Monday June 16, 2008
We did all we could?
“Death is a part of life,” goes the saying. It may be true, but it’s difficult to find anyone in our society willing to talk about it, much less prepare for its inevitable arrival.
For our final show of the season, we thought it fitting to stare the Angel of Death (or the Grim Reaper) in the eye...and maybe even smile defiantly in the face of it.
Hate to say it, but doctors and nurses deal with death all the time. It was harder earlier on in my career. I can remember many occasions as a resident in hospital when I became attached to my patients, only to watch them die before my eyes. People on my side of the gurney don’t like talking about death, because to us, it feels like failure.
But that’s about us. Death is first and foremost about the patient and the ones that love him or her.
One day, I received a profound lesson on the meaning of death from a patient of mine. He came to emergency quite a long time ago with chest pain. This was before clot-busting drugs were widely available. Today, those miracle drugs can stop a heart attack before it damages too much muscle. Back then, we gave nitroglycerine and did the best we could trying to keep more heart muscle from dying. Sometimes, despite the best of efforts, a massive heart attack would lead inevitably to a failed heart, and the patient would die.
That’s what happened to one of my patients. I admitted him, and took a history and a physical. His ECG showed a textbook anterior myocardial infarction – a heart attack. He was anxious and in distress, but smiling bravely in the face of great pain and fear. I did the best I could. But his heart began to fail. His pink color turned grey and his breathing became labored.
A look of great effort changed to one of resignation. I had seen other patients die of heart failure caused by a heart attack. What made this occasion different was that I knew he was going to die. An hour later, he was gone.
I remember uttering to his family one of those empty clichés we doctors say: “we did all we could.”
True, I felt sorry that I couldn’t save him. But later, I came to believe that he knew his death was near, and I did nothing to acknowledge his impending death while he was still alive… not a word, not look on my face. Perhaps I felt guilty that I had failed to save his life. But maybe, he wanted me to bear witness to his gallant struggle to fight until his last breath.
And that’s what I learned that day. His death was not about my distress. It was about his life.
We invite you to bear witness yourself. What follows are some of your stories. Perhaps you have one you’d like to share? Drop us a line at email@example.com or post an entry to this blog.
I'm a second year family medicine resident training in Victoria, BC, and I've had a couple experiences where I was with a patient at the moment of death.
The first wasn't my patient, but my dad, and it happened when I was 21, still four years before going to medical school. He had metastatic colon cancer, and had gone septic after the insertion of a feeding tube had unintentionally perforated his colon. He slipped away relatively quickly over a matter of days. At the moment of death, I, my step mother and my older sister where with him. His breaths became spaced farther apart, and then I noticed that his eyes dropped just slightly. I think that's when he died. It was incredibly peaceful, felt very "natural", and encouraged me further in my interest in working with patients.
The second was while I was doing a brief rotaton in palliative care this year. We had a patient who had end stage CHF, on comfort only care, who had basically been brought in for "support in dying". I had met his family the day before, he had never been able to communicate himself, that is how close to death he was. The following day, I came by to see how he was doing. I walked into the room and there were three people there, the patient lying on the bed, a counsellor and a volunteer. I quietly joined them at the bedside, and noticed that he took a breath. Then a long time passed, maybe 20 seconds, without a breath. I looked at the others, and they looked at me. "I think he just passed away." I listened to his heart and heard nothing. His neck occassionally twitched, as if he was attempting to swallow. But indeed no heart beat. He had passed. I can imagine nothing more peaceful. It felt satisfying to be able to describe this peaceful scene to his family when they arrived several minutes later.
Shauna Tierney, Victoria, BC
Amy Andrews here (PGY 2 Family Medicine at MSH), we've worked together in the ER.
Most of my experiences with patient bedside deaths have come from the deep, dark nights on Internal Medicine call. You remember those, don't you? ;-) Running from floor to floor (taking the stairs 'cause it's faster), arriving to respond to an urgent page out of breath and sweaty at 0330 so tired you're sick to your stomach?
This particular experience, however, occured in my second month of medical school at McMaster. My tutor, a Maternal-Fetal Medicine specialist, invited me and each of my group members to spend a 12-hour shift with her on-call for Obstetrics so that we could get a glimpse into the future and see what hospital duties were like for a day. One by one, my five groupmates took her up on the offer, generally having a great learning experience and enjoying their time on the wards.
I was the last person to sign on for a shift. I don't know why I hesitated. I'd been present for two vaginal births prior to medial school; the first, my baby brother's when I was 18 years old; the second, my best friend's first child. Both deliveries were uncomplicated and joyous.
In a nutshell, the shift still stands out in my memory as one of the saddest things I've ever encountered (and I've experienced many subsequent patient deaths, lived/worked in South Africa doing AIDS work in 1999/2000 and made the agonizing decision to discontinue the life-support of my own father following a traumatic brain injury). During the shift, a young Mom came in at 23 weeks gestation with severe pre-eclampsia. After much discussion and concern, the decision was made to deliver the child by c-section in order to preserve the mother's life and to give the babe at a least a slim chance of survival. So, I scrubbed in with the attending and the resident and we performed the c-section.
To tell you the truth, Brian, I didn't even stop to think that the baby might not make it. In my limited experience, babies were born healthy and everyone was happy afterwards. I was totally unprepared for what happened.
The baby that emerged from the uterus was the size of my two small fists put together. It didn't cry. It didn't move. My preceptor handed the babe to the waiting pediatrician and went back to work on the Mom, working to close the surgical site. I was in charge of retracting, but I couldn't keep my eyes off the neo-natal resus team. I felt calm. They were going to give the baby oxygen, right? I waited expectantly, praying for the little body in front of me. Then, I heard words I didn't understand at the time . . . "intubate" . . . "epinephrine" . . .
1 minute: nothing. I started to get worried.
5 minutes: nothing. I'm crying by this time. Tears are streaming down my face behind my eye shield and face mask.
6 minutes: nothing. My nose is starting to run, but I'm sterile and still retracting. I have to hold it together and not touch my face.
8 minutes: nothing. No cries. No squirms. Just hushed personnel rushing around. My this time, I'm silently gasping for air, almost hysterical. My face is soaked with tears and snot. I'm still retracting. Why isn't that baby coming to? Babies aren't supposed to die!
At the 10 minute mark, the NICU staff stands back from the warmer and shakes her head. All resus activity stops. I'm looking wildly around the room. Still sterile. Still retracting the patient's flesh from the repair the resident is doing. My eyes meet the eyes of a nurse across the room. She shakes her head at me an looks at the floor. I feel like I'm going to throw up. I want to wail. I want to scream.
All of a sudden, I think, "Who do you think you are? You're going to be a doctor, for pete's sake. Get a grip. It's not about you. Think about the child's parents!"
The parents. I'd forgotten all about them. They were there, too. Hidden behind the curtain separating the patient's upper body from her sterile lower half; her husband sitting silently beside her. Someone brings the still, little bundle to him. He knows what has happened and so does his wife. They were warned about this possibility and likely hoped that it wouldn't happen. They'd hoped for a miracle. Their priest was even in the waiting room with the rest of the family.
On the other side of the curtain, still sterile, still retracting, I hear them softly weeping. They say good-bye to their baby . . . girl. The new father soon stands up and takes the babe from the room for the priest to baptise. Once he leaves, the room is quiet and still with the exception of the final repairs to the mother's abdomen. As she finishes the surgery, my preceptor begins to speak to the mother on the other side of the curtain in a soft voice. ". . . I know it seems like a terrible injustice to have to endure the rest of the surgery after what has happened. We're working as fast as we can to ensure that you can go and be with your family as soon as possible." The new mother is silent.
We finish the surgery and prepare to transfer the patient to the post-op ward. I refuse to take off my eye shield and mask until the patient is wheeled out of the room. I just know that, as soon as they come off, I'm going to fall apart. "Just keep it together for a few more seconds . . . just until the Mom's out of the room. She's got enough to worry about. She doesn't need the medical student blubbering all over her."
The moment the door closes behind the patient, I rip off my gloves, gown and masks and collapse in the arms of a nearby nurse. She gives me a big hug, ignoring that I'm covered in snot and tears, and tells me it's going to be "O.K." I nod, sniffing and snorting, and ask for directions to the closest bathroom. Finally there, I sit on the counter and cry. I cry for the baby. I cry for the parents. I cry because I'm crying.
Back at the nurses station, I help put together a little memory box for the mother. A little pink nightie, little pink booties, a piece of cardstock for hand and footprints should the parents wish them to be taken. A nurse tells me about how most parents who lose an infant like to have some memories of the child. "It's not like it used to be, you know, when parents were told to 'forget and get over it'." I nod in understanding.
It took me over 2 years to fully get over that experience. It was several months before I stopped dreaming about the scene in the OR when I finally realized that the baby was dead. It took a few more months before I could think about the experience without wanting to cry.
I've now reached the point where I've made my peace with the experience and been able to incorporate it into my growing-but-never-to-be-sufficient understanding of life, death and medicine.
I'm a neonatal nurse. We are most often beside the patient as they are held by their parents when they die in our NICU. Sometimes, the families cannot get in on time, or they choose, for whatever reason, to not be there. In these cases we are privileged to hold these small humans as they pass. Not the most fun job but one of the most important. I remember a shift where the nurse held a small premature infant and an anecephalic infant as they both were dying - for hours.
We never let a baby die alone or unsnuggled. Cheers and I love your show
I have been present at their bedside when both of my parents died. Both took deep last breaths and died. Their journey to those last breathes, where quite different.
My father had been diagnosed with leukemia and had spent June to November slowly getting weaker and smaller. He had time to enjoy the visits of his sisters and brother, a cousin, many friends and was present to mark a few other celebrations before caring for him at home became too much for my mother and he was moved to palliative care. We took turns sitting with him for about a week, talking when he wanted to and listening to the radio from time to time. He slept a great deal, but was always alert. He drifted into a coma at the end of the week and died two days later with my mother holding his hand and my watching his strong
My mother died in a very different way. A phone call from the hospital in my sister's home town informed me that there had been a fire at my sister's home and mom and my sister were injured. The grandsons were fine. The doctors had decided to send my mother down to Sunnybrook Hospital in Toronto - could I meet the ambulance at the trauma unit? No warning, no time to think. Throw a change of clothes in a bag, phone mom's minister and a good friend in Toronto to look after the dog when I knew more about the accident. Mom had been visiting my sister and doing what she loved best, helping her family - how could she be
on her way to a burn unit?
When I arrived I was told that mom had just arrived and was being assessed - could I wait in the family room - it would be about an hour? I said that I would walk the dog and move the car and return. Midnight is the only time there is any choice in parking at a hospital. Walked the dog, cleared my head and bedded the dog down in the backseat for the remainder of what was left of the night.
Upon my return to the unit there was still no sign of the doctor, so I waited in the dimly lit room and watch the lights outside. When the doctor (so young) came in he told me that Mom had 2nd and 3rd degree burns to over 50% of her body and that given her age (80), he felt that there was little that could be done to see her to recovery. She had been heavily medicated and was not suffering, so he could keep her on life support but did not recommend it. I remember looking at him and wondering how many of these conversations this young man had had, as he looked a little worried that I would insist on heroic measures.
It was then, although very much in shock, I appreciated the very frank conversations that my mother had had with both my sister and myself about her wishes and attitudes towards death. It would be an insult to her beliefs to prolong her life for my selfish reasons to hang on to her. I asked him how long he thought that she would last when the respirator was removed and the medication, apart from the morphine, was discontinued? He thought a few hours. So I agreed.
They moved her to a quiet room where I got my first good look at her. Her face had not been burned. I sat beside her full of questions and no way to get any answers - how did the fire start? what was she doing? There wasn't much I could do except watch her breath in and out
for the rest of the night.
She took her last breath as the nurses were changing shifts. She died the day before the 7th anniversary of my father's death.
I have been present at other deaths, but not at their bedsides. Strange how life and death work -isn't it?