Monday, August 8, 2011

A Good Death

My last patient died yesterday when I was post-call (aka, I wasn't in to the hospital).

This morning when I logged on the EMR (electronic medical records), I thought it was odd that it listed him as "discharged." I thought to myself, "Why would anyone discharge him? He's far from being stable enough to go home!" Later during rounds, the attending told me and the intern taking care of him that he died Sunday night.

I wasn't surprised (he was in really really bad shape with zero hope for recovery) but it still shocked me a little. The family had decided to declare him DNR (do not resuscitate). Within 24 hours of his death, most/all of his family had flown in from all over the US to be with him in his final hours. He was put on palliative care right away, but since the palliative team doesn't work on the weekends (wtf is up with that?), my attending began standard administration of morphine to ease the pain. His breathing rate was high and the morphine actually brought it back down to normal. He died some time later.

I almost cried a little but it wasn't the time and place. I had only known him for about 3 days and we did everything right by him. As the senior resident later remarked, "I'd rather be dead than live on through that." His rights were respected (his son had the power of attorney) and by all accounts, he died a good death - quick, and not drawn out like with cancer.

What do you think? Is there such a thing as "a good death" and if so, what is it to you?

12 comments:

robert said...

Absolutely there is such a thing as a good death. I think you have to organize it yourself and have the drugs for self-delivery available. When you or those who love you think it is time to let go...you do it.

I experienced the no weekend work schedule in palliative care and wondered the same thing as you. Unfortunately that is when the death took place. On the previous Friday, the bed had to be changed because hospice was paid by a different agency. A nearly dead woman is moved from one bed to another in the same room based upon "the rules". Everyone was embarrassed by that debacle.

When the hospice team returned on Monday, nobody had informed them that the patient had died on Sunday. Awkward.

I was recently with a close friend who delivered himself after undergoing treatment for pancreatic cancer. He was at home, surrounded by friends and family, soft music and the scent of sage in the air. A good death? I think so.

I don't know why Americans have such a difficult time dealing with end of life care. I can only guess that denial has much to do with it.

Mike said...

That has got to be one of the toughest things to experience as a doctor. :::Hug:::

Jake said...

Suddenly my day doesn't seem so bad.

That would definitely be a good death. Part of me wants to say that having cancer and a chance to live crazy for say 3 months before you die would be awesome too, but I couldn't do that either. The gnawing feeling that you will soon be dead would be too much to stomach for a full 3 months.

A Wandering Pom said...

Aek

I'm sorry to hear about your patient: this must be one of the hardest parts of working in medicine.

As for your question, yes, I definitely believe there is such a thing as a good death - quick (though with enough warning for loved ones to prepare themselves), painless, and preferably with the knowledge of a life lived well.

Take care

Mark

Biki said...

Yes, I think there is such a thing as a "good" death. Its one that is quick enough not to drag out, put loads of stress on the family. But not so fast that one doesnt have time to say goodbyes and say what you feel the need to say.

That is one part I would find hard about being a doctor, having patients die.

Uncutplus said...

We are all mortal, and my medical power of attorney knows that my wishes are to let me go quickly and peacefully when that time comes, if I am unable to make the decision myself.

None of us know of the time and place, but I have seen many who appeared to be healthy come to any early end, because our lives are indeed fragile. I am indeed thankful for all the wonderful days I've had so far on this journey.

Stephen Chapman said...

Life is tough, but life in pain must be awful. A quick painless death, when you will die soon anyway, has to be the way to go.

If that can happen when I am 112 when just finishing the London marathon, I will be happy.

Mind Of Mine said...

Yes, I do believe there is good death. Someone who is suffering and in pain, where there is no chance of recovery or there would be no quality of life, would definetely be considered a 'good' death.

Someone sacrificing their lives to save someone else, although tragic it is also very noble.

The same can be said of organ donor deaths.

fan of casey said...

Aek: I think your reaction was appropriate. You still should feel empathy yet you do need to keep an emotional distance because you cannot be so invested in every patient you see. It is a difficult balance but you will find the right mix as you get more experience.

On another note, I saw this article on long shift hours that interns and residents have to do and wondered what you thought of it. My brother had to go thru the 30 hour shifts as part of his residency training and being an outsider, I thought it was ridiculous and an archaic practice akin to hazing. Not surprising if you read the comments, many old timer and retired doctors defend the practice while some newer ones support the change.

http://www.nytimes.com/2011/08/07/magazine/the-phantom-menace-of-sleep-deprived-doctors.html?hpw

Ron said...

I wouldn't say that there is such thing as a 'good death', but probably more a 'more preferred method and process of death'.

Ron said...

yeah i just did an entire reflective essay on safe hours regulation for junior/trainee doctors. there seems to be the most resistance from older generation of doctors, especially those from the surgical profession.

flying against the face of evidence-based research.

why is it that older generations are such a big fan of sticking with practices that are demonstrably harmful to people?

and some argue 'patient ownership', and that if you stay at the hospital for excess hours and end up being the first person to catch your patient's lab results, that makes you more 'identifiable' to the patient as 'their doctor', and others argue that there will be a poor 'shift work' mentality among new doctors.

what a load of bullshit.

what identifies you as your patient's doctor is the compassion you provide your patients, the time you spend educating them about what they're going through/what they have to go through, demonstrating that you're working within a whole team that is dedicated to their well-being, and being able to empathize with them.

look at ICU and emergency medicine. they work shifts. there are tons of handovers there. yet they are able to still provide proper care.

Aek said...

robert: Death is indeed a difficult thing to deal with. The last physician I worked with made it her point to ask every patient about code status regardless of their diseases.

Mike, A Wandering Pom, Biki: Hmm, not particularly (considering I only knew the guy for about 3 days). The hardest thing so far is spending all this effort making someone healthy enough to leave the hospital, knowing full well that they're going to come back because they refuse to change their lifestyle habits.

fan of casey, Ron: I read that article. Thankfully things aren't as bad as they used to be.