Wednesday, April 11, 2007
On Death. One.
I've been asked to review a book for Medscape. As it happens, its central subject is a theme about which I'd been planning to post at some point, and the reading has jogged me into it. After the review is posted, I think I'll mention more about the book. Meanwhile, some thoughts on death and doctors.
To a physician, death rarely comes unannounced. Because of what we know, we can see it coming before others do. That doesn't make the arrival any easier; in fact, because our essential aim is to cure or prevent disease, death is a repudiation -- perhaps even a humiliation. The author of the book I'm reading sees it as wrapped up in physicians' fear of death, in their need to convince themselves of their own immortality. I don't happen to buy that. But I do agree that, for complicated (because humans are complicated) reasons, we tend to turn away from our dying patients. Willing to do almost anything to stave it off, when death becomes inevitable in those under our care, we either fail to acknowledge it, pressing on no matter the reality, or we begin to detach ourselves from those most in need. Perhaps the "we" is presumptuous on my part: I think the tendencies are widely seen, but maybe I should speak just for myself. I learned by observing others, and by looking inward to my own behaviors.
The need for uncomfortable candor comes in many forms: telling a patient and loved ones of a fatal disease before starting treatment; dealing with a failure of therapy; informing of a sudden and unexpected death. Luckily, the last one is pretty uncommon: cataclysmic, I think it's the worst of all. Wholly unprepared, the family receives a horrible shock, often in the form of a phone call. The worst case of mine was doubly awful.
I'd done a routine operation on Mrs. Jones. In her seventies, diabetic but pretty healthy overall, she'd seen her doc before surgery and had been given the all-clear. On the first post-operative morning, a nurse had done a routine check, found her to be recovering appropriately. The nurse left the room for as long as it took to get a fresh IV bag, and returned to find Mrs. Jones dead. It was a heart attack; the biggest of the coronary arteries, occluded. "Just one of those things," some might say. I was stunned when I got the call, came immediately to the floor, found the husband's phone number. The idea of making such a call, of having to say what happened with no warning and to do so in some sort of gentle way seems so impossible, and is so repellent that there's a temptation to lie: to gain time, to prepare the family by saying she's taken a turn for the worst and they need to come right in. To meet them then, and tell them in person that it's too late. Would that be easier on them? On me? (Probably not on me: as hard as it is to make such a call, it's over -- in the immediate sense -- when I hang up the phone.) (Actually, it isn't: the gut aches after. And there's the need to be there when they arrive, no matter what.)
As I was talking to Mr. Jones on the phone, telling him the crushing news, a daughter arrived on the floor to visit her mom, unaware. Out of the corner of my eye I saw her heading toward the room, knowing there was no one in there but her mom. Like everyone's recurring dream, unable to move fast enough, I tried to signal a nearby nurse, but it was too late. I couldn't have torn away from the husband on the phone, could I? The daughter opened the door and walked in, coming out a moment later. Her shock-shredded face, perforated by the unnaturally widened holes of her eyes and mouth, is carved into my memory, as are her words, said with her hands held inches from her ears, as if unsure whether she wanted to hear the answer: "Is she dead? Oh my god, is she dead?" With the phone in one hand, and my head in the other, I didn't know where to turn. Waving and garbling, I managed to get the attention of the head nurse and point to the poor daughter.
With no preparation at all, the shock carries forward for a long time. I met with that family en mass at the hospital, and weeks later in my office, as they sought explanations. As unpleasant as the meeting was, it's the initial call -- and others like it -- that sticks to my mind like tar. "I have terrible news," it begins. Cliched, formulaic, mechanical. It's as if I'm split in two, watching myself play a role, detached, yet feeling real pain and searching for a way to make a human connection. Out of the blue, it feels like there's no way. The desire not to make the call is nearly overwhelming. Acute, immediate, finite and final, it's impossible, it seems, to do it properly. No way through it for either party. On my side of the phone -- and this applies to all of the death scenarios -- as I speak, I hear myself as if in an audience. As much as I am aware of the humanity of the situation, I also know I'm playing a role. I know the need to be sensitive: and look, here I am being sensitive. Where's the truth of it? If doctors tend to turn away from death, is turning back a matter of willing it? Can it be carried out effectively by rote?
When death gives us time, we can -- if we realize it and face it -- make an enormous difference for our patients and ourselves. The question is if we can do so without chipping steadily away at ourselves. The answer, in my case, is yes. And no. I'll try to write my way through it, next.