It’s painful enough to lose a patient. But I found it even more painful to try to console a family whom I’d never met.
Depending on your point of view, the limited patient contact afforded the anesthesiologist is a disappointment or a perk of the specialty. Anesthesiologists are steadily branching out into other areas of perioperative care where lengthier patient/family contact is necessitated but the preop encounter with the anesthesiologist is short and to the point. Nothing like an outpatient visit with a new internist.
With the pressure of a busy OR schedule it’s challenging enough to establish minimal rapport with the patient, even more so with a family. Then because many patients won’t remember that conversation because of the anxiety of the moment or the amnestic sedatives we give it may cause us to dismiss those critical few preop minutes even further. Time constraints and OR emergencies make it particularly difficult to fully engage in emotional conversations involving advanced directives, goals of care, and worst case scenarios with patients who are very, very ill. These types of conversations should almost always be had with the patient in the presence of family. But too often I fear these topics may be glossed over, avoided, or not specifically addressed with family at all.
One time I was guilty of this. I was very busy. The family was not at the bedside. The patient had a moderate degree of medical risk for a not all that uncommon surgical procedure that could be very complicated but normally goes well.
Again anesthesiology is different from other specialties. We don’t lose many patients. Anesthesiologists are not acquainted with patients dying on the scale of surgeons or intensivists for example.
Contrary to popular belief anesthesia is very safe and is becoming safer all the time.
When a patient does die on our watch many times it comes as no surprise. Gunshot to the heart. Ruptured aneurysm. The blow is softened because there wasn’t much we could have done anyway.
Even when patients have surgical or anesthetic catastrophes in the OR they rarely die in the OR. They go to the ICU or palliative care. Out of sight, out of mind for the most part.
But when a patient dies unexpectedly in the OR it is a very bad day. Shocking. Out of the ordinary.
I went and found one daughter weeping alone in the consultation room. If she had raised her head from sobbing she would not have recognized my face. Because we had never met. I had been too busy. I placed a hand on her shoulder but it was a cold gesture and unreceived. I was just another stranger in scrubs.
I felt in that moment like I had betrayed that medical student I was years ago who went to the funeral of the first patient I ever took care of. I followed him through his hospitalization to discharge to readmission and ICU complications till his inevitable demise from heart failure. His widow greeted me by name and embraced me beside his casket.
I admit there are practices I have come to rationalize that are at odds with what I knew and valued from the very beginning. This was an unfortunate way for me to be reminded of those values.
Anesthesiology is at the forefront of systems improvement in patient safety. Transfer of a patient from one caregiver to the next is very complicated and risky so “handoff communication” is the latest in these efforts. The communication that takes place between families and physicians especially the preoperative encounter is critical. Its importance, like handoff communication, cannot be neglected. Families are placing the life of their loved one in my hands. I must do everything to reach out to them and assure them of my firm commitment to do whatever is in my power to keep their loved one safe. And when the worst does unexpectedly happen, I must be ready to be a steady and familiar shoulder.
Jason McKeown is an anesthesiologist who blogs at McKeown’s Bevel.