Dealing with Death and Specialties

[Darkskies]

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I'm posting this in the medical school forum because I assume that med students and upper levels will be more knowledgeable of the subject. How do you cope with patients dying and relaying such disastrous news to the patient's family and relatives? If someone is ill-equipped emotionally to deal with this situation and at times being accountable for some of the deaths of patients in their care are there any specialties where the incidence of death is low or minimized? Thanks a lot,
Darkskies.

 

[howelljolly]

I'm posting this in the medical school forum because I assume that med students and upper levels will be more knowledgeable of the subject. How do you cope with patients dying and relaying such disastrous news to the patient's family and relatives? If someone is ill-equipped emotionally to deal with this situation and at times being accountable for some of the deaths of patients in their care are there any specialties where the incidence of death is low or minimized? Thanks a lot,
Darkskies.

How do you cope with patients dying - depends on the person... initally any combination of crying, kicking, discussing, quiet-time, debriefing, or moving on. It also depends on the circumstances, since older anticipated deaths are easier do deal with than pediatrics or accidents.

Notifying families - depends on the circumstances... expected vs. accident, cause of death, family support structure... etc. Sometimes its harder on the doc than on the family. It takes practice. You'll learn.

If you think you can't deal with death, there are specialties which have less of it. You'll have to get through med school and probably internship... and that will very likely get you to change your perspective on death. So dont worry too much.

But anyway... Death is a part of life, and different specialties have different roles in the death of patients.

Radiology... not much, but if you do interventional, you'll work on someone elses patients. Some of them will be very sick, or dying. You're providing a palliative treatment - a temporary intervention to ease their pain.

Pathology - deals with death, rather than dying patients. You wont be there while the patient dies, but you might have to deal with the family in the future, with the autopsy results. If the idea of death freaks you out....

Emergency Med, critical care, oncology - lots of death.

Neuro, PM&R, youre going to have lots of patients that are dying. You just probably wont be there to see it happen.

Internal med and all the subspecialties - you'll regularly be seeing patients that have end-stage this or that, and they will die. If you arent the primary doc, you might be able to walk away easier.

Surgery. Patients dont usually die. If the patient is very sick, surgeons wont touch them in the first place. Of course sometimes they do. When that happens, Medicine us usually on the case too.

Obviously not a complete list, but just to give you an idea. Point is that death is a part of life, and every specialty deals with it. You just need to know what exactly it is that bothers you about it, and you might be able to avoid that particular aspect in the specialty you choose.

For example, if you hate dealing with notifications and the families, avoid Emergency Med.

If you hate getting to know the patient and then having them die on you, even though the family is well prepared to handle it, avoid Oncology.

 

[Rendar5]

Well in 6 months of emergency medicine residency, I've been around for 1 death, and several essentially dead on arrivals. The DoA's do involve talking with the family which honestly is not that bad at all. I mean sure it sucks, but it's not that difficult and just needs a little bit of empathy.

The important tricks are:
1. make sure you're talking to the right person. There's nothing worse than telling someone their father died, and then realizing you're talking to someone who's dad is watching tv in the next room.
2. Ask them what they think happened/heard from relative/etc.
3. Explain to them that your father's heart was not beating. we performed cpr, gave many medications to try to get the heart to restart, (optional tell them you shocked them mulitple times if they had a shockable rhythm.
4. Ask if they have any questions.
5. Ask if they would like to see the body
6. Ask them if they'd like someplace to stay (a spare room) or have someone to talk to (e.g. hosp. chaplain).
7. Ask them if they want an autopsy
8. Go fill out all the death forms.

See it's honestly algorithmic, and after dealing with a couple deaths in med school you'll learn how you best deal with death.

The more rare dying in the ED (this is not the normal place to die in the hospital at all) while you're actively caring for them is prolly harder.

 

[Darkskies]

Thanks a lot guys.
I guess my main concern is the responsibility of it all. I don't think I fare well in dramatic/hysteric situations and don't have even the faintest idea of how to handle such situations. I get somewhat stiff when talking with strangers and superiors, especially when said stranger has a personality wholly distinct from mine. It also seems to me that trying to comfort someone I barely know about their dad dying would be at the very least awkward. Heck, I've never even had to comfort a FRIEND in any such related circumstances. I'm far from being shy around most people though but I do fear being at a loss for words or not being professional enough. I'm realizing now that my concerns seem to stem from whether I have/will have the appropriate communication skills. Does one learn all of these intangible skills throughout medical school and residency or are they just inherent(particularly loquaciousness and putting patients at ease/relaying your sense of empathy)? Additionally, how does one emotionally cope with being responsible for a patient's death? Does nearly every physician make mistakes that result in a patient's death at some point in their careers?

I know I'm really digressing but how also do you cope with residents(and when in residency, attendings) constantly berating and demeaning you? I feel like I might be overly sensitive to that and nervously make even more mistakes and ultimately feel like dirt.

Thanks so much!

 

[howelljolly]

Thanks a lot guys.
I guess my main concern is the responsibility of it all. I don't think I fare well in dramatic/hysteric situations and don't have even the faintest idea of how to handle such situations. I get somewhat stiff when talking with strangers and superiors, especially when said stranger has a personality wholly distinct from mine. It also seems to me that trying to comfort someone I barely know about their dad dying would be at the very least awkward. Heck, I've never even had to comfort a FRIEND in any such related circumstances. I'm far from being shy around most people though but I do fear being at a loss for words or not being professional enough. I'm realizing now that my concerns seem to stem from whether I have/will have the appropriate communication skills. Does one learn all of these intangible skills throughout medical school and residency or are they just inherent(particularly loquaciousness and putting patients at ease/relaying your sense of empathy)? Additionally, how does one emotionally cope with being responsible for a patient's death? Does nearly every physician make mistakes that result in a patient's death at some point in their careers?

I know I'm really digressing but how also do you cope with residents(and when in residency, attendings) constantly berating and demeaning you? I feel like I might be overly sensitive to that and nervously make even more mistakes and ultimately feel like dirt.

Thanks so much!

You can learn these skills in med school and residency if you want to. If you know going into this that youre especially concerned with this aspect, then seek out the proper training. Ask these questions to experienced docs in person. Definitely do an elective in palliative care. Do an elective in oncology. Ask for "Breaking Bad News" workshops. Keep your eyes and ears open when you are starting out and your residents and attendings are handling these situations in your presence. Make mental notes, and be able to model their behavior, until you can develop your own style. Read as much as you can - about psych and the greiving process, and personal accounts of these situations. Its very easy to skate through med school without ever learning any of this. You'll have to make the effort to pick it up.

We are NOT responsible for the death of our patients. We do what we can to prevent, delay, or reverse it. It NEVER works. It might have kinda-sorta worked. Whatever we do, the patient is still a little closer to death, if not dead as a doornail. The patient's physiology is responsible for their death. We are not.

Most doctors do not make mistakes that result in the death of patients. That would be malpractice.

That last bit.... its not like that. If you're an idiot, you'll be treated like one. Otherwise, its not that bad.

 

[GH253]

Just wondering, for those of you docs/residents who have had to inform families of deaths, how have they reacted?

 

[docB]

Just wondering, for those of you docs/residents who have had to inform families of deaths, how have they reacted?

The gamut. Quiet acceptance, sometimes relief as with an end stage cancer patient, sometimes inappropriate actions like yelling, throwing ones self on the floor, hitting things, violence, etc. You learn how to size people up and how to get an idea of how they will probably react.

 

[Darkskies]

That last bit.... its not like that. If you're an idiot, you'll be treated like one. Otherwise, its not that bad.

This is one of my main concerns. I've always been one of the slowest in labs and I feel like I make more mistakes than the average person. Academically however my grades are sufficiently above average and I do well on standardized exams. I really don't know why I make the sort of mistakes that I do and honestly it's not something you can put your finger on(just being slow or lacking common sense most of the time) but I have been dreading what the repercussions of this weakness could be. This is especially true when one is in a career field where much of the work depends on abilities other than academics that most people take for granted. I don't know if I'm just exaggerating since I haven't had much work experience but enough to see that if many mistakes are made early, it's hard to change the opinion of one's overseer even if you're improving. I will be involved in independent research this upcoming semester so hopefully at least my laboratory skills will improve.

I'm dreading passing my first two years of medical school and then bombing clinicals in 3/4th year or just performing poorly in residency which I think would be exacerbated by irate PIs.

Any advice and suggestions are much appreciated!

 

[howelljolly]

This is one of my main concerns. I've always been one of the slowest in labs and I feel like I make more mistakes than the average person. Academically however my grades are sufficiently above average and I do well on standardized exams. I really don't know why I make the sort of mistakes that I do and honestly it's not something you can put your finger on(just being slow or lacking common sense most of the time) but I have been dreading what the repercussions of this weakness could be. This is especially true when one is in a career field where much of the work depends on abilities other than academics that most people take for granted. I don't know if I'm just exaggerating since I haven't had much work experience but enough to see that if many mistakes are made early, it's hard to change the opinion of one's overseer even if you're improving. I will be involved in independent research this upcoming semester so hopefully at least my laboratory skills will improve.

I'm dreading passing my first two years of medical school and then bombing clinicals in 3/4th year or just performing poorly in residency which I think would be exacerbated by irate PIs.

Any advice and suggestions are much appreciated!

Hmmm. well a lot of medical school requires you to think on your feet, and be good at verbal question/answer stuff, and appearing confident...

How you can get better at it, Im not totally sure. I'm bad at practical OSCE or CS type exams myself, but I've managed to pass them all in med school. I suppose practice and confidence are important.

How to deal with it in med school... that depends on your personality as well. But, I'd say.... first of all, don't take things personally. Don't ever make the same mistake twice. Pay attention to what others are doing, and try to model them... and I mean pay attention to details.

Also, keep the big picture in mind. Realize that your school is someone elses workplace. So, the focus isnt on your education... its on getting some job done. Be involved and aggressive, but recognize when you should sit back so you dont slow others down. Again, its not personal... so you're more likely to get shouted at if you make someones job difficult, than if you are just not doing well academically.

hope that helps.

 

[Darkskies]

Thanks howelljolly,
Did any of your classmates falter quite a bit once the transition to third year was made? I hope I'm just being paranoid but no one's ever performed so poorly in clinicals that they had to be suspended from school right? How similar is residency to rotating in the given specialty in your 3rd/4th year of med school? I've read threads about residents being terminated and what is usually the cause for that? How do these residents even manage their lives after being terminated with such a gigantic debt load hanging over their heads?

I wish I could have some real life insight or experience in how the last two years of medical school and residency are like. Volunteering at the hospital and shadowing doctors contributes almost zilch to really knowing what sort of training is involved. It appears that that can only come with experiencing it. Unfortunately it seems that I won't find out whether I'm suited or not to medicine until at least 3rd year at which point I'll already have accumulated a mountainload of debt.

I just wanted to thank everyone again for the responses and apologize for asking so many wide and varied questions(I hope this isn't against forum rules). Your advice is truly invaluable to me since this is such a serious decision that I need to make! 🙂

 

[howelljolly]

Thanks howelljolly,
Did any of your classmates falter quite a bit once the transition to third year was made? I hope I'm just being paranoid but no one's ever performed so poorly in clinicals that they had to be suspended from school right? How similar is residency to rotating in the given specialty in your 3rd/4th year of med school? I've read threads about residents being terminated and what is usually the cause for that? How do these residents even manage their lives after being terminated with such a gigantic debt load hanging over their heads?

! 🙂

There really weren't any people that stuck out as being chronically sub-par on the wards. However, on every 3rd year rotation, there were people that needed correcting. There were people that gave really poor presentations of patients on rounds, who were usually corrected right away (in front of the team). In the OR, some students were kicked out of their case, but it doesn't go any farther than that. Some people were really bad at being quizzed on the fly (aka "pimped", a form of the Socratic Method of teaching). Once the pimping hit a wall, the student was told to read when they got home.

As far as residency - its totally different. As a resident, you are a doctor at your place of employment. You learn by experience, and your decisions are just double-checked by the Attending physician. The double-checking can occur within 5 minutes, or a day later. By the time you're a resident you've pretty much got patient presentations and a fund of knowledge down. Since its your job, and you are a doctor, you are held accountable for much more - you can be reprimanded for slacking off, not being a team player, being a lousy mentor for med students... etc. Besides, the daily feedback from your attending, you meet with the Program Director for your performance evaluation a couple times a year.

 

[Darkskies]

There really weren't any people that stuck out as being chronically sub-par on the wards. However, on every 3rd year rotation, there were people that needed correcting. There were people that gave really poor presentations of patients on rounds, who were usually corrected right away (in front of the team). In the OR, some students were kicked out of their case, but it doesn't go any farther than that. Some people were really bad at being quizzed on the fly (aka "pimped", a form of the Socratic Method of teaching). Once the pimping hit a wall, the student was told to read when they got home.

As far as residency - its totally different. As a resident, you are a doctor at your place of employment. You learn by experience, and your decisions are just double-checked by the Attending physician. The double-checking can occur within 5 minutes, or a day later. By the time you're a resident you've pretty much got patient presentations and a fund of knowledge down. Since its your job, and you are a doctor, you are held accountable for much more - you can be reprimanded for slacking off, not being a team player, being a lousy mentor for med students... etc. Besides, the daily feedback from your attending, you meet with the Program Director for your performance evaluation a couple times a year.

As far as patient presentation, what does that actually consist of and what would constitute a poor presentation? What kind of mentoring responsibilities do residents have towards med students? Are the skills necessary for all of this similar to being a good public speaker?

Are there any means to find out whether one would be successful at this prior to beginning medical school and incurring debt?

Thanks again!
Darkskies