Wednesday, August 29, 2007

Death and Dying in the Hospital


Sorry for the recent spotty postings.

This blog has been a way to jot down the meaningful experiences of life, things that I don't want to forget. It's randomly interspersed with interesting factoids that come up along the way. I'm always amazed (and touched) that people stop by to read some of the posts. For those frequent visitors, thanks for coming back. I hope you like what you read.

Part of the reason for the recent lack of posts, is that I've been trying to process some of the hospital cases we've seen. For whatever reason, we've had a number of very sad cases this month. People actively dying before our eyes.

People dying isn't new. We see it in med school. We see it in internship. Others see it daily in residency. But the derm world is usually a little more removed from the acutely ill, inpatient scenario.

And I've never been terribly bothered by seeing sick or dying patients. Of course, there are those patients that we will never forget, and whose death shakes us to the core. But it would be hard to work in our field if every illness and every death rendered us emotionally vulnerable.

Life, after all, must go on.

But we've just had a series of patients that have made me ponder about life. Maybe it's a function of getting older. Some of these patients are my parents age. Some are young enough to be my children. Some, are my age, or just a few years younger. Or maybe it's because I'm not used to seeing such sick patients day after day. I don't know.

Here's a few of the patients we've had:
A baby, born deformed, rejected by his parents, who dies without reaching his one month birthday.
A teenage boy who is perfectly normal until he collapses one day and is found to have a severe congenital problem that cannot be fixed.
A mother of five who had a simple elective procedure done, which led to a series of unexpected complications, which led to a transplant, which led to graft versus host disease, who dies.
An infant with a rare genetic condition who gets a bone marrow transplant, develops complications from the transplant, and is actively dying before our eyes.

How has the institution of the "hospital" evolved over the decades? The prior generation brags about how patients stayed in the hospital for weeks on end. Many of these patients would be today considered the walking well and not admittable. But as hospital admissions are harder to come by, especially at a tertiary care teaching institutions, hospital wards seem to be filled with death and dying.

Now, there's nothing wrong with death and dying, if it's done well. I'm a huge fan of well coordinated hospice facilities. But death and dying in the usual hospital way, with tubes and lines out of every orifice, rib-crushing chest compressions, veins pumped full of powerful medications, in a scenario all too often colored by the unwillingness by all involved to accept what was long coming, is not the way to go.

But what can you do?

Things often don't go wrong all at once. First the blood pressure is unstable. The the respiratory system is down. Before you know it, due to the miraculous, potentially life-saving advances that we have, the person has already slid to a place where they are dependent on life support. And once you start such interventions, what family member can truly look at their loved one, and decide to withdraw support? Even in the face of no hope of success, how can we even ask that of them? Because, at the end of the day, hope is a beautiful thing. And for those who withdraw support, who will they turn to if feelings of inadequacy or guilt arise?

Or what about the poor families who leave their loved ones to maybe grab a quick bite to eat? How do you explain to the daughter that, even though her mother has been obviously sick for a long time, she is now gone?

It's made me really think about how unfair life can be. How some people can be born and spend their entire lives blissfully unaware of how unfortunate the unfortunate can get, while others are born, suffer, and leave the world in a miserable state. Or how we each take our lives, our health, no matter how incomplete, for granted. Even if we are sick, we are not as sick as some others. As a wise man once said, "if you cannot be grateful for what you have, then at least be thankful for what you have been spared."

It's made me think about how lucky we are to have an uneventful day. That most of us are so very lucky to not be on the receiving end of a phone call starting with "I'm Dr. XXX calling from Big University Hospital regarding your father/ mother/ loved one." That our bodies are truly amazing things that keep on working no matter how we abuse it. That we shouldn't forget to tell loved ones how we feel, because tomorrow should never be taken for granted. And that we should truly seize the moment, live and love well, and be very grateful for what we have, because nothing - NOTHING - is guaranteed.

photo credit

8 Comments:

Blogger Susan Palwick said...

Hi! A few thoughts on this post . . . .

First, what about palliative care? Does your hospital keep interventions to the level desired by the patient and family -- as indicated in advance directives and so forth -- when the patient's clearly dying? (My understanding of hospice care is that hospices also often free up hospital beds, no?)

Second, about the person who steps out for a bite to eat and finds a loved one gone: I recently read a great book by two hospice nurses called Final Gifts, which is about how to understand what dying people are trying to communicate. The authors, both with many years of clinical experience, believe that dying people often have a certain amount of control over when the death occurs. We've all heard about patients who hang on, against all the odds, until some beloved person has had time to arrive at the bedside to say goodbye; but evidently people equally often die when loved ones have left, quite probably to spare them the pain of witnessing the death. So it's possible to interpret this as the dead person's final gift to the living.

2:21 PM  
Blogger wandering visitor said...

Hi Susan,

We definitely have a palliative care section to the hospital, and I'm a big fan of it. The unfortunate situations arise when people would benefit most from hospice/palliative care but opt (or family opts for them) for full codes instead.

Agree with your second point. But it's still heartbreaking to see a young girl's grief in part because she is not old enough to understand her mother's actions.

7:18 PM  
Blogger Pieces of Mind said...

This was... really poignant.

Sometimes people are clearly dying but I think oftentimes the demarcation isn't quite as clear. I mean, when do you decide? At what point does care cross the line into becoming futile?

The care team and the family and patient might think, "Well, there's this one more intervention we can try."

You can start with a fairly straightforward, treatable dx and then complications ensue, as you described, and things spiral out of control. I think it can sometimes be a moving target, and the decision-making process isn't necessarily clear-cut, at least as far as patients and families are concerned. Sometimes events get ahead of them, and intellectually and emotionally they have trouble catching up.

Health care professionals are probably more experienced at recognizing the signs that a patient is not going to recover. After all, you've had many opportunities to learn this and be able to recognize it. For the average layperson, death is not something that most of us experience close up. And when a family member is the dying patient, it's not just an intellectual exercise; it becomes very visceral.

I think it must be hard for health care professionals to know how to have these conversations. Just really, really hard.

I blogged recently about what it was like to be told I had cancer, and the upshot was that the most important thing (to me anyway) was to see that the dr cared and that hopefully I wasn't just another face in the crowd.

Heartbreaking as many of these situations are, I think it does help patients and families just to know that someone cares. They'll remember that forever. So even though you can't fix their heartbreak, maybe you can make some of their pain a little less sharp and not have to feel so powerless.

Sorry this was so long...

1:21 PM  
Blogger Terry at Counting Sheep said...

So well written, and so true. We take a lot for granted, and there but for the grace of God (or whatever or whoever you believe in) go I.

Thank you.

6:33 PM  
Blogger wandering visitor said...

Hi POM,
Thanks for your comment.
I think all physicians care (at least I hope they do! It would be soul-numbing to not care.) - and that we laugh and cry with you, whether or not you know it.

Medical training has a way of making one forget that you, as a human being, are enough to help/touch another human being. That, at the end of the day, regardless of the relationship between two people, each one is only human - and magnificently so - and that we, just as we are, are enough to heal each other.

Re-learning this has been a beautiful thing.

Welcome Terry! Absolutely agree - there, but for the grace of (insert higher being of choice) go I. Would that we never forget this.

10:47 PM  
Blogger Prudence said...

This is a moving post.

So far in my practice of medicine, I think the most difficult part is dealing with death and dying. When do we decide that we should all give up and just accept the inevitable and when do we put all aggressive measures, hoping that it will give the patient another chance? It is also difficult to deal with relatives of the dying patient because in one way or another, we know how they are feeling.

It has always been helpful to me to be constantly reminded that compassion in healing is a must, to not treat patients as mere cases, but to see them as human beings who feels things the way I do. Although medical training, somehow, hardens you to the more sad things that happen in life, it's important to remember that this should come hand in hand with being more sensitive to the other person's needs.

---Prudence, http://tesstermulo.com

5:49 PM  
Blogger Mark said...

Thanks for your thoughts (I stumbled across your blog looking for images) and thought this post was indeed insightful. Uneventful days are truly a beautiful thing and I thank you for the reminder. Take care.

10:55 AM  
Blogger wandering visitor said...

Hi prudence - thanks for visiting. Dealing with death and dying is always hard. Absolutely agree that although constant exposure to morbidity and mortality can "harden" us, I think it should harden certain parts (like fear of patients with disease) but not others (compassion for patients and their loved ones. Hope you are doing well in your training!

Hi Mark,
Thanks for your comment. I'm constantly forgetting things like this - part of why I write about these things - I don't want to forget the feelings!

10:27 PM  

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