COMMENTARY

Learning and Unlearning: How Medical Training Can Help Students Process Patient Deaths

Abdikarin M. Abdullahi

Disclosures

April 29, 2022

A group of nurses stood huddled outside my patient's room: an elderly man with end-stage cirrhosis and wavering mental status. As I walked by them to enter the room, I thought to myself, I wonder if he'll remember me today. My patient, who was a sturdy man with graying hair and a friendly smile, was sprawled out in his hospital bed with his lunch tray on his lap. Before I could jump into our usual morning dance, he beat me to the first step in our routine.

"What day is it today? Is it the 13th? I need to get a card for my girl; tomorrow is Valentine's Day!"

As he said this, he sat up in his bed and fixed his eyes on me. His piercing gaze melted away the bed he was sitting on and silenced the commotion of the hospital. He's here, I thought to myself. Actually here. I never knew whether he would be capable of having a conversation when I walked into his hospital room, so I was caught off guard when he snapped back into his usual self to make this request. The love he had for his wife was enough to reorient him that day, and I couldn't help but feel optimistic about his progress. I have to get that card, I thought, as we continued through our morning encounter.

I purchased a card that night with excitement and optimism. With his wife visiting him the next day, I believed he would only become more alert and oriented. Instead, I was met by an unknowing and distant gaze the next morning. The card lay forgotten on his hospital table as he began refusing all treatment, and he quickly deteriorated.

I was given the opportunity to speak with his wife in a goals-of-care conversation, and she ultimately made the decision that hospice would have been what he wanted. Although we, unsurprisingly, couldn't save him, I took solace in the fact that he would at least be comfortable. 

It's hard to explain what I was expecting when I checked his medical record a few weeks later. A notification appeared across my screen. He was deceased. The feeling of satisfaction with focusing on comfort measures somehow transitioned to sadness, and I quietly sat alone in my room, wondering what all this training was for.

Death. As a medical student, even typing that word produces an almost visceral reaction. We have been inducted into a profession sworn to heal. The lengthy and overwhelming training we undergo is a testament to our desire to preserve and protect life. But for a profession that demands we tether ourselves to the line separating the living from the lost, the concept of death feels almost taboo. Our training focuses so exclusively on recognizing pathology and preventing death that the loss of life often feels like a personal failing.

My second pivotal clinical experience with death came during the pandemic, when a brilliant team of University of California, San Francisco, residents and medical students addressed the solitude created by visitor limitations with an iPad video chat project. I had seen for myself how difficult the lack of visitors can be for patients, so I enrolled as a volunteer.

During one of the video calls I was trying to set up with a patient's family member, a second nurse walked into the room. "She's really pale; what's going on?" she exclaimed loudly. My frail, elderly patient extended her hand inches away from my arm, and then her hand dropped. Almost simultaneously, a family member of the patient picked up my call as a room of nurses assessed our patient for what they believed to be her demise.

There was initially some uncertainty about her status, and I remained in a state of limbo as we awaited a final determination. "Tell her son that the primary team will call them shortly," a nearby nurse gently advised me, so that a provider involved with the patient's care could break the news. My thoughts couldn't stop racing. This family member would've been able to say goodbye if I had only set up the call minutes earlier.

I had failed again.

The resident physician caring for the patient would soon enter the room and pronounce the patient deceased. But this time, I wasn't left to wrestle with the loss of a patient alone. The resident debriefed with me outside of the room, and she also invited me to join her team to discuss what happened. We talked about the patient's life, her hobbies, and what the team had learned about her during her hospital stay. They mentioned that she had the comfortable death she wanted.

Later that day, a resident leading the iPad project also debriefed the incident with me and was even kind enough to purchase my lunch. The next day, I received an email from an attending at that hospital with an offer to debrief if I wanted to discuss further.

There were two notable lessons from this second experience. The first lesson is that the opportunity to debrief in a supportive environment allowed me to offload my grief and embrace my humanity. The loss of life wasn't business as usual; space was created for both me and others to process the loss of our patient.

The second lesson is that instead of silently carrying a feeling of failure with us, we were able to celebrate her life and acknowledge that death doesn't necessarily equate to a "lost battle." For this patient, it was a comfortable end to her journey and our team was able to ease that passage.

The pandemic has brought with it a tremendous burden of death, both domestically and globally. Healthcare workers are confronted with death daily at a staggering and unprecedented rate, and this undoubtedly will have profound mental health effects. We need to create intentional spaces to process those feelings and support each other, but this will also require transforming the way we conceptualize and teach death in medical education and clinical practice.

A common refrain I hear is that the loss of a patient will sting less as a trainee gains more experience; that repeated exposure to death will lead to some emotional blunting.

I don't want it to sting less; we just need to be there to pull the stinger out for each other.

Abdikarin Abdullahi is a fourth-year medical student at the University of California, San Francisco, and is pursuing a master of public health degree at the Johns Hopkins Bloomberg School of Public Health. He is interested in the intersection between health inequities and health policy, medical education, and social justice. He is looking forward to dedicating his future career to mentorship and working with underserved communities.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....