The D Word: Death, The Final Frontier
On my most recent set of on call shifts, I was bleeped to patients who were hand in hand experiencing the three faces of death. Confused? So was I. Never in my six-month journey of junior doctoring did I encounter death in all his facades in the space of a 12-hour shift. Until now.
My first call, to a woman who had end stage renal disease. Her kidney function was non-existent, and she was fluid overloaded. Her breathing laboured; she was teetering on the edge of life. Every patient, whether they are in the community or in a hospital environment have a document that describes their resuscitation status. Often this document is filled in based on a discussion with the patient about whether they would wish to undergo CPR if in the unlikely event their heart would stop. We describe the process in all its gory detail, and go over other sections of the form that include the use of IV antibiotics or IV fluids etc. ‘Resus status’ is a piece of paper which highlights the uncertainty of life, documenting our mortality via a series of check boxes. This patient had opted to not undergo resus. Given the exact nature of her illness, she had made her wishes very clear a week or so prior. Documented in her medical notes, I laboriously looked for the slightest glimmer of hope about her condition. I knew what came next, but it was difficult to say or communicate to my senior. I had to make her end of life. And so, began the prescription of her ‘Just in case meds’. The medications which would make her transition more comfortable. I called her family, and after many tears and words of regret they came into the hospital. Masked and sombre, her son and daughter wept quietly and held her hands reminiscing on happier times whilst she slowly and surely slipped away peacefully. On her own terms and how she wanted.
The next call, sombre and serene rolled into one experience. Death certification. I was bleeped about an elderly patient on one of the healthcare of the elderly wards who had passed away. As I approached the bay, I knew immediately which person it was. Curtains drawn on all 3 sides, I entered the space and the patient lay on the bed. Eyes shut, hands either side of his body, he looked like he was sleeping. You would not be able to tell that this man had died. As I started my checks, calling his name at first to see if he awoke, trap squeeze for pain, looking for pupillary reactions every part of him was cold. The strangest and most humbling thing was his pulse, as I lifted his right arm and then wrist to feel for a radial pulse; nothing. No blood pumping, no heartbeat, no breath sounds, my patient had vacated his earthly home. I documented my findings in the notes and just as I was doing so, I was bleeped for the third and final time. What came next, I was not prepared for.
‘Cardiac Arrest – Cardiac Arrest call on Level 7’ I did not even stop to listen to the ward the patient was on, I just started running. As Junior doctors the crash bleep is often your responsibility during on call shifts, and when it goes off as my consultant once told me, you run. And so, I did just that, I ran. And kept running until I heard a commotion and was aware I was in the right place. My seniors still had not shown up, but as I rounded the corner on the ward and bay in question, ,again I saw three sides of the curtain closed and could hear one of the nurses performing CPR whilst another was counting. I donned red PPE as quickly as my hands would allow, and as the nursing team gave me a rundown of the patient, I readied myself to start CPR. Two hands mimicking his heart pumping blood around the body, my patient a man in his early 30s with a background of high alcohol intake and heart issues had become non-responsive and his ECG monitor had flat lined. I kept pushing harder and deeply into his chest cavity hoping this was helping him, but the only thing I could do was listen as the defibrillator called ‘Stand Clear’. My seniors had now arrived, and another member of staff took over. As I ungowned and washed my hands, I was in disarray at what had just happened. Twenty minutes of CPR later, the patient had died.
Despite everything we learn in medical school, these sorts of events are one of the many times in our careers that death will always prevail. And this is something as medics, we need to be ok with. A good death has many definitions, however, categorically is defined as something which is devoid of distress and suffering, in line with the wishes of the patient and their families within an ethical standard of practice. Whilst we often believe we as a patient’s physician are making clinical decisions in their best interests, we are rarely taught to walk the line between what we feel we should do and what is actually in the patients’ best interests. There is also almost a sense of failure as well that accompanies the death of a patient, as the goal we strive for is to improve quality of life and not to end it. Ultimately however, biochemical processes of the body are out of our control and that is something that now I have started working I have come to both admire and respect. Learning how to deal with death on the wards is something which is both challenging and humbling. It is by no means an easy feat but on reflection an integral part of the junior doctor journey and something which in the long term will make us better clinicians.
Author: Simi Singh
I am a Junior Doctor working in the South West with a particular interest in medical communication, medical writing and health literacy. I’m passionate about Global Health and using social media as a platform to give access to medical information and promoting mental health advocacy.