tell the truth or else it could potentially open you up [/QUOTE]

I wasn't implying anyone should give false hope just that it's a lot easier to be the consoler on the front end than it is the be the guy to deliver the bad news[/QUOTE]

Fighting that initial temptation to try and make everything ok is the first step to effectively communicating with the family. I love it when I can tell the family their loved one is going to be fine, but most of the time I can't. Even if we get the heart restarted, most of the time the person is going to die in the ICU or be in a persistent vegetative state.

Even for the septic shock patients, most of them (>60%) are going to survive but it's difficult to predict who is going to make it. Most of the time I end up saying some variation of "your loved one is very, very sick and the next 24-48 hours are crucial". That way I'm not screwing the intensivist by setting them up for a pissed off family if the patient does die.

 

[gutonc]

Most of the time I end up saying some variation of "your loved one is very, very sick and the next 24-48 hours are crucial". That way I'm not screwing the intensivist by setting them up for a pissed off family if the patient does die.

+1 on this. I give the same talk once they hit the floor or when they are headed to the ICU.

Setting your colleagues up for failure is not a good way to practice. It (and concern for my relatively fragile patient population) is why I call sign-out and recs on every patient I tell to go to the ED...even if it's 200 miles away

 

[Tornadoman84]

This has been a great discussion.

 

[Birdstrike]

That "you can be sued for anything" is a mythQUOTE]

Wrong. Hopefully you won't learn this the hard way, like most of us who've been doing this long enough have.