When my patient died

How do medical students learn to deal with dying patients? In doing so, Allison Barrett discovered more about herself

It was a day full of firsts: my first day of my clinical years of medical school, first time on call, first time working in the hospital. It was still light out when we got our first trauma page of the evening: "P1 MCC male, +LOC. Trauma 2. ETA 5 min" (see glossary). I didn't know what any of it meant. I was thrilled.

The team rushed downstairs. The patient arrived with a calm emergency medical technician on top of him giving him chest compressions. The technician's head was turned towards the patient's feet. She was watching where the gurney was going instead of watching her hands attempt resuscitation. I think she knew it was hopeless.

The patient was wheeled into the trauma bay, transferred to the table, his clothing stripped, and a monitor was readied to take his vitals. I noticed that in his left tibia there was an intraosseous port, a mechanism to provide large volumes of fluid rapidly. I was proud that I knew what it was, then I remembered the gravity of its presence.

He was unresponsive and without a pulse. Compressions continued. Thirty seconds passed, then a minute. Multiple people felt for pulses. "I'm ready to call it if you are," said one resident. Nods all around. "Time of death . . ."

There was a brief second of silence before things went on as usual. The resident called my name and told me to put on gloves. Several people were surrounding the patient, prodding his body, feeling for something that would explain his death. Someone threw a pair of gloves in my direction. I could barely get the gloves on over my sweaty hands. The resident put her finger on a spot just to the left of his sternum. She pushed down. Her finger sank into him. She grabbed my finger and pushed it on the same spot. It was-for lack of a better word-crunchy. His bones crunched under my fingers, and I heard his ribs grind down against his sternum. "Crepitus," she said, then she walked away.

He still looked alive. When I pushed on his chest, I expected him to open his eyes and scream in pain. In my head, I apologised to him for crunching his ribs with my unfriendly, unsteady fingers.

When he died, the resident forced me to touch him. She showed me what his broken ribs felt, and sounded, like. She forced me to confront his death. To her, his body was for teaching and demonstrating. She had no connection to him, and she brushed off the experience. Her objectivity was stunning. I was ashamed to feel emotional after this experience, seeing how unemotional she-and everyone else-was. I promised myself that I would learn to be more unemotional like her. Then I decided I didn't want that either. I told myself it was OK to feel for this death, as it was my first, but I didn't know how I should respond to my second death, or my third, or my fourth.

Who was he?

We did not know who this man was. He went to the morgue without a name, and I'm not sure if he ever got one. I looked in the news the next day, and there was nothing about an accident. Nobody on our team talked about him that night, or ever again. It was as though he just disappeared.

When his death was announced I had a sense of futility, then sadness. When I felt his crunchy ribs I was horrified, then nauseous. When I realised he was nameless I was curious, then I felt empathy. I couldn't sleep that night. I heard the crunch of his ribs and felt the softness of the pooled blood underneath. I saw his face, so pristine, without a scratch on it; it looked as if he could wake any moment from pain. Who was he? We'll never know.

I had seen somebody die. Another first for me, but it was not my last. During the rest of that year in medical school, I was involved with several patients who died. Some of them were willing, others were not. Some were expected to die and some not. Some people died of natural causes, and other deaths were iatrogenic.

It does not get easier. For my psychological wellbeing, I wish it would so that I could live my life outside the hospital without tears. On the other hand, if death became easier for me, I would lack empathy. How do we reconcile our grief with the need to move forward-and quickly-to treat the patients who we can save? I wish I knew.

Doctors vary in their approaches to dying patients, and I have seen the spectrum. From blunt, "The prognosis isn't good, and you'll probably only live a few days," to avoidant, "Well, we're still waiting for the pathology report, which may be another week or two . . ." The trauma team on my first night did not even confront the death of the patient, showing extreme avoidance.

My only experience of giving someone a terminal diagnosis was a middle aged woman who had recurrent and metastatic breast cancer. I was avoidant. I did not want to make her sad. I hoped that she already was expecting to hear the diagnosis, but I won't ever know. My resident, who stood by me while I spoke and interjected at times, said I did just fine.

I was too scared to talk to my next terminally ill patient. He had metastatic prostate cancer. When I spoke with his family, I was vague. I deferred to my resident or the oncologist or the urologist or whoever was nearby. I couldn't bring myself to tell them the ugly truth.

When it comes to death I have learned that I am avoidant, vague, not very helpful, and certainly not informative. On a positive note, I am neither hardened nor blunt nor unkind. In fact, I am clueless about the process of dying, my role in it, and my response to it.

We need guidance

Although some medical schools are trying, little formal education exists on how to deal with death. Harvard Medical School provides an elective course that links medical students with terminally ill patients to share their final months. It involves group discussions and homework assignments, as well as one-on-one meetings with a terminally ill patient. According to Block and Billings, "students learn from 'their' patients about living and dying with a terminal disease: about the fears and uncertainties that accompany a serious illness; efforts to make sense of one's life and death; the kinds of support that help patients to manage physical, emotional, and existential crises; the nature of suffering and hope; and the ways in which crucial medical decisions are made."

This type of learning, with the rare opportunity for open dialogue about death and dying, is unique. In the "hidden curriculum" of medicine, where learning about death comes from seeing it on the wards, there is little time, and often doctors are unwilling to discuss death and emotions relating to it. A personal education from a willing and honest patient is invaluable, and I applaud Harvard for this course and the students who choose to take it.

I think that a formal education on death is needed in medical school to encourage students to think carefully and discuss honestly the approach to a dying patient. That said, no curriculum can replace the experience of caring for a dying patient. We have no script to follow in approaching death. So without a script, I'll stick to my own approach, which needs some serious editing.

Glossary

P1-Level 1 trauma

MCC-Motor cycle crash

LOC-Loss of consciousness

Trauma 2-Trauma bay 2

ETA-Estimated time of arrival

A shorter version of this article was published in The Forum (2007;Spring:11 www.mcaap.org/forum/forum0703.pdf).

1 Block SD, Billings JA. Becoming a physician: learning from the dying. NEJM 2005;353:1313-5.

Allison M Barrett, fourth year medical student, Boston University School of Medicine, MA 02118, USA
Email: ambarret@bu.edu

Student BMJ 2007;15:427-470 ISSN 0966-6494 | December