The Dying Process

Last night I got slammed.  There were crises on both wards, a seemingly endless list of patients to screen for admission to Medicine, and angry emergency room doctors pestering me about why I hadn't seen their patients yet.  (You know, because I'd been sitting in my call room eating crumpets and tea all evening.)

I loved it.  As much as I wish for quiet nights and dread the sound of my pager going off, I actually prefer the busy nights.  I love the sound of my hurried footsteps echoing through empty hospital corridors, the slashes through completed tasks on my to-do list, the TBADM (to be admitted direct to medicine) icon that appears on the EPR every time I admit another patient.  I'm always stressed at the beginning of a busy night, worried that I'm not fast enough or competent enough to complete everything, but I quickly settle into my groove and start enjoying myself.  There's an incomparable satisfaction that comes from doing the work that you've devoted your life to doing.

Towards the end of the night, as I was entering the orders for my last patient and starting to mentally wind down, I got a desperate page from one of the wards about a patient who was crashing.  She was "no codes", so there would be no ICU team to help.  This one was entirely on me.  My heart and my mind raced as I yelled orders into the phone and then ran up to the ward to lay eyes on the patient.  "Airway, breathing, circulation.  Airway, breathing, circulation." I repeated these words in my head like a mantra as I ran up the stairs, reminding myself of the algorithms and the processes that guide emergent care.

In the stairwell, mere steps from the ward, I suddenly remembered why the patient's name had sounded so familiar to me.  I had seen her previously on a consult service and had been horrified by the severity of disease on her CT scans.  The only reason she hadn't been made palliative at the time of diagnosis was the suddenness of it, the need for time to process and come to some degree of acceptance.  Entering the room, seeing how sick the patient had become, hearing the screaming of multiple alarms fighting with each other for attention, it became clear that there wasn't any more time.

I'm usually slow to make decisions, taking time to weigh the options and ensure that no detail has been overlooked.  I like to think it makes me a good resident, although some might argue that it just makes me slow.  But in this situation, there was no deliberation.  My role in this situation wasn't to examine or investigate or intervene - it was to ease the passage out of life as much as I possibly could.  Orders were placed for morphine and scopolamine, family was called, and the transition to comfort care was made.  There was a palpable change in the patient and the atmosphere around her after the decision was made - from panic to calm, almost instantly.

If there's one thing I've come to believe fiercely in over my time in medicine, it's aggressive palliation.  I've been witness to many deaths in my training - both good and bad - and there are few things worse than a death that involves unnecessary pain and physical suffering.  The worst part of it is that it is often us, the providers of care, who are responsible for not palliating dying patients soon enough or well enough.  We're often unwilling to recognize the point at which we run out of options for curing a disease or extending life, as doing so is admitting failure, acknowledging that despite all of our tests and machines and iv bags filled with magic potions we are still limited in what we can do.  Even when we acknowledge this reality, we often avoid having the difficult conversations with patients and their families because they make us uncomfortable.  And our patients suffer as a result of our cowardice.

When my Dad was diagnosed with melanoma, one of his biggest fears was of the process of dying itself.  He had had a lifelong fear of drowning, and he was terrified of gasping for air from the tumours in his lungs.  Fortunately, he had a fabulous oncologist who was involved in pain and symptom control who ensured that he rarely suffered physically.  And he had two children in medicine, both ardent supporters of palliative medicine, who assured him that he was always in control of his treatment and that we would do everything possible to keep him from suffering.  Having seen the difference that this made in the dying process for my Dad, I view it as somewhat of a personal mission to ensure that all of my patients receive this same level of care.  While I can't save everyone from dying, I can make the process as bearable as possible.