As we all enter residency, we are thinking of how we are going to be the best doctor we can be in our respective specialty. Regardless of the field we are going into, I believe we all have common goals: to be compassionate, patient-centered, culturally sensitive, and evidence-based. These are the qualities we will all be constantly working on throughout the rest of our careers. Despite these noble goals, I believe there is one topic incredibly important to medicine we neglect. That topic is death and dying. Thus while I will strive to achieve the common goals of being compassionate, etc., I hope to reach a point in my career as a physician where I truly understand and am sensitive to the matters of death and bereavement.
From the outsidersâ€™ point of views, patients see physicians as people who are regularly in contact with death. Doctors give the prognosis of death, they announce the time of death, and they heartbreakingly relay the news to family and friends. Thus shouldnâ€™t doctors be most comfortable with death? Shouldnâ€™t physicians know how to deal with those who are grieving and those who are dying? Wrong. In fact, most doctors are extremely uncomfortable with death and are at lost on what to do to help patients through their dying processes or to console family members and friends.
â€œI had insinuated my hand into that mysterious nexus of stars and fate and destiny, and I had reduced that great passing of life into an arbitrarily calculated moment in time.â€ â€“Dr. Chen on the practice of announcing time of death.
Why do we suck at this? After dealing and being in the presence of death multiple times over years, physicians should have developed some sort of method to handle this heavy part of being in medicine. Unfortunately for most physicians, the method has been to become unfeeling, detached, or awkward.
Who can blame them? Dealing with death is hard. Hard does not even begin to describe it. Regardless of the Kubler-Ross stages we are taught, every person deals with death differently â€“ every family does. The ways people approach death and grief depend on family dynamics, culture, personality, and past history. The process is not the same for any two people.
Many years ago in my death and dying class in undergrad, we had to pick a death/bereavement topic and write a paper on it. During that time, I had some recent developments in my life, and I saw my family go through a personal, heartbreaking loss and then something else Iâ€™ve never seen them go through before. Iâ€™ll spare the details, but the memories I have of those moments of black, white, kneeling, despair, and anger-anger-anger-anger drove me to look into how the Khmer Rouge affected modern-day Khmersâ€™ grieving processes.
For context, my parents and their brothers and sisters fled Cambodia in the 70â€™s to America because of the Khmer Rouge. Cambodians went through a horrific, terrible time between the years of 1975-1979. The civil war/genocide was a nightmarish time of bodies left stranded on the roads, humans violently killed, and mass graves left to rot. By the end of the war, around one to two million people died; about 20% of Cambodiaâ€™s population. There was no way to bury a family member, and many surviving Cambodians were left not knowing where the bodies of their deceased family members were, and not knowing how to properly bury and grieve for them.
Grief was interrupted for many of them and left unresolved. Many never had any closure and many felt guilty over not being able to give their family members a proper burial. Then years later, the mannerisms of Cambodians changed; they became more secretive and closed off. Articles stated that as they became more closed off, Khmer families began to approach death with anger and resentment. It was a way of coping with grief adopted from the war where many blamed deaths on Pol Pot (the leader of the genocide).
Whatâ€™s my point of bringing this up? Just to show that death and bereavement is complicated with each person.Â Each human has a history that a doctor most likely wonâ€™t be aware of, and thus there is already a lack of understanding from the start. Itâ€™s a puzzle, a never ending dark maze that physicians get dropped into â€“ they donâ€™t know the beginning or the end.
So how do we, as future doctors, act in these situations? How do we make our patients the most comfortable when they are in a painful area no human should be at?
There is no right answer.
But there are some good answers.
The quote I used above is from one of my favorite books called Final Exam: A Surgeonâ€™s Reflections on Mortality by Pauline W. Chen. As a brilliant, compassionate transplant surgeon, Dr. Chen reflects on her experiences and from them, I take away many messages but one story stands out particularly to me.
While still a resident, Dr. Chen said that she usually found herself pulling away during the last minutes of a patientâ€™s life, making herself busy while waiting for her patient to die all the while watching family members move in and out of the rooms with teary faces and bunched up tissues. One night, however, as she left the room again of another dying patient, she watched as her attending resident drew the curtains around himself and the wife and the dying husband. Curious, she peeked into the room to see the attending leading the wife to the bedside and then slowly whispering something to her as she cried. Those words, as she found out later, were words explaining how life leaves the body, giving the patient a peaceful death. Days later, she received a letter from the wife thanking the team for ensuring her husbandâ€™s peaceful death. Dr. Chen described it as an experience that showed her a new world of medicine; it showed her that she could do more as a physician than just cure or diagnose. Ever since then, she states that sheâ€™s never left the dying and the family alone. She drew the curtains around all of them, spoke to the family slowly, and touched and hugged family members.
Dealing with this will never be easy, but I pray, as a future doctor, that I will have moments like this that unveils to me a different way to approach death. A different way to provide something to patients when I have nothing good left to give. Let us always remember to not run from death, but to take it on, and to morph it into something compassionate and dignified. This will be one of my main pursuits in becoming a physician.
â€œBy evading death, we miss one of the best opportunities for us to learn how â€œto doctorâ€, because dealing with the dying allows us to nurture our best humanistic tendencies.â€ â€“ Dr. Chen
And that says it all.