How does a doctor deal with patients deaths?
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How does a doctor deal with patients deaths?
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I am a new FY1 and encountered two (very potential) deaths in one day - my first ever patients to die. I filled out an LCP form for one of them - who just came from HDU and was dying due to bowel isc
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Forums » Open clinical » General clinical » How does a doctor deal with patients deaths?
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How does a doctor deal with patients deaths?
posted at 25/9/2012 4:51 PM BST
on bmj.com
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Posts: 4
First: 25/9/2012 Last: 29/9/2012 |
I am a new FY1 and encountered two (very potential) deaths in one day - my first ever patients to die. I filled out an LCP form for one of them - who just came from HDU and was dying due to bowel ischaemia. I felt so terrible crossing off all his medications - I felt like I wasn't treating him anymore and was reluctant to cross of his heparin in hope of preventing further ischaemic attacks, hoping to prolong his life as much as possible so he could talk to his son who was just told of his foreboding death by the critical care nurse and myself - during which I found it difficult, but managed, to hold back the tears. As I was filing out the form I couldn't help but discuss the terribly sad story of one of my other patients with the critical care nurse and burst into tears. I was surprised by my own reaction - perhaps its because I am the sort of person that likes to discuss things with others but often feel like my seniors are not interested or have no time - so when I did get a chance with the nurse it was very emotional. I cried about a patient who had just come in 3 weeks previously; a very socially active and intelligent elderly lady with presumably treated bowel cancer (surgical removal and liver ablation to liver mets but no sign of other mets on a recent CT) who was bleeding and we didn't know why. My consultant had just told her that very day that we were to give her a couple more units and that was all (a DNR form was filled out one week previously). She agreed to the further couple of units but how could anyone looking so sick, pale and frail make such a decision? It deeply distressed me that my consultant had made the DNR form and decided on only 2 more units of blood. I was too busy and frankly didn't even have time to think about my emotions to query my consultants decision at the time he made it, but later spend two days feeling miserable about it. I felt like as a doctor I should be saving people, and although I accept death I do not accept passive euthanasia. I feel like I am lacking in information, but overly charged with emotion. I feel like I need to talk to my seniors regarding possible other avenues we could have used for her - I have to trust in their experience over mine and I can't talk to them as I feel it will be too controversial. I guess all I can do is hope that my understanding of why it is necessary to cross off medications when a patient is put on the LCP is necessary, and why we decided to talk such action on the second patient will come with time. I am blogging this as I would like someone to shed some light onto my situation as I don't know whether or not I am mistaken in my thoughts, and would like to know if anyone else is in/has been in a similar position to me. Also, I have tried to research when it is that DNAR forms would need to be considered, and have failed to find clear-cut guidelines on this. If anyone reading this can give me some guidance on where to find this, or has knowledge on this, it would be much appreciated. Many thanks for your time in reading this, Suji |
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Re: How does a doctor deal with patients deaths?
posted at 25/9/2012 6:46 PM BST
on bmj.com
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Posts: 92
First: 20/3/2012 Last: 25/10/2012 |
Hi Suji. I feel for you, I really do. I remember being very emotional when I experienced my first patient who was dying (well, it was a DOA into A&E but we kept up CPR for an hour) and I had to leave for 20 minutes because I was so upset. I still get upset when dealing with patients and their families in this situation and I am frequently on the verge of tears, but then I am a very emotional person anyway. I am a nurse so some of what I write may help, some won't, but here's my views on what you have written. Firstly, as far as I am aware there is no specific guidelines concerning this. Ultimately, it is a patient by patient decision by answering a simple question: If we perform CPR, how will it affect quality of life?. Obviously, it's not as simple as that but quality of life is the main consideration. I just did a quick search on Google and found a useful piece by a Palliative Care Consultant. It is aimed at both nurses and doctors but may give you some help: With regards to the patient that was commenced on the LCP, it is understandable to feel like you are giving up by stopping all the medications. However, that is the aim of the LCP: To stop all unecessary medications, observations and procedures to allow the patient to die with dignity and as peacefully as possible. It is very unusual for a patient who has been commenced on the LCP to continue with any medications...normally the first thing we do is cross them all off. However, you also need to look at comfort and if, by stopping the Heparin, the resultant emboli would cause more pain than getting the Heparin, then you may consider keep using it. Beyond that, having Heparin while being on the LCP would not be worthwhile. As to your other patient, it is difficult when a senior person makes a decision that you are unsure off, either don't understand the reasons or don't agree. As a nurse, it is sometimes difficult for me to understand why a doctor has made a patient DNAR. Although it is difficult, you need to find the confidence to ask and question. Once I had a patient who had been made DNAR by a Registrar and I didn't agree with it (nor did the other nurses) and I questioned the decision. The Registrar tried to fob me off with an answer which I wasn't happy with and so I continued to press and even asked another Registrar to review it. Eventually (and it took a couple of days) they reversed it and made the patient For Resus again (it helped that the patient improved during that time). While I could have let it go, like the other nurses and doctors, I have always adhered to one of the most important rules of nursing (and medicine): We are there for the patient and we must be their advocate if they can't speak up for themselves, especially if it is something they are unaware of. I can understand to some degree the Consultant's decision as he/she is looking at a sick, frail eldely lady who has had cancer previously (which may return elsewhere) and who is bleeding from an unknown source. In this situation, the question would be: If she arrests and we resuscitate, what would her quality of life be? How is her quality of life now? The problem is that, while it is upsetting to be told only 2 pints of blood and no more, you have to understand that you can't just keep going with more and more blood (how many more pints would it take? 10? 20?). Would the patient be able to tolerate the investigations required to try and find the source of the bleeding? Would it cause her too much trauma? You are right to question these things and, with experience, you will begin to understand, more and more, the decisions that we have to make everyday. Yes, you could look at it like passive euthanasia and I understand why you do but sometimes it is better (or more humane) to do nothing. As a nurse, as with doctors, we are always doing everything in our power to heal people and make them better and it is very difficult to accept defeat (after all, the Hippocratic Oath says "I will do no harm" or something along those lines but, sometimes, subjecting a patient to more tests, exams etc in a futile cause, can be causing harm. I have been a qualified nurse for 11 years, working in Cardiology all that time which is a Speciality where we are sometimes the last to give up on a patient, even when others have (We once put a Pacemaker in a gentleman who was 104 because it would improve quality of life...age was irrelevant) and have been in healthcare for 20 years. I have seen most things and seen a lot of dying (from heart patients, to patients in a burns unit, to patients in a bone marrow unit) and I still struggle. My advice is: If you are in doubt, then ask. If you are unsure or disagree with a decision, then speak up...even if it means questioning seniors. If they are any good, then they will respect you for it rather than being annoyed. I hope some of that has made sense and it helps a bit x
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Re: How does a doctor deal with patients deaths?
posted at 25/9/2012 7:11 PM BST
on bmj.com
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Posts: 321
First: 12/11/2010 Last: 8/5/2013 |
Remember that prior to seeing the patient at work you had never had anything to do with them and once they leave the hospital you would also have no further contact. They are not relatives, they are work: You have to learn to package up the emotions in a mental box at the end of the day; nail the lid on and then throw the box away. Otherwise, you can end up never coping. |
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Re: How does a doctor deal with patients deaths?
posted at 25/9/2012 7:52 PM BST
on bmj.com
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Posts: 92
First: 20/3/2012 Last: 25/10/2012 |
In Response to Re: How does a doctor deal with patients deaths?: Remember that prior to seeing the patient at work you had never had anything to do with them and once they leave the hospital you would also have no further contact. They are not relatives, they are work: You have to learn to package up the emotions in a mental box at the end of the day; nail the lid on and then throw the box away. Otherwise, you can end up never coping. Posted by TimReynolds You make an excellent point there Tim and I totally agree with you. However, not everyone is able to compartmentalise their emotions. I have been dealing with patients for 20 years in one way or another and I still worry about my patients after I leave work....not enough to affect my life outside work but still. I guess it is slightly different for nurses given that we become a lot more involved with the patients. Anyway, I still occasionally worry but I have, through experience, learnt to balance it out. But, certainly, you have to find a way to cope with the emotions you go through, be it, compartmentalising as Tim suggests or having a very good friend that you can talk things through with or some other mechanism that helps you. Each person has their own way of dealing with what we see every day
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Re: How does a doctor deal with patients deaths?
posted at 27/9/2012 11:51 AM BST
on bmj.com
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Posts: 1784
First: 7/3/2009 Last: 18/5/2013 |
I don't necessarily agree with Tim Reynolds. Packaging away emotions for me is not possible and not my advice. Coping with emotions is. Creating a "block" between you and the patient, be he/she as ill as it gets should not happen. You need to think hard and you need to be absolutely sure you have done all. Saying 2 pints of blood is all and nothing further will be done is cruel in my opinion. If a patient is in sound mind, wants to live and we don't find the source of bleeding it is not enough in my opinion to rid yourself with 2 pints of blood.What made the registrar decide so? What was the source of bleeding? There are modalities to find bleeding site and sometimes we do perform laparscopic investigations to try to establish what bleeds and where.That gives also the possibility to try to stop bleeding. So, I would go with what Nursemorph says. Every case is individual. Every patient is a living human being. It is difficult to lose every single patient. You learn to cope but not to block emotions. If you become insensible then you should think about changing to a speciality where you need not deal with patients, Pathology for instance.
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Re: How does a doctor deal with patients deaths?
posted at 27/9/2012 12:32 PM BST
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
I write a letter of condolence in a quiet moment. It gives me time to feel, sometimes to get stuffy in the nose and wet around my eyes when no one is around I dictate it as if that person's loved one was with me and I talk of the patient as remembered smiling to a joke. I tell a tale of love and reflection. I feel my voice quiver and my feelings issue forth like water from that rock and sometimes I surprise myself as this other person, the real me, and not the rock, has brief licence to emerge. No one knows this but you . I do it in my own confessional, my own cell. I do it because I feel and my Muse writes for me. I see that great picture on the ceiling of the Sistine Chapel; God touching the finger tip of Adam reaching forth. For just a moment we touch and God breathes life back into me. Odysseus |
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Re: How does a doctor deal with patients deaths?
posted at 27/9/2012 12:48 PM BST
on bmj.com
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Posts: 1784
First: 7/3/2009 Last: 18/5/2013 |
In Response to Re: How does a doctor deal with patients deaths?: I write a letter of condolence in a quiet moment. It gives me time to feel, sometimes to get stuffy in the nose and wet around my eyes when no one is around I dictate it as if that person's loved one was with me and I talk of the patient as remembered smiling to a joke. I tell a tale of love and reflection. I feel my voice quiver and my feelings issue forth like water from that rock and sometimes I surprise myself as this other person, the real me, and not the rock, has brief licence to emerge. No one knows this but you . I do it in my own confessional, my own cell. I do it because I feel and my Muse writes for me. I see that great picture on the ceiling of the Sistine Chapel; God touching the finger tip of Adam reaching forth. For just a moment we touch and God breathes life back into me. Odysseus Posted by Odysseus I agree with you Odysseus.It is a noble way to say goodbye to a person whom you tried to help but couldn't beat death. And the families, I think the families find comfort in a human reaching out to them and sharing with them the memories of their loved one. That is what I think defines a Human.
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Re: How does a doctor deal with patients deaths?
posted at 27/9/2012 2:05 PM BST
on bmj.com
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Posts: 224
First: 15/5/2012 Last: 20/5/2013 |
Suji: Please do not see your patients as work. I have been practising Medicine and Surgery for 17 years, and, everyday I view it as a blessing and a privilige. Dealing with death is always a struggle and it diminishes you. All that is asked of us is to care and do our very best. Please take time to talk to your mentor/advisor and share your feelings and ask your questions. Please do not disassociate and lock your feelings- for one day, they will explode in your face. It is natural to feel emotions- the encouraging thing here is that obviously you care. |
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Re: How does a doctor deal with patients deaths?
posted at 27/9/2012 3:12 PM BST
on bmj.com
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Posts: 1784
First: 7/3/2009 Last: 18/5/2013 |
I would rather be treated by you Suji, than by someone who regards patients only as work. Never lose your humane feelings. Learn how to use them to do the best for each patient and be encouraged that you really care. That is where your strength comes from. It is no weakness. Those who don't care and create a wall are the weak ones and they are the ones who don't allow themeselves to take a frank open look at themselves. Your conscience is clean and I believe the dying patients were grateful for you having been there for them in their last days and hours of life.I strongly believe in that something being establshed between the souls of humans. It makes the transition of passing away easier for them.I can't prove it scientifically, but I believe in it.
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