When we were first year medical students, my roommate and I used base of skull as pen stands in our dorm rooms and took home the ‘set of bones’ issued to us to learn anatomy, during the holidays, which freaked out our families. My ‘dissection tablemates’ and I gave a name, ‘Charlie’ to the human cadaver that was ours to learn gross anatomy in the first year of medical school, and we made fun of the one classmate (not me) who fainted at the sight of cadavers in the anatomy hall. The fact that they once belonged to real walking and talking human beings was not high up on our minds. We were excited about learning and we were teenagers. We did not really dwell on death as a life experience. Later in life, I learned that the medical students these days write thank you notes to families and the medical schools gives the cadavers from the ‘willed-body’ program a proper burial or cremation.
During clinical rotations, the impact of death on families and the variety of emotions among clinical teams started to make sense, but not entirely, as I would learn much later in life. Family members received news of death in a wide variety of ways. Gut-wrenching wailing, quiet muffled sobbing, wild chest beating, banging head on the loved one’s bed, hugging and kissing the loved one for the last few times, rarely serene acceptance, to name a few. Once in a while, the family members turned aggressive and accusatory towards the medical teams but that was very rare. Very few patients had been ready to ‘accept death’ and ‘leave the world.’ The family members who were ready to let go of their loved ones were mostly those who couldn’t watch their loved one suffer any longer.
As for us on the patient care team, we too experience and express a vast variety of emotions. Feelings of defeat, acceptance, helplessness, inadequacy, a feeling of relief (from suffering) for the patient, anger, outrage, visceral and raw feelings about the cause of death (homicide, suicide, circumstances of death that we learn about during history-taking and subsequent interactions with patient and family members) and knowledge or thoughts on preventability, and the actual disease that the patient may be having. I remember a professor saying once on rounds, “This man has left this world already. You are working hard to tether him down in this world.”
Regardless of our emotions, thoughts or feelings about death, we were trained to talk about death in a factual, yet empathetic manner, and directly without unambiguous or technical terms. “Placing a barrier between your emotions and the patient’s and family members’ emotions preserves your ability to remain objective and also take care of other patients who need your attention on any given day,” we have been taught. You can’t really argue with that, until you find yourself in a situation that you really need to process all these emotions within, in order to feel like you are a whole human being and that being a doctor is a part of who you are. I still remember how one day (one night, actually, at 2 am to be precise), I came back from the ICU where I was rotating as an intern to my dorm room and my mom happened to be visiting. I woke her up and said, “mom, I am hungry.” My mom fixed something quickly as she always did, and the next thing I said was only after I wolfed down almost half of my heavy snack, “three patients died since the beginning of my shift,” and that was the only thing I said, as I proceeded to finish eating and then got up to go back to my ICU shift which was until 8 am. Only when I said bye to her did I notice the horrified expression on my mom’s face. She did not work in healthcare. I don’t think she slept for many nights after that and I don’t think I asked her whether she slept. It was a busy rotation.
Only much later in life when those I am emotionally close to, passed away, did I begin to feel the actual impact of a person’s death on those close to him or her. It’s one thing if the person who passed away is not a big part of the family members’ lives. Death has an entirely different feel for those who are emotionally connected to the person who passed away. I wrote a fair amount about my up close and personal experience with death when my husband passed away suddenly and unexpectedly. One of my colleagues in psychiatry told me that being caught off guard was a big reason why I felt the full impact of loss and I had no defenses against the full onslaught of emotional pain.
Now, as I pass the morgue on my way to rounds, I think about those whose loved ones are spending some time in the freezer, before they are taken for autopsy and/ or for proper last rites. I cringe whenever I remember the one family who received the wrong person’s body because of a completely unintentional mix-up on the hospital’s part. I do believe that the last image of a loved one leaves a lasting memory, regardless of how much ever we celebrate their life. My husband had such a peaceful look on his face in death, and that was not the look on many patients I have seen who met their end in the hospital. I can’t imagine how it must be to relive the memory of the last and final image of a loved one who suffered intensely at the time of death, or a loved one whose physical body was destroyed beyond recognition, say, because of a traffic accident, or a violent crime, or a serious illness. I hurt on those rare occasions when I am witness to anyone talk to a patient or family member about death in a matter-of-fact manner.
We as a society do not prepare our members sufficiently for the final journey, even though every one of us dies in the end. The result is a patient or family member not willing to talk to or not being prepared to talk to the doctor about death, and the doctor challenged with trying to achieve the best outcome in a time-constrained conversation. We work every day to delay death as much as possible for the patients we serve and our families and friends. We never defeat it. A doctor (who is not in a service like palliative care) talking to a patient about the possibility of death does risk coming across as a doctor not willing to fight enough for the patient and often finds that the patient and family members are not ready to talk about it. Death is universal. Longevity is a gift. It is good for us to strike a balance and achieve a good life and a good death for everyone we care for.