How will you handle death?

[meatie]

I'm sitting in the ED on a particularly slow Saturday night reading Allo's "Worst Moments In Med School" Thread and the topic of seeing your first patient death was mentioned. It made me kind of curious to hear your guys' opinions, concerns, or thoughts on how you think you will handle traumatic circumstances, violent deaths, or emotionally charged life-or-death scenarios.

Personal background:

Working in a trauma center I have seen a fair amount of people arrive either DOA or pass away in the hospital. It's always a poignantly sad thing to observe and through all the painful things I have witnessed I am grateful I have been able to see such a raw perspective of medicine.

One outstandingly rough day, we had a man arrive by rescue, comatose, after having fell backwards while choking on a large portion of his dinner. After removing a large, lego-block sized piece of meat blocking his airway, his head CT showed 4 different types of bleeding in his brain. It was unclear if this guy would ever wake up. His wife arrived several minutes later. She was in tears and absolutely inconsolable. She wondered how things could have progressed from a quiet night's dinner at home to a fitful night in the ER.

It set the tone for the rest of the night. Within 4-5 hours we had seen: a STEMI, a cocaine-meth-alcohol user who kicked my doctor in the face and had to be arrested by PD, a rape case, an angry Russian couple furious (and I mean yelling in the hallway with security called furious) that our ER was unable to provide chronic, long-term care options, a urosepsis patient, and just now, this man who had significant bleeding in his brain while choking on his dinner and had been without oxygen for an unknown period of time.

Once the train arrives, it never stops. The next case was not the most medically interesting, but it's the one that pushed me to make this thread. A man comes in after having collapsed at home following a couple drinks. He had gone into cardiac arrest and was not responding to EMS treatment. He arrives to the ED unresponsive and cyanotic. After coding the guy for an extra 30 minutes, he's pronounced. The trauma team slowly disperses as lines are pulled out and gowns are thrown in the trash. The floor's a mess. Wrappers are strewn all over the room. There's a heavy stench of perspiration mixed with the smell that comes from the EMS's equipment and clothing after so much exposure. The previously buzzing chatter and hollering in the trauma room falls silent following the pronouncement. Business as usual. As my doctor un-gloved and gathered his things, I took one last roundabout past the patient's head. The high-acuity cases and Code Trauma's were always the most exciting to me. The man's head was tilted up and to the right. His eyes were rolled back and lifeless. No shine or glimmer could be seen. He was gone. His weathered, brown face showed an unsettling shade of blue underneath. His lips were slightly agape and looking past his chin was the incredible mound of flesh that was his abdomen. I walked back to the documentation room with my doc asking him about why some people would begin posturing before death.

The doc has the pleasure of informing the now gathered family of the patient's demise. I don't think I can ever forget the reaction of the family members when my physician broke the news. The wife and daughter were both bright-eyed and pretty. They were cordial to nursing staff coming in and I remember walking by the family consultation room prior to breaking the news and seeing the daughter smiling while speaking with some of the techs. She had no idea what was about to happen...

A student at the local college near the hospital, she was here with her two brothers. She was wearing her school's sweater and I figured she was probably around my age, if not a little younger. When we entered the consultation room to let them know what had happened, both of her brothers were wearing sunglasses. It was past midnight, but I knew exactly what they were for. Could I really blame them?

The doc opened with a question about any past cardiac history or precipitating complaints the guy may have made prior to coming to the ER tonight. The family answers surely that, "No, not that we know of," and asks the obvious question, "Is.. Is he okay? Is he alive?" There's a dead hang in the air. It's only for a split second, but in that split second you can already feel the ****storm that's barreling their way. I tensed up a little bit, but kept expression stone cold.

"I'm sorry, but Mr. X passed away. We did our best..."

Trying to put their response in to words is difficult. The wife and daughter immediately and simultaneously shrieked out, "Oh my GOD!" and began bouncing in their chairs up and down while screaming and crying. The two sons, with their black shades, slumped in their chairs a little further and averted their gaze without much protest. I took the moment to muse on how uncannily similar these family members were reacting. The shared behaviors of family were always a little interesting to note. Before too long, I snapped back to what was going on in front of me.

We walked out quickly and left the RN chaperone to deal with the aftermath.


Question:

Is this something that you are concerned about when entering medical school? How do you think you will handle watching someone die under your care? Do you feel anything has prepared you to handle this kind of experience?

More importantly, I want to hear from people who are NOT particularly worried about dealing with these situations. Why do you feel this way? What is your reasoning? Do you think there were experiences in your life that made you better prepared to handle this particular challenge of medical school or have you always felt this way?

I would also love to hear from current medical students, faculty, or attendings and how they dealt with this issue as they progressed through training.

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[Hospitalized]

Not particularly worried because I'm not a very emotional person in general. I've been condition by the death of a brother, my grandmother, uncle, and diagnosis of terminal cancer in another uncle. I think my brother was the turning point for me, it changed my mindset to not take anything for granted in this unpredictable world. Life is not fair, and medicine takes a raw perspective on that. The happiest, healthiest, most compliant patient's can get the worst dx.

Just the other day as a scribe I saw a kindergarten teacher's CT head with a suprasellar mass that was likely inoperable. Completely healthy person with the brightest outlook just happened to get a headache one day.

Death is going to be difficult to deal with it. It's an aspect of life, not just medicine.

 

[noolsy]

Half-responding to @Hospitalized, I think death is an aspect of medicine, too. I think confronting death will always be really tough (a small part of me hopes I'll never be numb to that), but I've done as much as I can to prepare for it. If I'm not "too worried," it's because coming to terms with death and loss was an important factor in my decision to pursue medicine. Obviously, as a doctor, I will hopefully help postpone that as long as possible, but after a certain point, I think there are some things worse than dying.

The biggest help has been volunteering with hospice. I just visit/chat/sit with patients in-house for the most part -- and not as often with the "actively dying" -- but the experience has been enough to help me see that death is not necessarily where medicine fails. It's where health science fails, maybe, if we assume the goal of health science is to eliminate death altogether; medicine is unique, though, in that (esp. hospice) physicians stay with a person until their final breath -- i.e. medicine continues to help as much as it can even when there is no cure.

Though my perspective is admittedly very limited (pre-med, what do I know!), medicine seems to me more about honoring life than preserving it. Usually, these two goals are in agreement with each other, but their distinction becomes very difficult when, sometimes, they don't align since our impulse often favors preservation. (Not talking about euthanasia here -- I'm referring to DNRs, for example, or opting for hospice rather than terribly invasive/debilitating procedures.)

 

[DoctorLacrosse]

Like you, I have had quite a bit of experience with death over my last few years with different clinical jobs. I'm currently an ER tech, and not only am I heavily involved in all the codes/traumas, but it is also my job to wrap the bodies afterwards and help transport them to the morgue. Needless to say I am very emotionally adjusted to it already.

It always surprises me to see how hard a lot of medical students take it when we lose someone (I work at a big teaching hospital). I recall my first death, but i don't remember it really bothering me too much because it is kind of expected and it comes with the territory. Seeing the family is pretty much always the worst part in that regard, because you truly feel for them. I can actually recall two separate instances of medical students on their first ER rotation crying on the curb outside, one of which told me "I really regret medical school sometimes" while in tears. it's unfortunate, but hopefully the majority adjust to it over time.

I have been found saying similar things before, but I feel as though there should either be some kind of real clinical requirement as a pre-med, or much more experience should be required other than handing out blankets in a hospital for 150 hours. everyone kind of assumes they can handle the negatives of the field, but it is hard to know for sure without getting some kind of real taste of it. I guess it would be difficult to do and I'm sure many would disagree, which is also fine, but just my opinion.

 

[deleted407021]

I've yet to have too much direct contact with death. None in my family since I was very little, but certainly some within my circle of friends and acquaintances. Death doesn't generally bother me. We're just animals that will one day stop working for one reason or another and that's it, we're gone. It's the plight of the families, however, that gets to me. I get sad for them and the sadness they are enduring.

I've seen doctors on Trauma: Life in the ER break such news to families and most are relatively withdrawn and unemotional while others are clearly holding back tears in the midst of these families appearing to disintegrate with grief. Maybe I'll always be in that latter group or maybe I'll change somewhere along the way, but I think a little tear in the eye can convey - even if unknowingly - a bit of compassion regarding the situation, regardless of if that eye belongs to a doctor, a friend or a stranger.

I don't really find end of life or hospice care all that sad. It's sad, but not in the same way as sudden death and loss. There's a quite lead up and people can be prepared. When people can take control of their own deaths there's more of a calmness over the situation. The finality of death seems more frightening if you can't see it coming which is perhaps the reason we sometimes fear it.

 

[clairephillips]

I know you didn't want to hear from those who think they'll have a problem with death, which I will, but I want to agree about the experience of being a hospice volunteer.
Before beginning this journey, I was unsure if I could handle being a doctor because of how sad death makes me. In order to see if I could and prepare myself, I volunteered with hospice. The experience has been powerful, rich, and extraordinarily meaningful.
Some of the patients are still lucid enough to be communicative and I have gotten very close to a few. I have both sobbed uncontrollably in my car after saying goodbye to patients and laughed so hard I was crying with one particularly gregarious patient. What I've found is that the suffering at the end sometimes seems like so much I know they are ready to no longer be in pain and I too have hoped they are not in that pain for too long before transitioning. I have also seen the amount of life still inside some dying patients who relish the sun on their skin, smoking a cigarette, the taste of good coffee or a cold Coke in the Texas heat, a warm soft sweatshirt, an old movie from their youth. That is what I want to preserve in my patients, the time they can experience those good things. I've learned that life is not about the moments that the machine is still functioning, but about the good experiences that mean a great deal. When I'm a doctor, the end of those things is what I will mourn.

 

[Gurby]

I've seen plenty of death and it almost never bothers me. Seeing the family gets me every time, though. I don't think you ever would/should become numb to that.

I will say, though, that it doesn't cause me "personal difficulty". I don't get depressed or lose sleep. Usually these are actually positive experiences for me. It's heartbreaking to see people go through the loss of a loved one, but for me it is gratifying to be so close to the cycle of life/death and can really give back some perspective on life that I may have lost as a result of being too caught up with studying, work, etc.

 

[Boolean]

First was terrible. I had to work another 3 hours of volunteering afterwards. I got in my car after and just cried. Those that have happened after are always incredibly unpleasant, but I know that everyone did everything they could.