Dealing with death
Authors: Yasmin Akram
Publication date: 21 Nov 2012
Yasmin Akram’s first experience of death on the wards left her wondering whether juniors are adequately prepared
They say you will never forget the first birth that you see—or the first death. Maybe it was the 6 am starts, the screaming women, the overzealousness with which episiotomies were performed, or just the fact that I simply was not made to be an obstetrician, but I did not enjoy watching my first birth. In fact, I don’t really remember any of the births I attended.
What I do remember vividly is my very first death. It was the first night on-call shift that I had ever done; in fact, I was not far into my foundation year 1 medical rotation and so had barely done even day on-calls. It was a night during a bank holiday weekend, and so there had been a skeleton staff on the wards for four days. I was doing ward cover for all the medical patients in the hospital, and my senior house officer and registrar were trying to get through the backlog of patients waiting to be seen in accident and emergency.
As I was leaving a ward to go to see an unstable patient on the other side of the hospital (with my bleep going off incessantly and a list of jobs longer than my arm), I was stopped by a nurse who ushered me into a curtained cubicle where the patient was struggling to breathe.
The patient’s breathing was noisy, she wasn’t very alert, and her clinical observations were deteriorating. What the patient was displaying was Cheyne-Stokes respiration, her last breaths, but I had never heard or seen these before—I had never seen a person dying.
Now I would know what to do. I would know the key questions to ask about the patient’s clinical and resuscitation status as I started to examine her and be able to recognise and articulate what the limits of our medical capabilities were. But at the time I was scared and confused. I didn’t really know what to do.
Somehow I managed to keep it together, work out that the patient was having end of life care, and respond appropriately to calm the family. The patient had already been given appropriate care and drugs to make her comfortable, but for some reason I still said I would speak to my senior and see what else I could do for her, despite the fact that deep down I knew there was nothing more we could have done. I was still trying to find the registrar when the patient’s daughter came out told me she thought her mother had died.
I put the phone down and went back into the cubicle. The patient had indeed passed away, but what shocked me was the thick brown liquid that had started to ooze out of her mouth in large quantities. I realised afterwards that it was gut contents; the patient had had a bowel obstruction. Thankfully the nurse had kindly asked the family to step out for a moment while we cleaned the patient.
It was a tough night—in some ways a baptism of fire. I learnt a lot not only clinically but also emotionally from that situation, but is that the way it should have been? For me? For the patient? For the patient’s family?
We are taught how to break bad news to patients but not how to deal with it ourselves. Surely, there must be a better way to prepare medical students and junior doctors for handling death. Maybe there should be tailored palliative care rotations or compulsory supervised night on-calls for medical students. I don’t know the answer, but I do know from my experiences and those of my colleagues that this is an area that needs to be dealt with.
Competing interests: None declared.
Details have been changed to protect patient anonymity.
Yasmin Akram specialty trainee year 2
West Midlands Deanery, UK