Does Dealing With Death Get Easier?

Sara Cohen, MD

Disclosures

October 31, 2012

Question

What was it like the first time you experienced death in a hospital setting? Does dealing with loss get any easier?

Response from Sara Cohen, MD
Fellow, Department of Physical Medicine and Rehabilitation, Harvard University; Fellow, Department of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, Massachusetts

It's virtually guaranteed that every doctor will experience the loss of a patient at some point during medical training. For some medical students, this can be incredibly difficult. However, you might be surprised that your first time may not be as emotionally difficult as you anticipated.

I experienced my first patient death early in my third year of medical school. On the first day of my medicine rotation, I was assigned a female patient with Cushing syndrome. The reason for her hospitalization escapes me, but as a young medical student, I was fascinated by the way she exemplified the characteristics of the disease -- from her "moon facies" to her hirsutism to her central obesity -- that I had learned about during my endocrinology class. Unfortunately, she was too tired to have much to say, but I figured I'd get to know her over the coming month.

Except that when I went to find her chart the next morning, a nurse told me that she had died of a pulmonary embolism.

I stood at the nurse's station, realizing that this was supposed to be a meaningful moment, yet I didn't feel anything. I had shed more tears at the movie theater. How could the passing of a real human being feel less sad to me than a fictional death in a film? Although I felt guilty, I later learned that many of my fellow medical students had similar experiences.

I was fortunate in that I didn't encounter many deaths during medical school, and certainly no deaths of patients with whom I'd bonded. Early in my intern year, I was called to pronounce a patient dead for the first time. I had never met the person before, and when I entered her room, she was so yellow that her skin was nearly glowing. I wasn't sure what to do, so I followed the nurse's instructions: "Now listen to her heart. You're not going to hear anything." I filled out her discharge paperwork, and as the reason for discharge, I checked off "death." After finishing the stack of paperwork, I went back to admitting new patients as if nothing had happened.

It wasn't until the ICU rotation of my intern year that I started to lose patients I knew well. The first death on this rotation was that of a woman in her 60s, who I will call Mrs. Lin. Although she was relatively young, she had a lot of comorbidities and was in the ICU with a bad infection. She was a sweet lady who was eager to leave the hospital to see her grandchildren again. She always seemed depressed about her medical problems, however, which had plagued her for years. Eventually she was medically cleared to go home but was very deconditioned.

I spent a lot of time talking with Mrs. Lin's devoted husband, who asked me to call him John. I helped arrange nursing care for Mrs. Lin at home, and we set up myriad appointments for after her discharge. Prior to my day off, I remember Mrs. Lin smiling at the idea of going home and seeing her grandchildren again.

When I returned to work 2 days later, Mrs. Lin was not doing well. She had a new infection, was in respiratory distress but not intubated, and was clearly headed toward septic shock. Even with medications, we were not able to maintain her blood pressure. I was on call that night, and at around midnight, I went into the conference room with John and we discussed his wife's situation. We talked about how much she had struggled with her health problems, and we made the decision to make her DNR/DNI. He said he felt at peace with the decision.

The next day, Mrs. Lin didn't look any better and we were holding her blood pressure very tenuously. After a meeting with the attending physician, John made the decision to give her comfort care only. Right after the meeting, John came over to me and hugged me, thanking me for everything I had done for his wife.

I looked into Mrs. Lin's room during the last moments of her life. Family members, wearing yellow gowns for infection precautions, surrounded her. John was holding her, stroking her face, and speaking softly to her. I heard him say, "You're free, Mary."

I ran to the bathroom to cry because I didn't want anyone to see. In retrospect, I wish that I had allowed the Lin family to see how much her death had touched me, rather than feeling ashamed of my emotions.

Later that morning, I sat with my senior resident, going over our sign-out sheet. She noticed my eyes were a little swollen and asked me what was wrong. When I admitted I was crying over Mrs. Lin, she looked perplexed for a minute, then finally said, "Oh. I guess that was pretty sad." Later she crossed Mrs. Lin off our list of patients and drew a line in pencil through 2 more patients who she thought would probably die either later that day or the next.

I learned from watching my senior colleagues that no matter what, death gets easier. I rarely saw senior residents show emotion over the death of patients, and attending physicians seemed even more stoic. It would be impossible for an ICU attending to function if he felt the same degree of emotion over all patient deaths that I felt over Mrs. Lin's. Much like learning how to place an IV or suture a laceration, part of medical training is the natural process of learning to cope with the inevitable loss of patients.

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