Nothing in medical training really prepares you for the death of your first patient, the first time you officially pronounce a patient dead, the first time you tell a family member their loved one is gone, or the first time you fill out a death certificate.
The experience itself is the teacher.
I was an intern working a rotation in the general medicine inpatient ward. I had admitted a patient who had advanced stage stomach cancer. He had severe anemia due to slowly leaking blood vessels caused by the large tumor invading the layers of his stomach. I ordered a blood transfusion and spoke with his oncology physician about his prognosis, which was grim. There were no more treatments to offer, no more chemotherapy, no more radiation. But the patient was not aware that this was the end of his treatments, either because he didn’t hear it when the oncologist told him, or the news had not yet been delivered.
So, I told the patient the truth. There in his hospital room, with his daughter present, I told him there were no more treatment options, that the best thing for him would be to have another blood transfusion, consult the hospice service, and get home as soon as possible so that he could be comfortable and die in his own home. We agreed I would discharge him the following morning, giving me some time to get everything ready and his daughter time to prepare the home. The patient then broke down in tears, as did his daughter, and they both agreed it was the best course of action. He did not want to die in the hospital.
The following morning, I was working on the computer, putting in his discharge orders, when I got a page and heard the overhead announcement of a rapid response in my patient’s room. I ran down the hallway and pushed my way through the throng of nurses, nursing students, and the respiratory therapist. I looked around quickly and noticed I was the only doctor in the room.
Then I looked at the patient.
He was sitting up in the hospital bed with a splash of bright red blood all over the front of his gown, the bed sheets, and the towels his nurse had used in an attempt to wipe up the blood. There was a trickle of blood from his gaping mouth. His eyes were open, looking up at the ceiling. His limbs were frozen, and his chest was still.
I quickly looked around the room again, now filled with the shocked faces of nurses and students, and still, I was the only doctor present. I then understood it was my job to examine the patient and pronounce him dead. My heart was racing as I tried to remember what I was supposed to do. Listen for a heartbeat with my stethoscope. None. Feel for a pulse with my shaking hand. None. Look for a rise of the chest with my blurry eyes. None. Shine a light into his eyes to look for a pupillary response. None.
I looked up at the clock in the room and said the words, “Time of death, 7:10 a.m.” The nursing students were crying, the patient’s nurse had silent tears running down her face, and I was desperately trying to hold back my own.
I stepped out of the room only to see the patient’s daughter coming down the hallway, as she had gone to the garage to get her car to take her beloved father home. She came up to me and briefly smiled before she saw the look on my face. “What?” she asked me with fear in her eyes and voice. She tried to go into her father’s hospital room, and I stopped her.
I had to say the second hardest words of the day. “I’m so, so sorry, but your father has died. He started bleeding and we were unable to stop it.” She immediately started sobbing loudly and again pushed to get into the room. I asked her to give us a little time to get her father ready.
I re-entered the room where the main nurse was starting to wipe the blood off the patient. The nursing students had started to come out of their traumatic fog and were helping as well. Soon the patient was presentable, with clean white sheets, and no trace of his red death. We brought his daughter in and left her alone to say goodbye.
I went to the computer to fill out my first death certificate, fighting back tears. Again, I tried to remember what I had been taught. At that moment, my senior resident walked up to me and asked what had happened and what he could do to help. I recounted the events, he expressed some sympathy, and gave me some guidance on how to fill out the death certificate.
I learned so much more that day than about the intricacies of death. More than how to deliver bad news, how to confirm death, how to fill out death paperwork, how to console grieving caregivers and family members. I learned that I had the capacity to contain my own distress in order to get my job done. Though I was saddened that my patient didn’t make it home to die, I realized in a way it was a blessing. His daughter did not have to see all the blood and nurse’s tears, which would have added to her own trauma and grief. She could remember her father pristine and peaceful under white sheets, erased of the evidence of his bloody death.
What did you learn from your first patient death? Share below.
Dr. Brooke is a physical medicine and rehabilitation physician. She works at Renown Rehabilitation Hospital in Reno Nevada where she is the Stroke Program Director. Dr. Brooke was a latecomer to medicine; her undergraduate degree was in English Literature and she had a previous career as a massage therapist and small business owner. All names and identifying information have been modified to protect patient privacy.