Learning that a Death Can Be a Good Death

As a second year medical student I spend a lot of time beginning to learn about how to take care of patients. Every course and each examination focuses on the pathophysiology, the pharmacology, the surgical cures. But I know very little about what it is like to take care of a dying patient. By residency, American medical students will have received roughly 1-5 hours of formal training in palliative care. ¹ Even in the clinical setting in the second half of medical school and beyond, many students do not have the opportunity to participate in a family meeting about end-of-life preferences, or spend time sitting and talking with a patient about his or her hopes for care. ² When, then, are we supposed to learn these skills?

Growing up, I never had any personal exposure to death. I recall being afraid of death, afraid of thinking about death, afraid of confronting it. And I certainly never would have predicted that my high school English course would have foreshadowed my passion in a future medical career. But looking back, I see the beginnings of my interest in the issue of what it means “to suffer.” I was fascinated by the intricacies of Dostoyevsky's narrative in Crime and Punishment. I read his passages over and over, trying to discern the meaning of the troubled narrator's thoughts. I kept coming back to his statement, “Suffering is the origin of consciousness.” What did it mean? How could I apply Dostoyevsky's existential words to my own thoughts and to my understanding of the world around me? I pursued these questions in a final paper for the course, and these questions and ideas have stayed with me. But only this year, in medical school, did I realize their implications for my career in medicine.

As a first year student I was in the hospital interviewing a young female patient with a several month history of an irritating gnawing sensation in her belly, thought to be a “stomach bug.” Her abdomen became distended and the sensation persisted. As it became more painful, she became fearful. Soon thereafter in a local emergency department, she was diagnosed with metastatic ovarian cancer. When I met her, the physical pain, she said, was now largely gone. But what about her ongoing emotional pain, I wondered? To what extent was she continuing to suffer? Was she scared? Had suffering enabled her to view the meaning of her life differently? I probed further, listening to her story. I didn't provide her with any concrete medical treatments. No pills. No procedures. No cure. But she thanked me for helping her. I wasn't quite sure how I had helped, but I came away resolved to learn how to be the best provider in those situations, how to best care for dying patients.

Since then, I have delved both academically and emotionally into the field of palliative care medicine, specifically, involving the end-of-life care of children. I have rotated on the wards with the palliative care team and participated in a summer research project involving children with advanced heart disease.

Just 48 hours into my summer research project, I am observing the Medical Director of the Heart Failure/Transplant Program on daily ward rounds. She receives a page, excuses herself from the intern's presentation, and runs out of a house staff conference room. One of the nurses on the team quickly follows and motions for me to come – so I naively tag along, wondering what could be going on. I hear loud shrieks of sadness, sheer terror. We arrive at the door to a patient's room in the Cardiac Intensive Care Unit. Utter chaos and tragedy lie before me. The child is five years old. Swollen and bluish. A young woman, the mother, is crying, yelling for him to ‘come back,’ to ‘wake up from his dream.’ The intensivists are in the midst of a full code. Chest compressions. IV medications. Commotion. To me, it appears futile, but the chest compressions continue, perhaps just to assure the parents that everything possible is being done to try to save their child. And the time of death is called. The residents move on with rounds, while others stay behind to care for the parents, awash in grief.

During this moment, at the time that these young parents lost their five-year-old son, I was overwhelmed by my own sense of helplessness, feeling that I didn't deserve to be present at such a private, sacred moment for this family.

I had been introduced to this child just less than 24 hours prior to his death. He had appeared in no distress, but very unwell. My mentor had explained to me that he was dying. He had been in the hospital for five months, had undergone every possible intervention to repair his heart. But his organs started to fail. One by one. Heart. Kidneys. Liver. And, somehow, despite this painful and perhaps obvious progression, his parents had clearly been envisioning a turnaround, a way out of their worst nightmare, a blindness that perhaps kept them from thinking about what kind of death they would have wanted for him, be it inevitable. And I couldn't help but wonder if he had had the best death possible for him. That is, if such a thing as a ‘good death’ exists.

Throughout my medical training and future career, I am determined to learn as much as possible about how to alleviate suffering. Of course, much of this involves learning how to treat and cure disease. But I decided to enter the medical profession not only to learn how to cure disease, but also to help people through their illnesses. When treatment fails or surgical intervention proves unsuccessful, medical providers ought to have the skills necessary to continue helping patients. End-of-life care skills must be an important component of medical education. Whether in medical school or in residency training, the compassionate response of a compassionate profession is to continue caring for patients when medical intervention becomes futile. I feel grateful for the opportunity to learn how to treat patients with medical interventions, but also how to provide comfort, support, and care for patients when treatments fail.

I now know that alleviating suffering may mean learning how to help a patient cope with death. And that there is nothing to be afraid of.