Death and Dying

People ask me all the time how I deal with my patients dying. Quite honsetly, I think I do pretty well with it. After all, you're looking at a girl who's father has worked in "the business" since before I was born. And by "business" I don't mean he's involved in some sort of illegal mob-type situation (though he could surely pass for a member of the IRA). He's currently the superintendent of a cemetery and crematory, but before that he started out as a gravedigger. I remember being five or six years old and going to work with him on Saturday mornings and riding my bike around the cemetery. Then when I was older and in college, I worked for him delivering cremations or doing secretery work. I'd have to read through the death certificates and plug information into the computer, and I remember being so intrigued reading the cause of death. Cardiac arrest. Cerebral hemorrhage. Respiratory Arrest.

It's funny how something that we all literally have in common, is such a sensitive subject for most people. It's that dreaded conversation you wish you never have to have with your sick patient, uttering those powerful words, "You are going to die." And then the even worse conversation you have to have with the family afterwards where you tell them that their loved one has passed. But as doctor's we're so afraid of dealing with the dying part of our job. We put so much into taking care of our patients and trying to prevent death, that admitting a patient is going to die almost feels like a failure on our parts. But I'm learning more and more that actually accepting that your patient is terminal and then making a conscious decision to help them during their process of dying is one of the most important roles you have as a physician.

I recently had a patient with severe congestive heart failure. I saw him a total of two weeks in the hospital. He was my first patient I'd round on every morning because he was my sickest patient. I'd check his labs, check his vitals, talk to his nurse about how he did overnight, and then finally go in the room to ask how he was feeling and examine him. I'd then sit down and write my note on him which always ended with my treatment plan. And each day it became harder and harder to come up with a plan, mostly because we did everything already to try to help him. I consulted all the speciatly docs, I ordered all the labs, I ran all the tests. It eventually came to the point where I just didn't know what to do anymore.

Then one morning his nurse asked me about having the palliative care team come in. And she was right. I'd done my job up to this point and it was time to change my train of thought from helping him live to helping him die. I've never worked with the palliative care team before or really knew what they did. It was quite an eye opening experience. They're job is to speak with the patient and get an idea of what they really want out of their remaining time. Whether it's to just be "comfortable" and pain free or to have more aggressive measures taken to prolong their life. And whichever way the patient decides, they try to support their wishes as best as possible. But therein lies the point. The patient chooses how to die. They have the control and we, as doctors, simply help them with that.

After the palliative care team got involved and I sat down and spoke with the family in great detail, the decision was made for him to go to hospice. The day I discharged him to go, I went into his room to examine him one last time. I remember he looked more peaceful than I have ever seen him. There was calming music playing, the lights were dimmed, he was sleeping comfortably. I wished him well and said it was pleasure taking care of him. Then his sister pulled me aside and thanked me for all I'd done. I said I wish I could have done more, but she said I'd done more for him by helping him be comfortable and die peacefully.

This experience has made me realize that we can do everything in our power to prevent someone from dying. We can pump them full of fluids, puts tubes in their chest, shock their heart, inject hundreds of drugs.... but despite all that, death is inevitable. The greatest courtesy we as physicans can bestow on our patients is to talk to them about dying. What would their wishes be? By doing heroic measures are we really improving their quality of life or just prolonging life? Every patient should be given the opportunity to die the way they chose to and to hopefully die peacefully and comfortably. And it's the doctor's job to help them get to that point.