Working directly with patients in health care, in its most distilled form, is being a sentinel against death. Stand in the threshold, ward off Death as long as you can, make a patient’s time in the house of life as easy as possible until Death finally swoops through the door past you. As it does for us all, including one of my patients this week.
This guy—I’ll call him Diego*—crossed my path last summer. He was sent to our case coordination/social services department for a number of reasons. He had a long history of diabetes and heart disease. He lived in government-sponsored housing and didn’t understand the letters he got from Section 8. He had been hospitalized in a psychiatric department several years ago for crippling anxiety and threats of harm, but was calmer now with medication.
We worked together often, chipping away at his problems as much as possible. Sometimes I felt pleased with myself that I could make a difference, like explaining those Section 8 letters and derailing another panic attack. His A1C was dropping and he was happy with this progress (and the praise we lavished upon him for it). But years of poverty and stress can’t be undone by a cute girl telling you Buen trabajo, me alegro mucho que se cuide tanto. He was still sick.
He was sick enough to be sent to the emergency room during a recent specialist appointment, after a doc noticed some worrisome lab results and wanted him to be admitted for monitoring. The admission stretched on. He had stents put in his heart. I stopped by his room many times, although he was often doped up on meds and not really aware that I was there. I talked with his family and did discharge planning with the medical team. He was on the path to going home with visiting nurses and at-home physical therapy. He was set to get better.
Until I checked the RN notes after a couple of days of radio silence and saw that he went to the ICU for cardiac arrest. I called the nurse. “Poor prognosis,” she said matter-of-factly. “He’s on a vent and we’re talking with the family.”
I had other patients to attend to for the rest of the day. I knocked on my coworker’s door and asked for a prayer. “Just pray that he holds on tomorrow so we can say goodbye, okay? That’s all I want.” My colleague, a devout Baptist, folded my hands in hers and started to say, God our Father, we ask for your healing presence for this man, that you bring him into your kingdom when he is ready. Comfort him and his family during this time, and give them strength. We know it is not our time, but your time that orders our lives…
I went to the ward at 9 o’clock sharp the next morning. “Diego…” the nurse said. “He expired yesterday.”
Expired is always a little jarring. Like we’re cartons of milk.
“What time?” I asked.
She checked her record book. “4:12 PM.”
It was while we were praying.
You enter health care, you sign up to be on the death watch. Fact. We do our work on a scale, of course. I don’t know the adrenaline surges and crashes that ER docs or interventional cardiologists experience. I don’t have the deep wellsprings of compassion that hospice nurses need.
But mortality and decline are in my face every single day. Just a couple weeks ago, we had a department meeting on how to cope with patient death. Many of us shared our stories, and a few more experienced coworkers confided in me that they couldn’t because they were just exhausted by summoning up those memories, of loss after loss after loss.
So I find myself on shaky emotional ground right now. It is not death itself that bothers me. It’s 100% inevitable, so better get used to it (unless you’re Voldemort, who clearly had some issues getting used to the idea).
What I’m having a hard time with is striking the balance between acknowledgement of a natural process that I fully signed up to witness to….and acknowledgement of my feelings of grief and fear in the midst of it. I must keep working and tend to my other patients. I must allow myself to be sad to lose the company of a guy whose presence I generally enjoyed.
It’s walking the line between “I accept this” and “I accept this, with grief.”
Working in a supportive environment helps. After I found out, I told another coworker who had known him for years. Together, we went to our boss’ office and had time to utilize the Kleenex box and talk about how we felt. She told me some funny stories about Diego from before I met him. My boss shared her experiences of patients dying in the ICU. We made space for the sadness before getting back to everyday life.
Space is too often a luxury, though. Did you see that photo that went viral last month, of the ER doc crouched in a parking lot after the death of a teenaged patient? This article by Dr. Pamela Wible on KevinMD reflects on why it struck such a chord with the public. Doctors are not allowed to cry or feel grief, she argues, often to the detriment of their own health and well-being. The public, expecting doctor as automaton, was shocked to witness a moment of raw pain.
Listen, some medical professionals are cold and analytical by nature. But some create emotional distance as a way to cope when they are expected (as one Reddit commenter pointed out) to go from, “What do you mean, little Johnny’s not going to make it?” to “We’ve been trying to get ice chips for Grandma for TEN MINUTES and nobody listened to us, you’re a terrible doctor, we’re reporting you to the Department of Health!”
I was lucky that my more demanding patients left me alone for the rest of that day. The grief was compounded by two facts. One, this was the first patient death I had dealt with in a long time. Two, this week is the one-year anniversary of my mother’s mother entering hospice and dying. I barely said goodbye to her because she was so incoherent by the time she decided to “go upstairs.”
Diego was pretty incoherent the last time I saw him, too. Luckily, he was aware enough to wake up, smile, hold my hand, and say, “Carolina.”
One hopes that he greeted Death just as sweetly.
*Identifying details have been changed to protect patient privacy.