In medical training, each morning begins with pre-rounds, a sort of prologue to the work day that gives us a preview of our patients’ conditions. Like a daily ritual, we arrive in the hospital as the sun begins to peek over the horizon and proceed to visit each of their rooms. Some of them are still sleeping, but we wake them up anyway to needle them with questions. Any pain? Fever or chills? Were you able to walk around and eat and drink? Have you had any bowel movements or gas?
After jotting down their answers in a sloppy shorthand, we do a brief physical exam and move on to the next patient.
The patients’ responses are a gauge of their progress or lack of it. If they are pain-free and capable of walking and using the bathroom, then we’re more likely to discharge them from the hospital.
Recently, one of these patients was Mr. B. He was still a young patient, with a history of drug abuse and a failing heart that had led to multiple admissions to the emergency room. If a normal heart was meant to pump enough blood to fill a milk jug, then his could only fill a soda bottle. His feeble ventricles would only sustain him for a few more months, and he knew it. He was constantly reminded of it by his losing struggle to catch his breath and his distended abdomen full of fluid that would compress his chest with so much weight that he couldn’t lie on his back.
Imperceptibly over time, medicine becomes a routine for the patient and the provider. But the certainty of an early death disturbs this routine. Those questions and physical exam findings during pre-rounds suddenly seem puny and irrelevant, overshadowed by the looming certainty of an end. When you’re guaranteed to die within a handful of months, not having a regular bowel movement doesn’t seem as important as it once did.
So how do you talk to a dying patient? I ask myself this question every morning as I knock on Mr. B’s door.
Perhaps I’ll treat him like any other patient. I’ll feel his pulses, listen to his heart and lungs, feel his legs for any swelling or pain and abscond away without a second thought. But that would be a callous approach to caring for a dying man.
So I’ll stay for a few extra minutes then. The hospital is a lonely place and maybe he needs some company, another presence in the room who acknowledges his humanity. I’ll take a seat and delve into his life story. I can ask him about his family and his hobbies and travels. I can ask him about his future — what would he want to achieve in the next few months? Or would such a conversation be too painful a reminder of what he will be leaving behind and what he will be missing?
Maybe Mr. B still believes he will recover and be discharged. I could tell him to grasp onto any hope no matter how slim. Or would that only set him up for cruel disappointment? Maybe then it would be better to use words that will ground him in reality, nudging him to make the most of his time left.
I could follow the cliché-laden script that we were once taught in class. But what if he saw through my act and interpreted it as a sign of insincerity?
Or perhaps I should just focus on maximizing his comfort. I can recommend adjusting his medications to relieve any aches and strains, increase his oxygen flow, and grab him a few extra pillows to prop him up during the night. But would that imply that his medical team has given up on him?
I could keep the conversation topical. We can talk about baseball (he’s a lifelong Chicago Cubs fan), the weather, the horribly bland hospital food or politics. Maybe that will distract him for a few moments, relieve him of the constant pang of knowing that he is slowly drowning inside.
I can only hope that whichever words that I ultimately choose to pass along to Mr. B, the underlying message will leave him with a sense of peace and convince him to not take his existence lightly for he has left a permanent impression on a young doctor-in-training.
Steven Zhang is a medical student who blogs at Scope, where this article originally appeared.
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