Monday, April 18th, 2011
One cold Dunedin afternoon, halfway through third year when life still revolved around lectures and labs, there was a buzz on campus. It was the day we would pick up our brand new stethoscopes. What a journey it had been: What colour should I get, classic black or rebel pink? What brand should I get, Littmann II, or III; will it really make a difference with hearing those murmurs? And most important of all, should I shell out the extra hundy to get a proper engraving? Too ponsy, or was it the epitome of professional?
The week I took home my brand new burgundy Littmann II stethoscope (sans engraving in the end), I joked with friends and family that the only thing I could tell you was whether or not you were still alive. Ha, ha, hahaha… Funny how those words echoed in my mind three years later as I stood alone over a patient whose life — spirit — had just left their body. Just me and a human being who was now quite possibly 21 grams lighter.
During my third and fourth week of work, half of my team’s patients were pre-terminal. My hospital having no specific Oncology Ward meant these patients remained under General Medicine for palliative care and/or supportive management. And in the days leading up to Christmas, I found myself a death-certifying machine.
Certifying death is one of the jobs that will fall to you as a house surgeon. The first one you do will undoubtedly freak the shit out of you. And it will feel like one of the most unnatural things you have ever done. Two nurses witnessed my response and let me tell you now, it was not my finest moment.
At the start of my second week a patient was admitted to my team with sepsis. We weren’t sure where the source of infection was but they had positive blood cultures and the outlook was not good. Their partner was fully prepared as the patient had been living on borrowed time. We continued to give supportive management and for a few days they seemed to be hanging in there. On what turned out to be the morning of their death, the patient became dangerously hyperkalaemic. When I saw these blood test results I urgently started treatment to bring the potassium down. Five minutes later I got a call from my registrar who had talked this over with our consultant and the decision was made to withdraw all active treatment. As my registrar was away at Outpatients Clinic it was up to me to notify the partner.
How many lectures had I sat through on the subject of death and dying? How many times had I painfully watched a film of myself (with the rest of my tutorial group) ‘breaking bad news’ to an actor? How many times had I watched — with awe — incredibly artful, compassionate consultants tell someone that their loved one was dying? Yet nothing could have prepared me for the moment I had to speak those words myself. And I choked. Bad. I called the partner on the phone, told them the situation had changed, that we would not be treating this high potassium and with that, the patient would… [choke]… [pause]… not… [pause]… that they would not… that they… [awkward silence]… would not have much time left.
DYING. I couldn’t do it. I couldn’t say it. I couldn’t get the words out through my lips. Who are we to decide whether someone lived or died? How could I sentence this person to death? Or at least that’s what it felt like in that moment. It felt like I was making the decision.
But I wasn’t.
The patient was already dying. And the truth was, there was nothing more we could do.
It is the hardest message one human being has to deliver to another. As doctors there is no escaping the fact that it often falls on us to be That Messenger.
My choking which at the time felt like yet another failure on my part as a doctor only added insult to injury. And yes, I found myself crying in the staff bathroom yet again.
Less than an hour later, as I sat typing up a discharge summary, one of the nurses came to me and said, “Anna, I think the patient has passed away. You need to come certify.”
Having no idea what to expect I followed the nurse to the room. The patient was lying on the bed and there was no doubt that they were gone. For two days they had been grunting for breath, struggling to stay alive. And now all that Noise was replaced with, Silence. Upon entering the room, with two nurses standing behind me, I literally freaked out. The only dead bodies I had seen was in a dissection lab, solid, unreal cadavers reeking of formalin. I freaked out, exclaiming I had no idea what to do. Way to stay calm under pressure, Doctor Choi. But I wasn’t a doctor. Or at least, I didn’t feel like one. I felt like a med student posing as a doctor, waiting for someone to call me out on the lie I was living. What qualified me to declare this person… dead??! How could I be sure??!! Maybe they were still alive?!! These thoughts ran through my mind as I left the room.
Fortunately I found another house surgeon working nearby and told her what had just happened. She was incredibly supportive and thankfully had taken notes during the ‘Certifying Death’ lecture we had during Orientation (which, on retrospect, I probably should have paid more attention to). She reassured me that everything would be okay, that I should give it about ten more minutes, then head back in and be the doctor that I was.
It’s so unnatural, placing your stethoscope on the chest of a dead body. It’s so scary, lifting their eyelids to stare directly into hugely dilated, hazy-white pupils that seem to extend into a sea of infinity, like as if the entire universe was suddenly contained inside this person’s eyes. It’s so strange, feeling for a pulse you know you won’t feel, listening for breath sounds you know you won’t hear.
“House Officer Note
ATSP re- certification of death
Paged by nursing staff at 1400hrs
Patient unresponsive
No pulse for 1minute
No breath sounds for 1minute
No heart sounds for 1minute
Pupils fixed and dilated
Likely time of death, 1400hrs
May they rest in peace.”
In the lead up to Christmas I felt like the Grim Reaper. There is a look that patients get in their eyes before they pass away. A look of peaceful resignation. A look which I got oh so familiar with. How does someone stay optimistic when everyday you are hit with the reality that actually, patients die. The reply I received from a member of the Palliative Care Team when I asked that question was a tirade on the naturality of death, how death was a part of life and how as a health professional I had to accept that. I’m not sure of their intention but they made me feel like a school child being berated on something as simple as the importance of good manners. Of course I know and accept that death is a part of life. But you know what? When you watch your patients die one after another it doesn’t make it any easier.
It sucks.
It’s sad, it hurts, and it sucks.
And you know what else? You’re allowed to feel sad. You’re allowed to hurt. It’s okay for it to suck. Because it should.
On Christmas Eve I had certified a patient whose family reminded me too much of my own. I cried when I found out on arriving to the ward that morning. I fought tears as I ran into the family in the corridors. I cried as I sat in the Bereavement Centre typing up the Discharge Summary — “Discharged: To Mortuary.” And I cried on Motorway 20 driving home.
The worst part was that it was Christmas Eve and I felt completely alone in my sadness. Who could I talk to who could relate? Despite being surrounded by loving, supportive friends and family and colleagues, I felt completely alone in my sadness.
And alone I continued to feel…
