Wednesday, January 26, 2011

My Stages of Grief

This post continues on from my first one, "The Night I Became a Doctor".  And as a note for my future posts, I use a unisex "they, their" reference to patients in order to help keep private information confidential.  As much as I would like to make my stories more personal by using he/she pronouns, I feel compelled to use as little information possible so that I may protect a patient's identity. 

After staying up for 30 hours covering the unit, and most important to me at the time,  keeping someone on the brink of death alive through the night, I felt exhausted, almost zombie-like by the time I left the hospital.  I had a day off the next day.  I couldn't have been more thankful for the free time.

I took a quick nap when I got home, and then awoke with an almost annoying amount of energy and life despite only having slept for 3 hours in the past 35+.  Just being awake and not being at the hospital, not having another long shift looming the next day, made me feel revitalized.  I was living on adrenaline, and it felt great.  I stayed up late that night, I enjoyed the rare and blissful stress-free time by going to my favorite neighborhood pub, hanging out with my wonderful girlfriend, and staying up past my bedtime.  But, despite this, I still couldn't keep myself from thinking about my patient.  I (unfortunately in this case) had access to the electronic records at my hospital from home, and I kept looking at them periodically; Checking vital signs, following labs, noting how much drip medication was required to keep their heart going.  My girlfriend thought I was crazy... Being a nurse, she understood, but she still had to keep kindly reminding me that I was not at work that day, and that they gave me days off for a reason.  I never thought in my life that I would have a woman encouraging me to play video games instead of focusing on my job (yea, she's a keeper). I normally don't have a problem enjoying my days off, but this was a particularly difficult one. 

The day off passed, and I was back to the unit by 6am just like usual... it was a blur, almost as if I never had a day off at all.  Overnight, my patient had not done well.  They had deteriorated fairly quickly in the last 24 hours.  All of that work I had done to keep them going... trying to keep them alive, all for naught.  They were going to die.  My mind began to dart to blame;  My colleagues covering for me on my day off had done a poor job... they didn't have my anal attention to detail... they were to blame.  Or, no, it was my fault for not giving them good enough instructions before I took my day off, or maybe I had never made them healthy enough to begin with.  Shit, maybe I should have even called them on my DAY OFF (one of only four for the whole month) when I saw their vitals/labs going downhill.  And last, but certainly not least, and I am ashamed of this.  Very ashamed.  I even blamed my patient.  Why had they let themself get so fat?  Why so much smoking despite inordinate amounts of warning?  Why didn't they ever listen to a doctor about any of their choices previously?  Why did they have to end up in MY care knocking on death's door?  What the fuck was their problem?  Oh my... I was feeling anxious, guilty, angry.  Selfish.

I caught myself... I realized just how irrational I was beginning to think.  Only in hindsight, now, do I realize that at the time I was already going through the stages of grief. 

I knew this person that I had become invested in.  I had spent a lot of time conversing with them about their life... and then on the flip side I had spent what FELT like an inordinate amount of time trying to stave off death.  And now, I knew they were already gone.  I had gone through so many feelings in the last few days... Denial, sadness, anger.  Sound familiar?  The stages of grief are comprised of Denial, Sadness, Anger, Bargaining, Depression, Acceptance.

Denial:  The night I stayed up with so much enthusiasm keeping this patient "alive".  Sadness:  The 10 seconds prior to entering into, Anger:  Blaming everyone I could think of including the patient.  I was grieving over the looming death of this person and I didn't even realize it.  Bargaining never happend for me, but depression and acceptance would soon follow.  Sometimes people skip stages... I guess it's in my personality not to bargain.

This patient's family had been visiting almost every day during the hospitalization.  I had called and spoken to them on the phone numerous times, including while taking a break from chest compressions to tell them they needed to come to the hospital ASAP.  We had also bonded in our own way after the code with family meeting decisions.  They had made it clear that their family member would never want any suffering, not to be kept alive by machines, and that they probably never would have wanted the first "Code" I wrote about in my first post.  After a fairly short, very reasonable, and well understood conversation on both sides, the decision as made to "pull the plug" so to speak.  The patient was being kept alive on a ventilator, on multiple drips of powerful medications to keep their heart and circulation going.  These remedies are routine in an ICU setting, but they are far from natural... we were essentially keping this person alive artificially.  The second we took them away from any of these remedies they would pass within minutes.  The family knew this, and that is exactly what they wanted because keeping them on these therapies meant more suffering with almost no hope for recovery of a good quality of life.   So what did they want?  A quick, painless death with dignity.  But, they didn't want to feel like they were withdrawing all care at once, so we formed a plan. 

I had a meeting with the nurses to inform them about how we were going to hande this. They already knew what was going to happen before I even came out of that meeting with the family.  They were sharp.  They had been through this so many times.  Here I was, the person they looked to for orders, the person they called at 3am when they had a problem that was out of their scope of practice... and yet I felt so naive and inexperienced in their presence during this time.  I barely had to say anything to them.  They already knew.

We had decided to pull the breathing tube and turn off the cardiac drips shortly after but not simultaneously, with the three closest friends/family at the bedside.  Everyone else was cleared out of the room to wait in the family waiting area.  I was waiting around the outside of the room pacing, my resident had the afternoon off and I was on my own.  One of the nurses came up to me, her eyes gave me a soft and nurturing look, and I being someone who almost never looks away, our eyes met, and with just enough silence to let me collect myself she spoke, "Are you okay sweetie?...  This might be a while... just go do your work. We'll take care of it."  I felt so clumsy, but I felt so relieved at the same time.  I wasn't really that "okay", but I told her I was "okay" to save face, and began to make myself busy around the unit with this patient in the back of my mind the entire time.  About 40 minutes later, the same nurse came by to me and silently handed me a small printed EKG strip.  Flatline.  They had passed.  I knew what I had to do now.  I had never done this before, but it was my time to go into the room and pronounce the patient dead.  There were still the three closest friends/family members at the bedside.  There was no heart monitor on, no vital signs being displayed in the room... they wouldn't know for sure if the patient was dead until I told them.  I walked into the room... fortunately we were all familiar with each other by this point and we had established some trust.  They recognized me and asked me almost immediately, "Are they dead?  We think they might have passed in the last couple of minutes..." Two of them let out a sigh of exasperation, almost simultaneously.  The closest to the patient said in a voice of defeat, "Just tell us it's over".  My heart broke.  They all scanned my every move, attended my every sound.  I explained to them that the patient had likely passed by the EKG flatline, but that to be absolutely sure I had to examine them (which might seem strange to some families, so I explained all of the steps I would take before I did the exam).  They all had visceral and palpable responses to my news, despite the fact that they knew what was coming; they had been waiting for this.  I let the room fill with silence for about 15 seconds to allow the situation to display its weight.  I then listened for heart sounds, I watched and listened for breaths, I checked for reflexes, shined a light in their pupils, felt for any hint of a pulse.  Nothing.  "I'm sorry..." I looked up at the family who had been awaiting in agony.  "They have passed."  I gave a few seconds and then looked up at the clock.

"Time of death, 1:59"

Those were the hardest words as a physician that I have ever spoken. 

The one who had been closest to the patient thanked me and hugged me, fairly vigorously, a man who had been quite stoic throughout this process... a few tears slowly trickling down his cheeks. I used every ounce of energy and manhood that I possessed to fight off even a single tear in response.  I was their doctor.  I had to remain strong.  I shook hands with the others and nodded my head in acknowledgement of their loss.

I was sad.  I was already feeling the next stage of grief:  Depression, before I even left the room.  I wanted to cry with that family member so badly... but I knew it was selfish.  Crying would have let me release my own emotions, but I needed to stay strong and professional for that family.  I used every ounce of energy to hide my feelings.   

I left the room, closed the door, never to see the family or the patient again.  Their body would be cleaned, tagged, and bagged up  by the nursing staff, a job I had once done myself as a nurses assistant prior to medical school.  I did not envy their task.  I was not the same that day after I left the room.

Normally I would be chomping at the bit to leave early on a day during this grueling rotation that pushed the limits of work hours with our 30 hour shifts every three days; but it was almost unfortunate that I had a short day of work that day.  I would have rather had another 30 hour day so as to stay busy while unknowingly trying to deal with stage five of grief (with my stubborn self skipping bargaining):  Depression.

I thankfully quickly went through the depression in the next day... reminding myself that unfortunately people must die.  Sometimes people die and there is nothing you can do about it.  Fortunately this person had a family/friend-unit that cared about their wishes and let them die the way they would have wanted.  We should all be so blessed. 

Once I had processed my patient's death, I became uncomfortably aware of my own mortality.  I thought about how little I had done to work on my own life the previous month or two, and reminded myself that my life could end before I knew it.  It reminded me that I should try to get the most out of every day that I was given, even if that whole day was spent caring for the passing of another.  I accepted "my first death" fairly quickly after that, and found privilege in the event. 

It still didn't make it easy...


  1. Thanks for sharing this, Jon.

  2. Well written Weebs. Jeremy's had more of these "tough" work days than I think he'd imagined he'd ever have at this point in his career.

    Also good to hear that you have a special lady friend who encourages video gaming/fun time. I'm pretty sure that's why Jeremy and I ended up together. Dirty dishes in the sink can wait to be washed...