It was my second day rotating through the palliative care service at an Atlanta hospital. The first day, I rounded on the floor with the nurse practitioner. The patients were all ill, but none were in the last stages of death like I had expected. On this day, I worked with the physician on the inpatient hospice unit of the hospital. These patients were taking their final breaths; their care was about providing comfort and support during the end of their life.
The physician and I discussed the first patient we would be seeing that day: a man in his 50s who presented with necrotizing fasciitis of the neck. The otolaryngologists had debrided his neck, but the infection had already spread to his respiratory tract. There was no hope of him surviving. On the hospice unit, providers worked to control his pain and provide daily wound care. When the physician and I walked into the patient’s room, two nurses were changing his neck dressing. The open wound immediately took me aback; muscle, bone and nerve were exposed from his neck and extending to his face. I had never seen anything like it. I couldn’t imagine seeing my loved one’s face completely disfigured.
Soon after our arrival to the room we heard the patient take a breath, and I recognized the sound of a “death rattle”. The physician explained to me that the death rattle occurs when saliva and secretions accumulate in the back of a person’s throat when the patient has lost the ability to swallow. We discussed drugs like atropine and scopolamine that can be used to dry up some of those secretions. The physician began to explain what happens to patients in the last stages of life. He said the patient might be cold. When I reached my hand to touch the patient and assess his temperature, it felt like blood was not coursing through his body. This scared me; I knew he would not be with us much longer.
As the physician and I discussed what to expect when a patient is dying, we noticed that we had not heard the death rattle since first entering the room. I realized that the patient may have passed away while we were talking. The physician took out his stethoscope and listened for a heartbeat. It was not present. I was in shock.
I had never been in the presence of a patient at the very last moment of a life. I had never seen a man take his last breath. I did not know how to react. Do I cry? Do I pray? Do I pretend like this is an everyday occurrence for me? When I took a moment to observe what was going on around me, I noticed that the nurses and physician were having normal conversations. This was an everyday occurrence for them, and I could tell. It was not that they were disrespectful of the patient, but it seemed like death to them was just another part of life. I had not yet gotten that comfortable with death, and I felt like I owed the patient something for watching him die.
The only other time I had been in the presence of death was on trauma call in the hospital. The patient was most likely dead when he arrived; the chest compressions we did were a futile attempt at saving his life. I remember the nonchalant attitude of the team after his death, and I even remember jokes and laughs being exchanged seconds after time of death was called. This was disturbing to me, but I never spoke of my feelings to the team.
This second time I did not feel disturbed, just uncomfortable that nothing changed when we pronounced this patient dead. The two nurses continued their conversation. The physician continued to teach me. I stopped listening and reflected on this man’s life. I thought: “What did he do for a living? Where is his family? Did he believe in God? Is his spirit with us in this room?” Then I began to pray quietly to myself. I felt tears pooling around my eyes and at that moment I focused my attention back to what was going on around me. I nodded my head at the physician’s comments about end-of-life care; I smiled at the nurses.
We left the room to see other patients. The physician finished writing orders. Our work was done for the time being. As we walked down the hallway to see consult patients in the inpatient unit of the hospital, the attending did something I never expected: he asked me how I was feeling about the death we had just witnessed. He asked if I had ever been in that situation and what my thoughts were. I felt my eyes begin to swell with tears again, but I did not cry. I explained to the physician that it was always a bit disconcerting to me how medical professionals treated death in such a casual manner. I talked about my experience on trauma call. I told him that I was troubled by the patient’s death, and that it surprised me that no one else in the room seemed sad or concerned that they had just observed a dying man take his last breath.
The physician did not judge me. He listened to me and he validated my feelings. He said it was okay to feel that way, that nobody should ever be completely numb to death. My attending gave me a different perspective. He said he believed it was a defense mechanism that kept medical professionals from having to confront the feelings each time, especially for the ones who work in the trauma bay or the intensive care unit. It allowed them to go back to everyday life and duties. If the health care team got emotional every time a patient died, it would become impossible to do their jobs. The physician emphasized that it was all about balance. As a physician, there must be some balance between feeling emotional after death and putting those emotions aside so you can continue to do your job and care for the next patient.
Two things in particular stood out to me when I reflect on this day on the palliative care service. The willingness of the attending to take me aside and discuss my feelings meant so much to me. Some day, I want to be what that palliative care physician was for me. As an intern, resident and attending, I will strive to help those around me cope with death, especially if they have not been in such a situation in the past. The attending’s words helped me to better know how to deal with death in the future and to understand why my colleagues may react in a way different than me. I am grateful to him for taking the time to have such a difficult conversation with me.
When I have a patient who dies, I vow to take a moment to meditate and reflect. It might take a couple of seconds or a few minutes, but I will always give the patient the respect he or she deserves. If I died in a hospital bed, I would want the people around to do the same for me. I believe that my patient would have appreciated me paying him my respects, and I know that witnessing this event has helped lay the foundation for how I will cope with death in the future.
To my patient: I want you to know that I will never forget, and I sincerely thank you for teaching me such a valuable lesson.