1 MEDICINE, SCIENCE, AND SOCIETY
Death and Medicine: A Personal Account ANNEL. PETERS,M.D.,LosAnge/es,Ca/ifornia
en years ago I started medical school and began T the long journey through medical training in the United States. During those years I learned volumes of facts and information about disease and its many manifestations, but relatively little about an inexorable part of medicine-death. What follows is an attempt to look at how I came to understand this phenomenon, and my suggestions to all those who have to help people deal with loss and grief. The first place a medical student officially greets death is in human anatomy lab. For me this occurred the first afternoon of my first day of medical school. I had spent considerable time the preceding summer wondering what it would be like to dissect a human body. As it turned out, it was relatively easy. I hadn’t known “Millie,” our cadaver, prior to death, and I was able to deal with her as a lab specimen rather than as a person. I had never known her alive so I did not mourn her loss. My focus was on finding the branches of the brachial plexus, rather than on developing a philosophy about death. Death did not impact much on my second year of medical school, but it was unavoidable as I started my third. During my first few weeks on the wards, I took care of a middle-aged black man admitted with a lung mass. He was eventually found to have widely disseminated pancreatic cancer. I was there the Saturday he died. He was from a large Baptist family and many were present in his room that day. He had been made a “No Code,” but as he began to deteriorate, my intern dutifully carried out a number of last-minute taskschecking a set of labs, measuring one final ABG, monitoring vital signs, and so forth. I was there to help, but ultimately ended up standing to the side, watching the patient die and the family react to this event. The second his breathing ceased the family burst into hysterical sobbing. I was close to tears myself (and embarrassed by this fact), but before I could really react to the situation, one of the patient’s relatives fell to the floor clutching her chest with chest pain. My sorrow was dispelled as we jumped to action, doing EKGs, giving nitroglycerin, and transferring her to the CCU. When I left the hospital that evening, I sat in my kitchen and tried to come to grips with what I had experienced. I was struck by how complete death was-that one minute there was life, some undefinable but almost palpable entity, which just stopped existing (or went elsewhere, depending on one’s beliefs), leaving the now empty physical body behind. And more than feeling for the death of the individual, I was aware of how detached I was from the process of mourning. Many times that year, and for the next four From the Division of Endocrinology, Cedars Sinai Medical Center, Los Angeles, California. Requests for reprints should be addressed to Anne L. Peters, M.D., Division of Endocrinology, Room 8131, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California 90048. Manuscript submitted February 7, 1990, and accepted March 21. 1990.
or five years of my training, I felt separate from the sorrow-I knew that the death that had occurred would have a great impact on the family members and friends who survived, but I had no sense of how they truly experienced it. I never knew how to talk about death with the families, so I didn’t. I felt awkward and inadequate. And besides, I didn’t have to spend much time dealing with it because there was always another admission or some pressing piece of “scut” to do. But I felt unsettled by this detachment, this lack of understanding. As a fourth-year medical student I spent three months working in rural Africa and was exposed to a new philosophy of death. Never before or since have I been so directly involved with as many people dying. Patients died of many, seemingly unnecessary causes such as routine infections because we couldn’t always get the appropriate antibiotics, or of diabetic ketoacidosis because we were unable to deliver adequate fluids or check labs. When I covered the hospital at night, I would be called to see some desperately ill patient or help the midwife with a difficult delivery. At first, in my ignorance, I would try and do something. But in most cases this was futile; it only wasted supplies that might be used to help someone who could survive. I fought against the ingrained doctrines of Western medicine and learned that there were times to do nothing, even in the face of death. I would hold distressed newborns in my arms as they gasped their first-and last-breaths. A neonate who could not spontaneously breathe died; we often had no electricity, much less ventilators. And as I did this, I had to believe some of the philosophy of the stoic Africans I cared for. This philosophy, in its crudest interpretation, embodied a sense of timelessness and eternal cycling. They felt we are all part of a circular continuum of which death is an inevitable part. Death meant the end of an individual’s existence, but the person was not really gone since his or her “life force” continued in the cycle. And although they mourned the loss of each individual who died, this sense of life recycling helped them accept the event. It helped me to witness a belief system that allowed people to live with death and loss, because without it none of us could have tolerated all of the suffering and death that existed around us. Back in the United States, I became an intern and Africa faded quickly. There were far more cures, but much less time to think. One of the chores of an intern, however, was that of pronouncing patients dead and calling the families with the news. Often these were patients I barely knew; many were those I was covering for the night. But when I would be called by the nurse to see the dead person, I almost found comfort in those few minutes I got to spend alone with the newly dead body. I knew that there was nothing more to do than check for a pulse, listen for respirations, and spend a few minutes in silent reverence for the event that had just happened. But then came that horrible phone call July 1990
to the patient’s relatives; I never knew how to do it right. How can you make the news of a death any easier? What helps? Often I had never met the family members and felt completely helpless in the face of their sorrow. I wanted to do something, anything, but could do nothing. I hated those calls; I felt that somehow I should be able to cushion the blow, but I could never figure out what words of comfort might help. Later, as a resident and then as a fellow, I was more removed from the immediacy of death, although I felt no closer to understanding how to help others deal with it. I was morbidly curious to hear tales of other people surviving a loss; I wanted to decrease my sense of detachment. But although I intellectually improved in my understanding, I did not feel I developed any true ability to empathize with those who I knew were suffering. Then it all changed. My only sister, my dear friend, was dead. It was sudden and irrevocable. I couldn’t believe it had happened, but it had and I couldn’t fix it. Now I know how stunned one feels by hearing the voice on the telephone say “I have some bad news to tell you about your sister. . . .” It feels like a physical blow and every part of your body wants to will it not to be true. My life has not been the same since. The next task, after hearing the news, was to find my parents in Europe and tell them she was dead. No training in the world could have prepared me to deal with the pain and disbelief in my father’s voice as I broke the news to him. Suddenly it was not someone else’s loss, it was mine. Over two years have passed since my sister died. I am no longer a stranger to grief-I know it all too well. But as I have healed, I have found that I am a better doctor than I ever could have been before. The feelings of grief and loss occur frequently in medicine-more often than I realized. Patients mourn the loss of a limb, the diagnosis of diabetes, the dissolution of a marriage, just as they grieve over the death of a loved one. The intensity of the emotions may vary, but there is a very common theme. Now I can truly empathize with these patients. I know that what a mourner needs most is to be given love, acceptance, and understanding. It’s OK that I can’t fix it-most of the time it is not the doc-
tor’s “fault.” Death happens, in spite of the best medicine we have. I no longer feel tongue-tied or uncomfortable with silence. I know that in these situations a few honest words of sympathy, “I’m sorry he died, I know you must be devastated,” do mean something. And then it is up to the mourner to talk, if he or she needs to. Words cannot make up for the loss, but listening and caring can help. Maybe I should have understood all of this much sooner. Others who had experienced a loss earlier than I undoubtedly intuited these things before they were involved in patient care. But I never had a good role model for coping with death, and throughout my training it was ignored. I think that since death is so often viewed as failure, physicians tend to avoid discussing it, or at least the true feelings surrounding it. And it is important that we teach our medical students and house staff how to feel comfortable dealing with this aspect of patient care, because it cannot be avoided. Hopefully, suffering a major personal loss is not the only way to learn about death, although I think it is one of those intangibles that does not lend itself to classroom lectures. Those of us involved in education should strive to talk about it with patients’ families and with the house staff and the medical students we teach. All too often on Monday morning attending rounds, when a patient’s follow-up is “he died over the weekend,” minimal discussion occurs and attention is quickly shifted to the next patient and his or her workup. I agree that it is important to discuss the living, but a few words about those who die and the feelings of the house staff and family members are also appropriate. If we, as physicians, can become more comfortable talking about death and our reactions to it, as well as understand the feelings of grief and loss, then I think we can become more empathetic, effective physicians. Dealing with death is never easy, but I would like to think that future generations of physicians can learn about the feelings of grief without having to lose someone they love. ACKNOWLEDGMENT I wish to thank Drs. Scott R. Votey and Mayer B. Davidson for listening and caring.