“Have you ever pronounced someone dead before?”
The question caught me off guard. A few minutes earlier, I had gone looking for my resident to check in about any other tasks we needed to complete for our patients. He asked me, “Did you hear? Your patient, Mr. J, passed away. . . .” Five-second pause. “Have you ever pronounced someone dead before?”
You aren’t really taught to be a doctor so much as you are told to pretend to be a doctor until you feel like you are one.
Medical school is a less elegant process than one might expect. After a few years of coursework, you begin two years of the apprenticeship model, learning how to care for patients by doing just that. Of course, your residents and attending physicians watch nearly every step you make, but it is mainly a learn-as-you-go process. You aren’t really taught to be a doctor so much as you are told to pretend to be a doctor until you feel like you are one.
For the most part, this is a successful teaching method. In particular, it helps develop your physical examination techniques, your diagnostic reasoning, and your ability to perform procedures. All of these skills can be incorporated into daily rounds with patients without adding much time. Every patient needs to be examined, have a diagnostic plan, and have procedures performed on them. So letting a medical student handle these tasks in the presence of supervisors, although it adds extra time, is essentially doing a service that would have to be done by others anyways.
But the part of becoming a doctor that is not so easily incorporated into the busy hospital apprenticeship model is learning how to deal with heavy emotional situations. Particularly learning how to deal with these situations while taking care of many other patients–how to deal with death when it is not the focus of your day, but rather just a transient part of it.
Technically, I had been prepared for this moment—for the moment my first patient died. During the first few years of medical school, my classmates and I talked about death and dying in the classroom, and about hypothetical situations in which we would have to deal with “end of life” issues. Of course, this involved discussing some of the legal and ethical decisions that go into end-of-life decisions as a preview to what we would eventually have to do. But we also read prose and poetry by health professionals about caring for dying patients that highlighted their emotional experiences. My medical school curriculum was entirely case-based, so we actually learned medicine by walking through the course of care for hypothetical patients–from the patient initially coming into the clinic to being cured of her or his disease (or not). I distinctly remember the first case we had in which a patient died. We had a fairly long discussion about how this patient dying was affecting us; we discussed potential ways to cope for when it would happen in real life down the road. I give my school credit for addressing these issues in the classroom before I had to deal with them in the hospital.
But, of course, it’s different when it happens.
I had been taking care of Mr. J since he came into the emergency department a week earlier. The emergency doctor paged my senior resident, who then told me to go down to the emergency department and examine Mr. J. The patient was a seventy-two-year-old man with a history of lung cancer, who had been on chemotherapy in the past. He was short of breath and tired, and his partner had finally called an ambulance to bring him to the hospital, against his wishes.
Mr. J was not happy to meet me. He insisted nothing was wrong, and wanted to go home. He was breathing quickly and his oxygen saturation was low. When I put a stethoscope to his chest, it sounded like someone was blowing bubbles through a straw, a sound referred to as “crackles,” suggesting there was fluid in his lungs. Sure enough, an X-ray confirmed the fluid, and we admitted him to the hospital. After he was settled in his room, I reviewed his old records. His story was eerily similar to that of my grandfather, Papa, who died a few years earlier of lung cancer himself.
My mother’s parents lived in the same city as us, so I was at their house a lot growing up. Papa was a proud, quiet man of few words, but he did not need them to show he cared. He came to every grandparents day at school and every graduation. He used to take my cousins, siblings, and me to the park growing up, where he would walk around a lake with us at a calm pace as we ran around in all directions, averaging the same pace as him with our inefficient circling advances. Whenever he would come home from work, he would “surprise us” with breadsticks that he had stashed in his coat pocket (as if it was a possibility that he would forget to bring us a treat) from the hotel where he worked as a security guard. Although he was quiet and calm most of the time, he had a great sense of humor, which is what I miss the most about him. He would use his default demeanor to his advantage to tell deadpan jokes, leading on whichever kids happened to be visiting him that day. And when he heard something funny, he would reveal an enthusiastic smile that was infectious. As a child I remember one day asking him about why he had a Band-Aid on his head. He convinced me that a tree had started growing out of him, and that he had had to chop it down before it got too big. I was sure that my seemingly serious grandfather was telling the truth, and wondered why all the others around me were laughing.
Papa had been admitted to the hospital repeatedly for shortness of breath due to fluid in his lungs, and I remember looking at this situation from the family perspective. I remember asking my parents, who are in the medical field, what was happening with Papa.
“He was having trouble breathing, so we brought him into the hospital. They found some fluid in his lungs, and they are going to take it out.”
“So he’s going to be okay? For now?”
Similarly, Mr. J had been coming to appointments at the hospital fairly regularly over the past few years after being diagnosed with lung cancer. His cancer was not operable, so he had received chemotherapy, but now the cancer had relapsed and it was causing fluid to build up rapidly.
I spent a lot of time with Mr. J and his partner, Ms. S, over the next few days. We had a routine: I came in to check on him, and he demanded I explain why he couldn’t go home yet. Of course, he knew that I would answer him politely, and that he couldn’t really frazzle me. If he had to be there, he was going to give me a hard time as well.
I took care of Ms. S. too. I didn’t care for her medically, but I talked to her as much as I did to Mr. J. I remembered what it was like being at Papa’s bedside. I remember wanting to hear updates from the doctor about how he was doing, and hoping the doctor would come to check on him so that I could ask questions. So many questions would come up throughout the day, and the day would always seem like a week. All day I was trying to interpret Papa’s progress based on random movements he would make or readings on machines that I didn’t understand. But then I realized that most of the time, you only get to see the doctor for a few minutes once a day. And most of the time, due to no fault of their own, they cannot predict the future. But while the doctors were equal in their ability to predict the future, those that I appreciated the most were the ones who took the time to ask if I had any questions, to really explain things to me, and to see how I was doing. If the doctor did that, then things seemed slightly more tolerable right afterward, and it made me feel like someone was thinking about Papa, even though they could not be at the bedside the whole day.
As the days went on, it became clear that Mr. J would not be going home anytime soon. We drained his lungs, but then fluid built up again. While initially this was only noticeable on X-rays, I soon began to see a change in Mr. J. He turned from a feisty sarcastic man who could not sigh enough at my explanations why he must remain in the hospital, to a man devoid of vigor, using most of his energy to mutter two-word answers. Soon he was barely able to lift his arms. I began to realize that Mr. J might die.
But there was no time to dwell on that.
Things needed to be done. I had other patients. My team—an attending, a senior resident, two first-year residents, a fourth year medical student, and I, working together as a unit—had other patients. And when you are on a busy medicine service, the demands do not stop. Just when you discharge several patients home, more come in. There are always sick people.
Much needed to be done for Mr. J as well. His family had to be called. But it wasn’t as simple as that. Initially, he didn’t want to call anyone. But eventually, his partner convinced him, and he asked us to call several of his family members, who lived nearby.
I spent the most time with Mr. J out of anyone on the team, and, although overwhelmed by my responsibilities, technically I had the most free time. So it made sense that I was the one to talk to his family members when they came in. How do you tell someone’s siblings that their brother is dying? There was no time to really prepare for it— so I just did it.
I had been on the other side of this conversation before. I knew what they wanted to hear—just a sliver of hope; just a 'for now.'
I had been on the other side of this conversation before. I knew what it was like on the receiving end. I knew what they wanted to hear—just a sliver of hope; just a “for now.” And I wanted to give them that. In general, I am a people pleaser; I have always had trouble saying “no” or telling people what I don’t think they want to hear. Even cancelling dinner plans can be a struggle. So delivering the news about Mr. J did not come naturally for me.
“Is there a chance he will recover?”
“He is not doing well. We think he is going to get worse.” I never lied to his family about his chances, but I couldn’t say the big word either—the “D” word. Why was this so hard for me?
No time to think about that then. I had other to-dos piling up for other patients. I also had to convince Mr. J’s estranged son to fly in to see his father.
“It’s just such short notice. I can’t get off work that quickly.”
“I understand this must be difficult, and I’m sorry for the short notice. We are just urging you to come now because his condition has changed so quickly,” I replied to Mr. J’s son over the phone.
“I appreciate it. But I can’t just leave like that. How much time do you think he has anyways?”
I paused for a moment and thought about it. This estimate had changed nearly daily. “It could be a few days.”
At this point he exhaled as if he finally realized something. “Alright. I’ll see what I can do. Thanks, Matt.”
This was hard enough, but to add to it, Mr. J’s siblings other family members were upset at his son, and they were unloading to me about their issues with him. But I know family tensions run high in these situations; I’ve been there. Unload away if it’ll help you through this. I get to walk away from this when I walk out of the hospital . . . right?
Mr. J continued to deteriorate. Now the palliative care service had stepped in, and Mr. J was taking morphine to help with his breathing situation. Morphine is never a good sign. I remember coming to visit Papa after he had been started on morphine. I only “saw” Papa once when he was on that drug. My mom shook him awake when I arrived, fairly forcefully, and said “Dad! Matt’s here!” His intermittent moans stopped for a second and his eyes focused. “Matt!?” The last memory I have of actually interacting with the real Papa was seeing his eyes recognize me, for a second.
Mr. J’s body was struggling to maintain itself. He needed help with everything. His extremities needed to be moved by others. His lips needed to be wet by others. He stopped swallowing frequently, leading to the typical “death rattle” (a textbook term) sound caused by pooling of fluid in his airway.
Despite his transformation, I still knew how to communicate with Mr. J—I just looked for his eyes. Every time I checked on him, I would sit on his bed, grab his shoulder (somewhat tightly), and loudly say, “Mr. J! How is your pain?” And I’d be ready. I’d be there looking right into his eyes for that moment when he would open them, recognize me, and have the ability for a second to answer me. “Finnne. Fiiiiiii.”
But eventually, it was time. We called a family meeting. Mr. J’s partner, family members, nurse, oncologist, palliative care doctor, and medicine doctor were all called to a room. My resident had told me an hour earlier, “I’m going to check on someone. I’ll see you at the meeting in an hour.” He never came. There was something more urgent. My attending decided to take the reins and start the meeting. “This is Matt Pantell. He’s been taking care of Mr. J. He’ll be leading the meeting. Matt?”
I panicked internally, thinking to myself, Why did she ask me to do this? Where is my resident? I’m underqualified for this.
What? Seven heads turned to look at me. I panicked internally, thinking to myself, Why did she ask me to do this? Where is my resident? I’m underqualified for this. I’m the type of person who likes being prepared. I do the reading when it’s due. I watch the instructional video before class. If anything, I prepare a little too long for things. I was thinking to myself that I was not ready, but then I realized that being invested in Mr. J’s care was all the preparation I needed—I knew his case, and more importantly, I knew him—better than anyone on my team. And also in the end, this is the way things typically go in medical school. You just have to pick it up as you go along.
Up until this point in my life, death was always something I had faced in the context of family. Because several close family members of mine have died, I know how to play the role of a family member in the context of a dying person. But it was new to play a professional role, and I struggled with what this meant. I had grown fond of Mr. J. As I took care of him, flashbacks of Papa filled my head. I had witnessed Papa’s final days, and he and Mr. J went through a similar process of dying – even had the same disease. They had the same preservation of their soul in their eyes until they passed. For both of them, as their bodies deteriorated, their eyes still moved and spoke.
I had grown attached.
But it was time to switch roles. I had to lead a meeting and tell Mr. J’s family what was happening. I went through the facts of the past week and beyond, told them why he’d come in, what we had done, how he was now, and what our plan was to take care of him from now on. But I didn’t address the elephant in the room.
Luckily, the palliative care doctor realized what I wasn’t going to, and he decided to add something after I was done speaking. “Your father, your family member, your partner . . . he’s dying.”
Nobody ever likes to say it, but it’s so important to. To just say the word ‘death.’
After the meeting, the palliative care doctor came up to me and told me I had done a good job, but then he said, “Nobody ever likes to say it, but it’s so important to. To just say the word ‘death.’” I had switched roles. I was on the other side of the conversation. I had to learn to say “death.”
I began trying to be more “professional” by going somewhat emotionally numb. I didn’t try to relate to what Mr. J’s family was going through. This didn’t mean that I was cold-hearted—I comforted Mr. J’s family. I checked in with them multiple times throughout the day. I embraced them while they cried. But I did not let myself feel what was going on. I wouldn’t. I couldn’t. It was not a decision I came to after much thought. It was, like most things during medical school, a choice of survival—what I needed to do in order to get my job done. While I could and did relate to what they were going through, I couldn’t go through it again; not at that particular time. I had to take care of myself in order to take care of my patients, and this meant not reliving the feelings of losing someone.
“Have you ever pronounced someone dead before?” my resident asked.
I had not. I listened, as he taught me the lesson of the day: how to pronounce someone dead. “Be very respectful of his family. You don’t know what the mood of the room will be. Look at his monitors. Then take a listen with your stethoscope. Take a good long listen. His nurse told me he passed, and, of course, I trust her judgment. But the listen is not just for you, it’s for his family. Listen for at least a minute, so they know that you were thorough, and present.”
As I entered the room, it felt different. Something had changed. Mr. J lay motionless in his bed, with a relaxed brow and lips slightly ajar. Monitors showing no heart activity. We both placed our stethoscopes over his heart for one minute. Nothing. He was dead, but he looked peaceful. His eyes were closed.
My resident and I looked at each other and nodded very slightly, then turned to his family. They already knew. “He’s passed.”
As it turned out, that was the last day on my medicine rotation. In fact, that was the last official duty I performed while in that hospital. For the first time in eight weeks, I did not have another chart to review. I didn’t have another lab test pending. I didn’t have another patient.
As I walked out of the hospital, I paused—I had the chance to pause—for a second. I finally thought about what had just happened. And I wept.
But after a few moments, I turned that switch off again. I had my medicine exam in an hour, and I had to get myself together. And after that, I needed to start studying. Next week I would begin my obstetrics rotation, delivering babies.
Matthew Pantell is a medical student in the UC Berkeley - UCSF Joint Medical Program. He would like to thank Martin Mulkeen, Teja Patil, and Guy Micco for their comments on this piece.
Illustration by Joe Wierenga.