Abstract
I was asked at my interview for medical school what I might find difficult if I became a doctor. It was death then, too. Not that I was worried about the end of life, the physical act or the body; no, I was concerned about how I would answer the unanswerable questions surrounding death: How long have I got? Will I be in pain? Why did he have to die? Can't you do something to make her better?
As a student I was taught how to “break bad news,” and I understand the Kubler-Ross Model for Five Stages of Grief. However, nothing prepared me for the feeling of utter helplessness the first time I was faced with death—a young motorcyclist brought by air ambulance to the emergency department on a beautiful sunny day. He had been hit by a lorry, thrown metres from his bike, and never regained consciousness. His body had too many injuries to sustain life despite the outstanding efforts made by doctors at the roadside, paramedics, and the emergency department team. A decision was made to stop resuscitation and his body, in tattered leathers, died before us.
The image is still vivid, 4 years later. I walked away from the department, he didn't. His family's lives were changed at that moment and I had no answers to give.
Curiously, since I qualified I have only had to verify the death of 4 patients and have only completed 2 death certificates. I had to make it a learning point during my Foundation 1 year. Have I avoided it? I don't believe so, as I have worked on 2 busy surgical firms, a stroke unit, in an emergency department, and in obstetrics and gynecology.
A 78-year-old female patient presented with hemoglobin of 4mg/L when I was working in urology. She had been admitted in the early hours of the morning, so when I first met her she was being transfused the first unit of blood. She confessed finally to a 2-year history of worsening hematuria, knowing that there was probably something seriously wrong but denying its importance as she was feeling well and continued to smoke 30 cigarettes a day. She was an intelligent woman in denial. I got to know her well throughout her stay. She trusted me to be honest with her at every stage of the inevitable diagnostic process. I unblocked her catheter when it was so full of frank blood that she was in excruciating pain; went to theatre with her for the initial cystoscopy, sat with her during the computed tomography scan for staging imaging, and held her hand when she was told she had bladder cancer. She underwent cystectomy and nephrectomy and recovered well from the surgery. Nevertheless, she will die. I saw her again recently at a follow-up appointment, and the metastatic disease means that the radiotherapy treatment offered will be palliative.
I feel like I have been through Kubler-Ross's stages of grief with her. We have talked about her death and she accepts it now. She isn't scared of the end of her life, but she is very concerned about her family and how they will cope when her life comes to an end. Her family is supportive, hard-working, and very compassionate. But I don't think that my patient has had those kinds of honest conversations with her husband or children. I maintain patient confidentiality always, yet find it very difficult to know that I have spoken to my patient about her fears and expectations of death and her family hasn't had that experience. I feel hugely privileged. And I know that I will be very upset when she dies. I wonder whether this will be worse because I have seen her throughout her illness, or worse because she has shared her thoughts and feelings with me.
Is young death worse than old death? On the gynecology ward, while desperately trying to find some equipment in an unfamiliar clinic room, I became aware of a man beside me holding a small basket. He asked me for help. I was about to explain that I was new and didn't know where anything was, when he removed the cover from the basket to reveal a dead baby. Do you call it a baby or a fetus or a child? Do the semantics matter? I was utterly shocked. I had never seen a dead infant. Her skin was red, transparent, and hairless. Her tiny formed fingers, curled up as if grasping for something. Life? Her eyes, unframed by lids or brows, were staring incomprehensively at me. She had been born 20 weeks too soon.
The man was the chaplain. He wanted help to dress this little creature in a woollen robe. He was taking her to be with her parents to be blessed. I struggled to tie the tiny garment around her unformed body before laying her back into her basket. They left the room and left me stunned.
I really wanted to talk about it with someone. I really wanted to share my feelings and thoughts. But the next acutely unwell patient was waiting for me in the next room, her distress apparent as she was miscarrying an early pregnancy.
Doctors have to do that. We have to move effortlessly from one patient to the other, “parking” emotions somewhere in our brains to be dealt with later, or never dealt with.
I didn't think I had an opinion about termination of pregnancy. I'm still not sure whether I have one. However, I have had to think about it much more and have struggled emotionally with some situations. My belief still holds that it must be the woman's choice about her pregnancy, but can there be caveats?
In the emergency gynecology unit I have resuscitated women with massive bleeds following termination of pregnancy in other establishments; one woman had had 4 terminations during the last year as a form of contraception. Do I even have the right to question her decisions?
So death has been on my mind. I don't suppose I shall ever “get used to it” nor do I want to. I think that to become accepting of death, as commonplace, would be complacent, uncaring, and crass. It should always matter.