I told a man that he was dying

Two weeks ago I told a man that he was dying. We sat together in the mid afternoon haze. Puffs of snow meandered by the hospital window and wended their way down to the ground. The sun was lost behind winter’s never ending clouds.

The tempo of my voice was steady, lacking variation in tenor and pitch. I clung to my lab coat as if I was floating outside the window and being blasted by the inclement conditions.

I waited coldly for a response. At first, he stared at me quizzically. His eyes asked so many questions but his lips remained still. He shook his head and sighed. I glanced above him at the ticking clock.

You’re wrong. It’s not my time yet!

***

Two days ago I entered the same room. I watched as my patients chest heaved up and down slowly. His laborious breathing like spikes piercing the insides of his family members. They sat somberly around his bed in a circle.

It won’t be long now.

As the words slithered out, I realized that I failed to convey the proper warmth. My voice box robotic and stale. The phrase lost in a haze of familiarity.

***

Two minutes ago I pronounced him dead. The room still heavy with doubt and false expectations. The social workers and case managers huddle around the family as funeral plans are made.

And in two days, I will call his wife. I will express my condolences and ask if there is anything I can do.

Then, most likely, I will never speak to her again.

***

Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrance.

He’ll stare deeply into my eyes and I’ll detect a hint of mirth.

We’re all dying my friend.

He will draw in a deep breath and put his hand on my shoulder.

The trick is learning how to live.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • http://twitter.com/Hootsbudy John Ballard

    Poignant and relevant. 
    In my career as a manager I dealt with a range of human shortcomings among employees, sometimes bending over backward to accommodate them. I learned that I could not correct in a few weeks or months what life had failed to correct in twenty-five or thirty years so the choice was either accept the problems or replace them. However, patients, like customers (and family members) cannot be fired. In many cases the best you can do is not make their problems worse. And denial of human mortality must be the worst of all. You have no reason for even a shred of remorse. Pity, perhaps, but no guilt.

    Your other case reminds me of a lesson about aging I have learned from watching the public for years. Those who say people get cranky as they get older are wrong. There are too many sweet old people. As we age we may become more brittle, but whatever we have always been will not change much. Those cranky old people were once cranky young ones. And sweet old people used to be sweet young people. Except for neurological changes (Alzheimer’s, mental illnesses, etc.) age affect people as it does wine, food or art. If it starts good it gets better, but poorly made it is apt to get worse. 

  • Zuni Harper

    Well in the past 30 years on several occasions I have been told I was not expected to live, no one did under those conditions, yet here I sit!  And on too many occasions I have chatted with teens and young adults one day only to learn the very next day they were dead.  Life can be so very cruel at times.  It takes a lot of bravery to stand next to a dying person and discuss this coming event.  If it takes a robotic voice to get the job done at least you could do it.  Most family members/friends do not have the strength.

  • Michal Haran

    We become physicians because we want to fight death, disease and human suffering.We later realize that this is too ambitious so we at least want to fight disease. With time we understand that many times all we can do is relieve a bit of human suffering, and even that is not always easy to achieve. Realizing our own vulnerability, understanding that we ourselves are not immortal, learning to face death in a peaceful way and helping our patients and their loved ones do the same is probably the hardest of all. Yet, it is an important and integral part of our work. A patient’s death is not our failure, it is the reality of life. A patient’s needless suffering is. As I do talk with some of my patient’s families years after, I know that it does make a big difference.
    The angel of death is our biggest rival, yet one we have to treat with respect. This is something I wrote a few years ago, (after I myself had a “brief” encounter with him): 

    My first encounter with the angel of death
    was many years ago, when I was a young resident in the internal medicine ward.
    There was nothing unusual in the routine message that I received from the ER.
    Even when the patient was Wheeled into the ward I did not suspect a thing. The
    first “clue” was when in the middle of the sentence he suddenly
    stopped breathing and I could not feel his pulse anymore. This was the first
    time that I faced what until then I have only practiced on dummies in medical
    school. I began resuscitation at once; I gave urgent orders to the nurses and
    kept on pressing on his chest at the same time, using all my force, again and
    again. And then the unbelievable has happened. The monitor started to show a
    near-normal EKG, his pulse returned as well as the color to his face. A few
    days later the endotracheal tube was taken out, and I saw him sitting in the
    corridor. He was totally unaware of the drama that took place a few days
    before. I will never forget how I felt at that moment. I felt almost like god.
    I have won. I managed to defeat the angel of death. It was not in vein that I
    have sat and studied for so many years. I have done the impossible.

    Since then I have met him many times. It
    was not always easy to recognize him. I have learned to see him even when
    he was very elusive. I could recognize him in the face of a patient with a
    “mild infection”, in the eyes of a young woman with sickle cell
    anemia, in the sudden heavy breathing of a patient with stroke, which denoted a
    pulmonary embolism. I used every weapon that I could possibly find. I did not
    hesitate to consult my colleagues, or even bring urgently
    needed medications from pharmacy. I tried to learn from  inevitable mistakes of myself and others and constantly develop new strategies. I made sure that my patients will be seen in
    a timely manner- day or night. I myself would come many times at night to make
    sure that he is not taking advantage of a shift with one physician and very few
    nurses, to quietly sneak in.

     

    I did not always win though. Many times after a
    long and exhausting battle, he would have the victory.  

    With time, I have also learned
    to respect him, to know when to give up. I ,learned when to stop a useless battle,
    to understand when further fighting will only lead to suffering, but the defeat
    will be inevitable. I learned to talk about him with my patients and their loved ones. I learned how to be there with them making that last and inevitable farewell as painless as possible.

    • Anonymous

      I work in hospice and discuss with physicians the benefits of  hospice on a daily basis.  Not only am I conveying what hospice is and what it isn’t, I am trying to help physicians learn to pass that knowledge on to their patients.  I really liked the comment ” A patient’s death is not our failure, it is the reality of life.”  I feel that when more doctors embrace this fact, we can then provide end of life services to all who deserve it.  All too often in hospice we hear from a family “we wish you would have come sooner”.  Never once the opposite. We all are going to die-that is not a choice.  However, how you choose to do so is.  Thanks for being one of the physicians who understands this.  All too many times others claim to embrace the hospice philosophy but fail miserably with the execution.  No one wants to face this part of medicine. It really can be the hardest part. 

  • http://www.facebook.com/people/Haleh-Rabizadeh-Resnick/1134586817 Haleh Rabizadeh Resnick

    I have a problem when doctor tell patients that they are going to die.  How do you know?  Haven’t you seen and heard of enough patients who don’t die on your predicted timeline? And don’t you think it hastens death to pronounce it’s arrival?  

    Haleh Rabizadeh Resnick, Speaker and Author of Little Patient Big Doctor
    http://www.littlepatientbigdoctor.com

  • http://www.facebook.com/people/Haleh-Rabizadeh-Resnick/1134586817 Haleh Rabizadeh Resnick

    I have a problem when doctor tell patients that they are going to die.  How do you know?  Haven’t you seen and heard of enough patients who don’t die on your predicted timeline? And don’t you think it hastens death to pronounce it’s arrival?  

    Haleh Rabizadeh Resnick, Speaker and Author of Little Patient Big Doctor
    http://www.littlepatientbigdoctor.com

  • Michal Haran

    This is a complex topic. I fully agree with you that in general no time-lines should be given because we really don’t know . Yet, terminally ill patients usually know they are very ill and do want to be given the place to discuss it and so do their loved ones. How, where and when to do it, and with which patient and or family members is the art of medicine and the unique human relationship a physician has with his/her patient. There are no rules for that, or something you can learn from a book.