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Tuesday Jul 07, 2015

Dealing With Death: Why Helping Patients' Families Helps Me

I remember more details about my first patient who died than I do about the movie I saw last week.  

The death of a patient has an effect on me regardless of how the person dies, whether it is unexpected or anticipated. The first time it happened, I was a third-year medical student. I admitted a patient in the afternoon, explained the results of her echocardiogram and lab work to her mother and husband, and then I went home for the night.

I walked to her hospital room the next morning, but a different patient was in it. I went to the nurses' station, but no one seemed to know who I was talking about. It didn't occur to me that she had passed away. These were the days of paper charts, so I couldn’t log in and search by her name. Eventually, I found one of the residents who carried around nifty patient census lists, and I asked him what room my patient was in (because clearly she had just changed rooms).  

The next thing that happened is what I am still grateful for. He stopped writing notes, actually put down his pen and sat down to tell me that the patient had died during the night. Most important was how he said it: "Oh, I’m sorry, but she passed away." He easily could have just kept working and -- without eye contact or compassion -- simply said, "She died, so go find a new patient to present in rounds." But he didn’t.

The resident then explained what happened -- that despite aggressive diuresis, she went into decompensated heart failure. He had personally been called to run the first code, then talked to the patient's family after the second and final code, which occurred in the ICU. I remember the patient's name, her age, her family’s faces, even her pajamas. And I remember learning a lot about right-sided heart failure after that because I think that was all I read about for the next two days.  

Even though I wasn’t involved in running the codes or having the difficult conversations with her family, I learned so much about dealing with death through this patient. I needed the news to be broken to me gently, and that resident knew that. After that experience, it was months before I was involved in the care of anyone else who passed away. But when it did happen, I immediately recalled the respect and compassion that stressed, post-call resident had shown for that patient. In fact, I have remembered it each time since.  

Given that residency has a lot of hospital-based training, we are exposed to extremely sick patients, ICU care where the mortality rates are the highest and, therefore, death. In medical school and residency, we learn about delivering bad news. We even practice it as students with standardized patients. But we don’t learn how to handle our own grief and emotions associated with losing a patient. I know it's probably in the curriculum somewhere, but it's likely theoretical and is presented early on, before you are really immersed in clinical care. I did a literature search for doctors dealing with the death of patients and found nothing. I wanted a book or something to tell me how I was supposed to process these experiences. How do you tell a family their loved one just died and then go home to your own family and act like nothing out of the ordinary happened that day? What I came to realize is, you don’t.

We are human beings, and we went into medicine -- especially those of us in family medicine -- because we value relationships. We thrive on getting to know patients; their families; and their priorities, goals and weaknesses. There aren’t any resources that I found helpful, personally, because I had unique connections with each patient I have lost, and their deaths had different effects on me.  

The only constant I have found in each of these experiences is that the degree of comfort I am able to provide the family seems to make the patient’s death less traumatic for me as their physician. So that is what I share with residents and students -- that they will be changed by these experiences. But the more we commit ourselves to the process and the more compassion we are able to show everyone involved, the less wounded we feel.

I have not always embodied this. I do recall telling an intern -- who lost a patient she had just admitted (and met) a couple of hours before -- that, "Really, this is nothing, wait until you have taken care of them for years and know their entire family. Now that's a loss that hurts." But the reality is that they all hurt because patients are why we do what we do. I may have been the one to deliver the terrible news to that patient’s son, but the intern was the one who had looked into her eyes and made a connection. And in my office now, I am often the first to find out if a patient dies, and everyone in the office is affected by that news and the way I deliver it.

As physicians, I think we hear "thank you" more often than people working in a lot of other professions. And sometimes they are huge, heavy thank yous from patients or families who genuinely feel we saved a life or changed the quality of a life. But for me, the ultimate thank you was being mentioned in one patient's obituary. I wasn’t there when that patient died, but I had spent hours on the phone, in the hospital room, and in support of the patient and his family throughout his battle with leukemia.

That patient didn’t pronounce my name correctly, but everyone knew he was my patient. A colleague let me know within minutes of his passing, and I cried as if I’d lost a best friend. I wish I could have been there for the family and patient at the end, but I also realized that the work I did to prepare them was just as valuable and that they knew I cared.  

We gain trust as family physicians in many ways, especially in rural areas where we see generations of relatives. One patient’s experience with me can extend rather far. Comforting a patient and respecting  that patient's wishes as he or she transitions to end-of-life care is just as important as treating one of the family’s new babies.

I have a lot of homebound patients, some of them healthy but with limited mobility, others terminal with no plan to leave their homes again -- especially not for the hospital. One of the most powerful things we can do as physicians is to respect those patients and reassure worried family members that they are actually doing the right thing by not forcing the patient to go to the ER every time he or she has a complaint. It's worth the extra effort -- arranging for mobile imaging, home health care or home visits, or even calling home hospice -- to make sure the patient’s wishes are honored in a way that helps the family feel secure and supported by their physician. Family members need reassurance at the end of life just as they do when you are simply explaining supportive treatment for a viral upper respiratory infection.

Everything will be OK, even if it means losing someone because sometimes, letting that person go is the right thing to do.   

Kimberly Becher, M.D., graduated from Marshall University's family medicine residency in 2014 and practices at a rural federally qualified health center in Clay County, W.Va

Posted at 01:23PM Jul 07, 2015 by Kimberly Becher, M.D.

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