Why I still cry

Share a young internist's reflections on the death of a patient at the end of a long day.

I have been in this place many times before, yet the sorrow feels fresh and new. They tell me it will get easier with time, but it doesn't.

Walking home along the crowded sidewalk, I feel alone. The sky is pale gray, and a gentle mist surrounds me. The mist seems uncannily suited to my mood. I battle against the tears that are beginning to pool—I'm not willing to share my emotions with the rest of the world. Yet the wrenching sensation in my stomach and chest prevails as I recall the words that I'd uttered just minutes before: "Time of death, 5:13 pm."

Muriel was not a young woman. At 71, she had a host of medical problems—underlying idiopathic pulmonary fibrosis, chronic cor pulmonale, and atrial fibrillation. On top of those, she had recently been diagnosed with breast cancer.

She'd been admitted to the floor for cellulitis and was transferred to me in the MICU several days later with hypoxic respiratory failure. Her functional capacity was limited at baseline, and her condition upon transfer was grim. Tubes protruded from nearly every orifice. Her matted hair framed her listless face and her hospital gown clung to her rotund body as our team of nurses, doctors, and respiratory therapists swarmed around her.

I'd met Muriel's husband and daughter yesterday afternoon when, in my sleep-deprived state, I did my best to explain her condition. My voice was tender—it was almost as if their pain and suffering were my own. A thick melancholy invaded the air, making it difficult to breathe. Their grieving process had already begun, and they looked to me for guidance. Inside I choked up as her husband asked me, "If this were your mother, what would you do?"

I'm fairly certain that if I'd advised them to stop all efforts right then, they would have. Sometimes the power we physicians have terrifies me.

Instead, I advised giving Muriel 24 hours to wean down her oxygen on the ventilator; then we would reassess her progress. Despite successful weaning, by morning things had taken a turn for the worse. Her blood pressure had fallen low enough to require pressors, and her WBC had doubled. Prognosis: sepsis.

The nurse told me that the family appeared ready to withdraw care, so the attending, the nurse, and I joined Muriel's husband, son, and daughter in a small waiting room adjacent to the MICU. The gloom in the air was suffocating.

An eerie sense of sorrow penetrated my core as I was filled with memories of all the end-of-life discussions I'd had with families over the years. I felt simultaneously enmeshed and withdrawn from the family in front of me. Their suffering was clearly expressed in their heavy eyes and sagging shoulders; I knew they were ready to let go of their loved one.

Appropriately compassionate, the words flowed easily from the attending doctor, almost too easily. However, I took comfort in the hope that his words had brought the family a bit of solace during this difficult time.

As senior resident it was my responsibility to withdraw care. I entered an order to discontinue Muriel's blood pressure support and to begin a morphine drip. We had emphasized to the family that our primary goal was to make her comfortable. We all hoped that without her pressors, her blood pressure would rapidly fall and she would pass gently without having to extubate her. After two hours of waiting, it was clear this was not going to happen.

Although her blood pressure had fallen, Muriel maintained a solid pulse. I approached the family and asked if they wanted to continue to wait or if they wanted us to discontinue her ventilatory support. Her husband, without hesitation, said that he wanted us to extubate her.

I asked Muriel's nurse to give her an extra bolus of morphine so she wouldn't experience air hunger when we removed her endotracheal tube. Just then, as her nurse was pushing the morphine, the waveform on the cardiac monitor widened, and Muriel passed away. I confirmed that she no longer had a pulse and pronounced her. Despite having done this countless times, I marveled at the awesome responsibility we have and our influence on life and death.

I walked out of the room, leaving the family to spend a last few moments with Muriel. A haunting emptiness assaulted me as I found myself suddenly detached from my bustling surroundings. Although confident that her death was for the best, my inability to save her left me with a sense of inadequacy. I was permeated by a huge sense of loss—the loss of my patient, the loss of a life.

As I walk home alone, I can't stop thinking about Muriel's family. Her husband's creased forehead, the tears in her children's eyes. Do they know how they have moved me? Do they know the heartache I feel over their loss? Do they know I am still thinking of Muriel as I walk down the corridor, ride the elevator, and escape the hospital walls? I can still feel my fingers on her skin, searching for her pulse but finding none. Time of death, 5:13 pm.

 

Jennifer Rosenblum. Why I still cry. Medical Economics 2002;13:65.